Behavioural disinhibition in frontotemporal dementia investigated within an ecological framework

Disinhibition is a core symptom in behavioural variant frontotemporal dementia (bvFTD) particularly affecting the daily lives of both patients and caregivers. Yet, characterisation of inhibition disorders is still unclear and management options of these disorders are limited. Questionnaires currently used to investigate behavioural disinhibition do not differentiate between several subtypes of disinhibition, encompass observation biases and lack of ecological validity. In the present work, we explored disinhibition in an original semi-ecological situation, by distinguishing three categories of disinhibition: compulsivity, impulsivity and social disinhibition. First, we measured prevalence and frequency of these disorders in 23 bvFTD patients and 24 healthy controls (HC) in order to identify the phenotypical heterogeneity of disinhibition. Then, we examined the relationships between these metrics, the neuropsychological scores and the behavioural states to propose a more comprehensive view of these neuropsychiatric manifestations. Finally, we studied the context of occurrence of these disorders by investigating environmental factors potentially promoting or reducing them. As expected, we found that patients were more compulsive, impulsive and socially disinhibited than HC. We found that 48% of patients presented compulsivity (e.g., repetitive actions), 48% impulsivity (e.g., oral production) and 100% of the patients group showed social disinhibition (e.g., disregards for rules or investigator). Compulsivity was negatively related with emotions recognition. BvFTD patients were less active if not encouraged in an activity, and their social disinhibition decreased as activity increased. Finally, impulsivity and social disinhibition decreased when patients were asked to focus on a task. Summarising, this study underlines the importance to differentiate subtypes of disinhibition as well as the setting in which they are exhibited, and points to stimulating area for non-pharmacological management.

PRRT2 mutations: a major cause of paroxysmal kinesigenic dyskinesia in the European population

OBJECTIVE

Paroxysmal kinesigenic dyskinesia (PKD) is a rare disorder characterized by recurrent attacks of hyperkinetic movements. PKD can be isolated or associated with benign infantile seizures as part of the infantile convulsions with choreoathetosis (ICCA) syndrome. Mutations in the PRRT2 gene were recently identified in patients with PKD and ICCA. We studied the prevalence of PRRT2 mutations and characteristics of the patients in a European population of patients with PKD and ICCA.

METHODS

Patients were recruited through the 1996-2011 database of our DNA bank, to which physicians refer DNA with a putative diagnosis and clinical information. Two movement disorders experts reviewed the information on patients with a putative diagnosis of PKD. Patients who fulfilled the criteria for PKD and ICCA were included. The PRRT2 coding sequence was analyzed by direct sequencing.

RESULTS

Among 42 index cases of unrelated families referred with a putative diagnosis of PKD, a total of 34 patients, including 32 with isolated PKD and 2 with ICCA, were selected for genetic analysis. Mutations introducing premature termination codons were identified in 22 of 34 patients including 13 of 14 families and 9 of 20 patients with sporadic cases. The previously described c.649dupC/pArg217ProfsX8 and c.629dupC/pAla211SerfsX14 were present, respectively, in 17 patients and 1 patient; we also report 3 novel mutations: c.649delC/pArg217GlufsX12 in 2 patients, and c.562C>T/pGln188X and c.649C>T/pArg217X, each in 1 patient. The group with mutations was characterized by a younger age at onset (9 years) compared with the patients without mutations (15 years; p < 0.01).

CONCLUSION

Mutations in PRRT2 are a major cause of PKD in familial and sporadic cases in the European population.

Impact of Newly Available Drugs on Clinical Progression in Patients with Virological Failure after Exposure to Three Classes of Antiretrovirals

Objective

To study the prognosis of HIV-infected patients with virological failure after exposure to three classes of antiretroviral drugs (ARVs).

Design

Cohort study. Setting: French Hospital Database on HIV.

Patients

Patients previously exposed to at least two nucleoside reverse transcriptase inhibitors (NRTIs), two protease inhibitors and one non-NRTI, with viral load (VL) values of >5000 copies/ml after the exposure criteria were met and a new treatment initiated between 1998 and 2001 with VL >5000 copies/ml.

Main outcome measures

Risk of new AIDS-defining-events (ADEs) or death from first introduction of a drug never used before occurring between 1998 and 2001 defined as baseline.

Results

The main baseline characteristics of the 1092 patients were: previous ADE in 49% of cases, median CD4 cell count 181 μl, median VL 4.9 log10 copies/ml, median duration of ARV therapy 5.0 years and previous exposure to a median of nine ARVs. The crude progression rates were 20.1/100 patient-years among patients included in 1998, 15.1 in 1999, 11.1 in 2000 and 8.6 in 2001. After adjustment for baseline characteristics, the calendar year of inclusion was associated with the risk of clinical progression ( P<0.001). When the types of newly available drugs used at baseline or during follow-up were introduced into the model, year of inclusion was no longer associated with the risk of clinical progression ( P=0.42), while exposure to amprenavir/r, lopinavir/r, abacavir or tenofovir was associated with a lower risk.

Conclusions

The clinical prognosis of heavily pretreated patients experiencing virological failure improved between 1998 and 2001, mainly thanks to the use of newly available drugs with more favourable resistance profiles.

Frequency of cytokine-producing T cells in HIV-infected patients treated with stavudine, didanosine, and ritonavir

To assess prospectively the influence of the control of viral replication on the frequency of cytokine-producing T cells, and to correlate these changes with immune activation, we conducted a 15-month follow-up study of IFN-gamma- and IL-2-producing CD4+ and CD8+ T cells at a single-cell level in 12 previously untreated patients receiving highly active antiretroviral therapy (HAART). At baseline we observed a strikingly high proportion of IFN-gamma-producing CD8+ T cells. The treatment-induced decrease in the proportion of IFN-gamma-producing CD8+ T cells ran parallel to the decrease in HLA-DR+ and CD38+CD8+ T cell subsets and was associated with the reduction in HIV RNA level. IL-2-producing cells were mainly CD4+. As a consequence of CD4+ T cell loss, the number of IL-2-producing CD4+ T cells was lower in patients than in control subjects (52 vs. 171 cells/microl), but the proportion of these cells was unchanged (22.4 vs. 19.3). During therapy the proportion of CD4+ IL-2-producing cells was initially stable and then fell markedly at month 5, followed by a gradual return to previous values. The reduction in viral load was associated with the fall in the proportion of CD4+ activated subsets. Intracellular cytokine assays are a new approach to the assessment of T cell function in HIV infection. Our results suggest that the functional capacity of CD4+ T cells is probably less severely altered than previously thought on the basis of conventional assays. CD8+ T cells exhibit an increased capacity to produce IFN-gamma that is associated with an increase in activation marker expression. These alterations decrease partially and in parallel under treatment.

Predictors of short- and long-term survival in HIV-infected patients admitted to the ICU

STUDY OBJECTIVES

To evaluate the prognosis of HIV-infected patients admitted to ICUs and to identify factors predictive of short- and long-term survival.

DESIGN

A prospective study from January 1, 1990, to December 31, 1992, including all consecutive HIV-infected patients admitted to our ICU for the first time. ICU survivors were followed up until January 1, 1994.

SETTING

An 18-bed infectious diseases ICU in a 1,300-bed university hospital in Paris.

PATIENTS

Four hundred twenty-one HIV-related admissions were recorded during the study period (33.5% of 1,258 admissions to ICU); 354 HIV-infected patients were first ICU admissions and were analyzed.

MEASUREMENTS AND RESULTS

Predictive factors on univariate and multivariate analyses (logistic regression and Cox model) for short- and long-term mortality were performed. Respiratory failure was the main cause of admission (49.2%), followed by neurologic disorders (26.8%), sepsis (10.2%), heart failure (4.5%), and miscellaneous disorders (9.3%). For these groups, in-ICU and in-hospital mortality rates were as follows: 16.7% and 33.9%; 23.2% and 41.1%; 38.9% and 58.3%; 25% and 68.8%; and 12.1% and 24.2%, respectively. In-ICU and in-hospital mortality rates were significantly different across the groups (p=0.026 and 0.002, respectively). Multivariate analysis showed that the in-hospital outcome was significantly associated with functional status (p=0.05), time since AIDS diagnosis (p=0.04), HIV disease stage (0.016), simplified acute physiology score (SAPS I) (p=0.06), need for mechanical ventilation (p<0.000001), and its duration (p=0.0001). In the 281 patients who were discharged alive from the ICU, cumulative survival rates were 51%+/-38% at 6 months, 28%+/-38% at 12 months, and 18%+/-30% at 24 months. Median and crude mean+/-SD survival times were 199 days and 316+/-343 days. Multivariate analysis showed that the long-term outcome was significantly associated with functional status (p=0.000001), weight loss (p=0.00001), the CD4 count (p=0.00001), the HIV disease stage (p=0.01), the duration of AIDS (p=0.001), the admission cause group (p=0.03), and the SAPS I at admission (p=0.00001).

CONCLUSIONS

The short-term (in-ICU and in-hospital) outcome of HIV-infected patients was mainly related to the severity of the acute illness (SAPS I, cause of admission, need for and duration of mechanical ventilation), and to the preadmission health status, based on functional status and weight loss. Some of these parameters, in particular the SAPS I and preadmission health status, also influenced the long-term outcome. Whereas HIV-related variables had little impact on the in-ICU outcome, they were closely related with the in-hospital outcome and even more strikingly with the long-term outcome. Thus, the life expectancy of HIV-infected patients, which depends primarily on the natural history of the HIV infection, is the most powerful determinant of the long-term prognosis. Our results confirm that ICU support for HIV-infected patients should not be considered futile.

Evaluation of high-dose regimen of paromomycin against cryptosporidiosis in the dexamethasone-treated rat model

In the dexamethasone-treated rat model of cryptosporidiosis, paromomycin was effective at a dosage of 50 mg/kg/day or more for ileal infection and 200 mg/kg/day or more for cecal infection. At 1 and 3 weeks after treatment, a persistent infection was demonstrated in all rats. These results confirm the anticryptosporidial activity of paromomycin and underscore the limitations of this compound because of its potential toxicity at such high dosages and its inability to eradicate the infection.

Reevaluation of the relative risk for susceptibility to celiac disease of HLA-DRB1, -DQA1, -DQB1, -DPB1, and -TAP2 alleles in a French population

In a population of 46 children with CD recruited in the Paris area of France, an excess of DRB1*03 and DRB1*07 alleles and of DR3/DR7, DR3/DR3 and DR11(or 12)/DR7 phenotypes was found (RRs of 6.3, 9.3, 24.6, 15, and 15.1, respectively), which is reminiscent of the markers of susceptibility observed in southern rather than in northern European celiac patients. More importantly, the highest association with CD was not found in individuals expressing the DQA1*0501-DQB1*0201 heterodimer in single dosage (RR = 24.9) or in homozygous state, but in people co-expressing one copy of DQA1*0501-DQB1*0201 on one haplotype and a second copy of DQB1*0201 on the second haplotype (RR = 35.7). This suggests that in our population either DQB1*0201 or a gene closely linked to DQB1*0201 influences the susceptibility to CD conferred by the DQA1*0501-DQB1*0201 heterodimer. Significant positive or negative RRs conferred by some TAP2 or DPB1 alleles were found. However, they were moderate compared to the RR conferred by the expression of a second copy of DQB1*0201. Moreover, they were no longer significant when patients were compared with HLA-DR matched controls. This suggests that associations of CD with TAP2 and DPB1 alleles are secondary to linkage disequilibria and argues against the contribution of these alleles in resistance and/or susceptibility to CD. Thus the "raison d'être" of a "DQB1*0201 second haplotype effect" in susceptibility to CD remains to be elucidated.

The pharmacokinetics of chloroquine in healthy and Plasmodium chabaudi-infected mice: implications for chronotherapy

The schizogony of malarial parasite is a typical cyclic phenomenon where the different stages of parasite development appear at regular time intervals. Each of the stages is specifically sensitive to different antimalarial drugs. Knowledge of the details of the cycle, drug susceptibility and the pharmacokinetics of drugs, could allow the improvement of drug action by the chronotherapeutic approach: treatment at the time of appearance of the drug sensitive stage with a drug that displays rapid pharmacokinetics. Since murine malarias serve as preferable models for in vivo drug testing, the pharmacokinetics of subcutaneously (sc) administered chloroquine (CQ) were tested in the whole blood of healthy mice and in animals slightly (1.5-3.5% parasitemia) or heavily infected (21-25% parasitemia) with Plasmodium chabaudi chabaudi. The half-time of absorption was around 5 min and almost independent of parasitemia. The apparent half-time of drug concentration decay was around 40 min in healthy animals, about 90 min at low parasitemia and about 410 min in heavy infection, indicating that the concentration of CQ is a typical spike, that is prolonged by asymptomatic disease, and considerably more by the active accumulation of CQ in infected cells. The latter is confirmed by the 3-fold higher peak blood [CQ] at the trophozoite stage and < 1.5-fold increase during schizogony. In conjunction with our previous experiments which showed that a single sc injection of 5 mg/kg CQ is sufficient to eliminate the drug susceptible mid-term trophozoite stage, the present results seem to justify to propose the chronotherapeutic approach for the treatment of malaria.

Demographic factors associated with HTLV-1 infection in a Gabonese community

An epidemiological study of human T-lymphotropic virus type 1 (HTLV-1) and syphilis has been carried out in a multiethnic community of seven neighbouring villages located in eastern Gabon on 1240 subjects over 5 years old (82.7% of the population in this age range). Antibodies to HTLV-1 (anti-HTLV-1) were detected by ELISA with confirmation by Western Blot and antibodies to syphilis by Venereal Diseases Research Laboratory assay with confirmation by the Treponema pallidum haemaglutination assay. The prevalence rate of anti-HTLV-1 was 8.5% and increased from 3.7% in the 5-14 years age group to 23.8% in the over 60 years age group. Logistic regression showed that the positivity for anti-HTLV-1 was associated with age, ethnic group and sex (higher prevalence in females). The seroprevalence rate of syphilis was 8.2%. Seropositivity for syphilis and HTLV-1 were related but age was a confounding variable in this relationship. This study showing a highly heterogeneous distribution of HTLV-1 in a geographically limited area suggests the role of environmental and behavioural factors in HTLV-1 transmission.

Evaluation of curative anticryptosporidial activity of paromomycin in a dexamethasone-treated rat model

A dexamethasone-treated rat model of cryptosporidiosis was used to evaluate the curative activity of paromomycin. Although eradication of the parasite could not be demonstrated, statistically significant decreases in oocyst excretion and in the intensity of ileal parasitism were observed in animals receiving 100 mg of paromomycin per kg of body weight per day.

Population-based study of serum hepatitis B virus DNA in Gabon

The prevalence of serum hepatitis B virus (HBV) deoxyribonucleic acid (DNA) was measured in a Gabonese community at high risk for HBV infection. Among 698 subjects 5 to 24 years old, the prevalence of HBsAg was 11.1% vs. 57.9% for anti-HBs and 7.2% for anti-HBc alone. The prevalence of HBeAg among HBsAg-positive subjects was 26.5% vs. 59.5% for anti-HBe. The prevalence of HBV DNA tested by a hybridization spot test was 2.1% in the overall population and 18.7% among HBsAg-positive subjects. HBV DNA was found in 15 of 21 HBeAg-positive subjects but in none of the subjects positive for anti-HBe or negative for both HBeAg and anti-HBe. HBV DNA was not detected in any HBsAg negative subjects. The prevalence of HBV DNA decreased with age. This low prevalence of HBV DNA contrasts with the high level of endemicity in the study population.

Dapsone-pyrimethamine compared with aerosolized pentamidine as primary prophylaxis against Pneumocystis carinii pneumonia and toxoplasmosis in HIV infection. The PRIO Study Group

BACKGROUND

Pneumocystis carinii pneumonia and toxoplasmic encephalitis are frequent life-threatening opportunistic infections in patients with human immunodeficiency virus (HIV) infection. Primary prophylaxis against P. carinii pneumonia is now common, but there are few data on regimens for primary prophylaxis against toxoplasmosis.

METHODS

We conducted a randomized trial that compared two prophylactic regimens: dapsone (50 mg per day) plus pyrimethamine (50 mg per week) was compared with aerosolized pentamidine (300 mg per month). The patients had symptomatic HIV infection, no history of P. carinii pneumonia or symptomatic toxoplasmosis, and CD4+ counts below 200 per cubic millimeter (0.2 x 10(9) per liter).

RESULTS

In an intention-to-treat analysis, after a median follow-up of 539 days P. carinii pneumonia developed in 10 patients in each group, whereas toxoplasmosis developed in 32 of 176 patients in the pentamidine group and 19 of 173 patients in the dapsone-pyrimethamine group. Those assigned to pentamidine had a risk of P. carinii pneumonia that was similar to the risk in those assigned to dapsone-pyrimethamine (adjusted relative risk, 1.13; 95 percent confidence interval, 0.44 to 2.92; P = 0.79), but a higher risk of toxoplasmosis (adjusted relative risk, 1.81; 95 percent confidence interval, 1.12 to 2.94; P = 0.02). Among the 262 patients with serologic evidence of past exposure to Toxoplasma gondii, the relative risk of symptomatic toxoplasmosis was 2.37 times higher in those assigned to pentamidine (95 percent confidence interval, 1.3 to 4.4; P = 0.006). More patients discontinued dapsone-pyrimethamine than pentamidine because of toxicity (42 vs. 3; P < 0.001). Survival was similar in the two groups.

CONCLUSIONS

For primary prevention of P. carinii pneumonia, dapsone-pyrimethamine is as effective, though not as well tolerated, as aerosolized pentamidine. Dapsone-pyrimethamine also prevents first episodes of toxoplasmosis.

Efficacy of intramuscular amopyroquin for treatment of Plasmodium falciparum malaria in the Gabon Republic

The efficacy of a 12-mg/kg (of body weight) intramuscular amopyroquin (ApQ) regimen (two successive 6-mg/kg injections at a 24-h interval), previously established from kinetic studies on healthy volunteers and multicenter studies on patients with malaria, was investigated in 152 patients (children and adults) in Gabon with Plasmodium falciparum malaria. All children in the present study (ages, 1 to 14 years) showed higher degrees of parasitemia and temperatures and lower hematocrit values than did adults at the time of admission. No major side effects in the patients were observed. On day 7, all patients were apyretic; clearance of parasites was obtained in 143 of 152 patients (94%); a low level of parasitemia was observed in nine patients, all of whom were children (6%). In vitro chemosusceptibility tests carried out on P. falciparum isolates from patients demonstrated 51% of resistance to chloroquine (Cq). A correlation was found between the in vitro chemosusceptibilities to Cq and ApQ, but no relationship between the in vitro activity and the in vivo efficacy of ApQ could be found. Concentrations of ApQ in blood assayed by high-performance liquid chromatography on day 2 did not differ significantly between the groups in whom therapy was a success or a failure, although the mean ApQ concentration in blood for the group that failed therapy was 31% lower. Concentrations greater than 100 nmol of self-prescribed Cq and amodiaquine per liter, which were assayed simultaneously with ApQ, were observed in 78 patients (51%). They did not correlate with degrees of parasitemia compared with ApQ alone, which did. Successful treatment by day 7 was obtained in 69 of 74 patients (93%) who had no other 4-aminoquinolines in their blood. The results of the present study show that an ApQ regimen of 12 mg/kg over 2 days may be an alternative for the treatment of Cq-resistant malaria, at least in adult patients, in the field.

Is steroid dependent Crohn's disease a separate entity?

Crohn's disease has been sometimes considered as a syndrome including different entities. In this prospect we tried to assess whether steroid dependent Crohn's disease could be a separate sub-group. Eighty five patients (mean follow-up: 6 years) with documented Crohn's disease were classified into 3 groups: 1--patients never treated with steroids (NS) (N = 37); 2--patients in whom steroids had been given but had been withdrawn (NSD) (N = 37); 3--patients dependent on continuous steroid therapy (SD) (N = 11). Ten variables were considered: age at onset, sex, CDAI, cumulative topography of lesions, extra-intestinal symptoms, albuminemia, ESR, surgical operations, annual frequency of relapses. Monofactorial analysis (analysis of variance and CHI2 test) showed group SD to be significantly different from group NS and in term of age at onset, CDAI, ESR, annual frequency of relapses, extra-intestinal symptoms, surgical operations. In contrast, a multivariate analysis of correspondences applied to the 3 groups and to 9 dichotomous variables showed that group SD is not a separate entity, but the limit of a continuum extending from group NS to group NSD. This was ascertained by a CHI2 test applied to the dichotomous variables. Thus, within the limits of this study Crohn's disease appears to be a homogeneous entity rather than a heterogeneous syndrome.

Echotomographic and serological population-based study of hydatidosis in central Tunisia

A population-based echotomographic (ECT) and serological survey of hydatidosis was carried out in a high risk community located in Central Tunisia. 1434 subjects over 5 years of age (93.3% of the population in this age range) underwent an abdominal echotomography (ECT) and a serological test (ELISA with confirmation by counterelectrophoresis). The ECT prevalence rate was 3.5% and increased with age reaching 7.7% in the over 39 years age group. Most subjects (96.0%) had liver cyst(s). The serological prevalence rate was 2.9%. A strong agreement was found between ECT and serological results (Kappa test = 0.449). Taking ECT as a reference, the relative specificity and sensitivity of serology were 99.3 and 62.0 respectively. Most ECT positive seronegative subjects had calcified cysts. These results confirm the presence of highly endemic foci of hydatidosis in Central Tunisia, show a good agreement between serological and ECT results at a population level and demonstrate the high feasibility of ECT as a screening technique.

Assessment of the protective value of antibodies to the Plasmodium falciparum ring-infected erythrocyte surface antigen (RESA): an epidemiologic study in Madagascar

The ring-infected erythrocyte surface antigen (RESA), a Plasmodium falciparum merozoite antigen, is a major vaccine candidate against falciparum malaria. To investigate the protective role of antibodies to RESA and its 4-mer, 8-mer, and 11-mer repeated amino acid sequences under conditions of natural exposure, a case-control and a cohort study were carried out in 1988 in a rural community in Madagascar where malaria reappeared recently. Fifty cases with greater than 1,000 P. falciparum per microliter of blood, and 45 controls with a negative blood smear were enrolled and sera were collected. Forty-one controls were followed for 20 weeks to identify malarial attacks. Protection against clinical malaria was assessed by the absence of malarial attacks requiring therapy. At enrollment, positivity rates and reactivity levels to RESA or repeats were similar in cases and controls. The 11-mer repeat antibody level was higher in the 26 controls who experienced at least one malarial attack during follow-up than in the 15 other controls (p less than 0.01). Thus, antibodies to the 11-mer repeat were predictors of the subsequent appearance of the disease. After adjustment for antibodies to the 11-mer repeat, antibodies to whole RESA had a negative predictive value on the occurrence of malarial attacks (p = 0.04). Different epitopes within the RESA molecule may elicit production of antibodies with different activities.

[Epidemiology of HTLV-I infection in its hyperendemic foci (Japan, tropical Africa, Caribbean)]

HTLV-1 infection is endemic in Japan, black Africa, the Caribbean and several regions of South America. In these foci, the infections is very heterogeneously distributed (variations from village to village, intrafamilial clustering). The virus is transmitted from mother to child, and breast feedings seems to play a major role. Sexual transmission is usually from man to woman. The frequency of transmission by blood transfusion must not be underestimated. It justifies the systematic detection of HTLV-1 infection in areas where it is economically feasible.

[A fosfomycin-gentamicin combination in the treatment of experimental endocarditis caused by Klebsiella pneumoniae producing type TEM-3 beta-lactamase]

The authors studied the activity of fosfomycin (FOS) and/or gentamicin (GEN) against a Klebsiella pneumoniae strain resistant to all beta-lactams--except cephamycins and imipenem--by production of a plasmid mediated extended broad-spectrum beta-lactamase-TEM-3, to all aminoglycosides--except gentamicin--by production of a plasmid mediated 6' aminoglycoside acetyltransferase IV, to sulfonamides and to tetracyclines. In vitro, the combination FOS (MIC = MBC = 32 mg/l) + GEN (MIC = MBC = 2) appeared indifferent (FIC = 0.75; FBC = 1). In vivo, on experimental endocarditis in rabbits, FOS alone was ineffective, GEN alone was active but only at high dose regimen, FOS - GEN combination was active as compared with controls. Fosfomycin - gentamicin combination may be an alternative in the therapy of severe infections due to multiresistant Enterobacteriacae.

Prevention of Pneumocystis carinii pneumonia relapse by pentamidine aerosol in zidovudine-treated AIDS patients

To examine the efficacy and tolerance of pentamidine aerosol in the prevention of Pneumocystis carinii pneumonia (PCP) relapse in patients with the acquired immunodeficiency syndrome (AIDS) being treated with zidovudine, 51 patients who had had an episode of PCP in the previous 5 months were enrolled in a randomised controlled study. 25 patients (group I) received pentamidine mesylate aerosol (4 mg/kg every 2 weeks for the first month then monthly) and zidovudine, and 26 patients (group II) zidovudine alone. 3 group I patients withdrew from pentamidine therapy prematurely and were excluded from the analysis of efficacy. Relapses of PCP occurred in 2 out of 22 (9%) group I patients and in 16 out of 26 (61%) group II patients after a mean follow-up of 10 and 8.7 months, respectively. The two groups differed significantly (p less than 0.0001) in proportions without relapse. They did not differ in proportions surviving. Bronchial intolerance was common (47%); no systemic side-effects of pentamidine were observed. Pentamidine aerosol thus seems to be effective in preventing PCP relapses in AIDS patients on zidovudine. The early termination of the trial prevented assessment of the long-term efficacy and safety of pentamidine given by aerosol.

Pharmacokinetics of intramuscular amopyroquin in healthy subjects and determination of a therapeutic regimen for Plasmodium falciparum malaria

The disposition of amopyroquin was investigated in 10 healthy volunteers after a single 2-mg/kg (body weight) intramuscular dose of amopyroquin base. The major form of the drug in plasma and in whole blood was nonmetabolized amopyroquin, and only very low levels of its primary amine derivative were detected. After a rapid absorption phase (15 min), levels in plasma declined, following a tri-exponential model with a terminal elimination half-life of 129.6 +/- 92.5 h. The apparent volume of distribution (V/F) and the systemic clearance (CL/F) were 238 +/- 75 liters/kg and 2,063 +/- 1,159 ml/min, respectively. The renal clearance, calculated by using urine excreted during the first 48 h, was 119 +/- 99 ml/min and represented about 6% of the systemic clearance. About 1.2 and 0.2% of the amopyroquin dose was excreted in the urine during the first 48 h as nonmetabolized amopyroquin and its primary amine metabolite, respectively. Twenty-two Plasmodium falciparum malaria patients were studied after treatment with one of the following regimens of intramuscularly injected amopyroquin base: 3 mg/kg (body weight), 6 mg/kg, or 6 mg/kg followed by 3 mg/kg 24 h later. Parasitemia was cleared at day 7 in one of six, four of seven, and seven of nine patients, respectively. On the basis of this study, a regimen of 12 mg/kg (body weight) administered in two or three injections is suggested.

Distribution of surgical hydatidosis in central Tunisia (1982-1985)

The mean annual surgical incidence rates (MASIR) of hydatidosis were measured for the 1982-1985 period in central Tunisia in order to investigate the natural history of human hydatidosis and provide baseline data for the evaluation of future prevention campaigns. 986 cases were identified from surgical records of regional hospitals to which cases from central Tunisia are mandatorily referred. The overall MASIR was 19.3 per 10(5) inhabitants. The MASIR according to district varied from 0 to 56.6 per 10(5), was higher in women than in men (22.6 versus 15.8 per 10(5] and increased with age (maximum 53.0 per 10(5) in the 50-59 age group for women and 27.1 per 10(5) in the 40-49 group for men). Among the 940 cases with single organ hydatidosis, liver ranged first (55.3%, 545/940), then lung (32.4% 320/940), kidney (2.7%) and spleen (1.8%). Among the 865 subjects with single lung or liver hydatidosis, liver was more often involved in women (349 out of 503) than in men (196 out of 362) (chi 2 = 20.9, p less than 0.001). In both sexes, the lung/liver ratio decreased with age. These data reveal the existence of highly endemic foci of hydatidosis within central Tunisia. The predominance of infection in women might be due to sex related behavioral differences. The causes of liver predominance in women and variation of lung/liver ratio are open to question.

Serological screening for hydatidosis in households of surgical cases in central Tunisia

Household members of surgical cases of hydatidosis were screened for the disease in two high-risk districts in Central Tunisia. Seventy-four index cases were identified from the 1980-1984 surgical records of Sousse University Hospital. Household members over five years of age were tested by ELISA, and if positive by counterelectrophoresis (CEP) for detection of band 5. Positive subjects underwent a chest X-ray and echotomography (ECT). Eight of the 355 household members (2.2%) living in four different houses were serologically positive. All eight had a normal chest X-ray; a hepatic cyst was detected in seven of them. Five of the seven subjects in whom a cyst was diagnosed lived in two neighbouring houses (19 household members from the same family). Among these 19 subjects, six had been previously operated on for hydatidosis (cumulative rate: 11/19). The comparisons of these results with results obtained through community-based screening in the same area suggest that households members of patients are not at particularly high risk of hydatidosis.

Disposition of amopyroquin in rats and rabbits and in vitro activity against Plasmodium falciparum

The disposition of amopyroquin was studied in rats after a single 50-mg/kg (body weight) oral dose of amopyroquin base. After a rapid absorption phase, the drug concentrations decreased in the plasma, with a terminal half-life of 14.5 h. The drug was widely distributed in the liver and lungs and, to a lesser extent, in the kidneys and spleen. In rabbits, the kinetic parameters were compared after a single 10-mg/kg dose of amopyroquin base through intravenous, intramuscular (i.m.), and oral routes. The similar bioavailability values (0.67 and 0.69) suggested that the drug could be used through i.m. or oral administration. Clearance and distribution volume did not differ significantly among the three modes of administration, and the terminal half-lives were 18.1 +/- 3.3, 23.9 +/- 6.7, and 25.7 +/- 5.4 h for intravenous, i.m., and oral routes, respectively. The ratio of concentrations in erythrocytes and plasma was about 5 in rats and rabbits. Three metabolites were detected in both animal species (one was tentatively identified as the primary amine derivative). The amopyroquin in vitro activity was tested against four chloroquine-susceptible and 11 chloroquine-resistant African Plasmodium falciparum strains. For all isolates, the 50% inhibitory concentrations of amopyroquin were much lower than those of chloroquine and monodesethylamodiaquine.

Absence of relationship between Schistosoma mansoni and hepatitis B virus infection in the Qalyub Governate, Egypt

In order to determine whether infection with S. mansoni is related to a higher rate of infection with HBV and/or to a higher probability of HBsAg chronic carriage, a population based survey was carried out in Egypt in which HBV markers were studied in 67 subjects with heavy long-lasting S. mansoni infection. Controls were 67 subjects with no or low grade S. mansoni infection individually matched with the cases for age, sex and village of origin. 41.8% of the cases and 37.3% of controls showed no marker of HBV infection. The prevalence rate of anti-HBc alone was 4.5% in the cases and 7.5% in the controls. For anti-HBs the figures were 53.7% and 55.2% respectively. No cases or controls were positive for HBsAg. These data do not support the hypothesis of an interaction between infection with hepatitis B virus and S. mansoni.

Fifty cases of late prosthetic valve endocarditis: improvement in prognosis over a 15 year period

The clinical course, prognostic factors, and management of 50 cases of late prosthetic valve endocarditis, occurring more than two months after valve replacement, were reviewed. Twenty nine cases that presented from 1971 to 1980 were compared with 21 cases that presented from 1981 to 1985. Apart from an appreciable decrease in the frequency of neurological complications between the first period (38%) and the second period (10%) no differences in clinical or bacteriological features were seen. Seventeen (59%) of the 29 cases in the earlier period and four (19%) of the 21 cases in the later period died. The rationale for antimicrobial treatment was similar during both periods. Cardiac surgery was performed in eight of 29 cases between 1971 and 1980 and in 11 of 21 between 1981 and 1985; the mean (SD) time between diagnosis of endocarditis and operation was 28 (19) days and 43 (44) days respectively. Six of the eight cases operated on in the first period died as did two of the 11 operated on in the second period. Twenty seven of the 29 cases presenting between 1971 and 1980 were treated with anticoagulants--either warfarin (15 of 27) or heparin sodium (12 of 27). Sixteen of the 21 cases presenting later were given anticoagulants and 15 of these cases were given heparin sodium. Control of anticoagulation was inadequate in nine of the 27 cases treated with anticoagulants during the first period and in only two of 16 treated during the second period. During the first treatment period neurological complications were more frequent when control of anticoagulation was inadequate.

Infection with hepatitis A and B viruses in French volunteers working in tropical Africa

The risks of developing hepatitis A and B virus infections were studied in 233 French volunteers working for 18 to 35 months in the field in West and Central Africa. During their stay in Africa, the seroconversion rates to antibody to hepatitis A virus of the immunoglobulin G (IgG) class and hepatitis B marker(s) were 48.1% and 10.5%, respectively; 21.5% of the volunteers developed jaundice, and 78.0% of the jaundice cases were associated with hepatitis A seroconversion, 14.0% with hepatitis B seroconversion, 4.0% with seroconversion to both, and 4.0% without seroconversion. Male health workers were at lower risk than other male occupations for hepatitis A infection. Female health workers were at higher risk than other female occupations for hepatitis A infection. Health workers were at a lower risk of hepatitis B infection, but the significance was borderline. Populations such as these volunteers should receive immunoprophylaxis against hepatitis A and B infections.

Pulmonary function at 1 year of age in survivors of neonatal respiratory distress: a multivariate analysis of factors associated with sequelae

We studied pulmonary function 1 year after neonatal respiratory distress (RD) in 54 infants who had been treated at birth in the same neonatal intensive care unit. RD was related to hyaline membrane disease in 36 cases (group I) and to other causes in 18 cases (group II). Compared with predicted values, dynamic lung compliance (CL) was lower (less than -2 SD) and total pulmonary resistance (RL) was higher (+2 SD) in 18 (33%) and 12 (22%) infants, respectively. The relationships between these functional abnormalities at 1 year of age and the characteristics of the neonatal respiratory disease were assessed using a multifactorial analysis (multiple correspondences analysis). We found that elevated RL (greater than +2 SD) at 1 year of age was very significantly related with hyaline membrane disease, involving both high rate of positive pressure ventilation and prolonged intubation, and with the presence of both tachypnea and abnormal chest X rays at the time of discharge. Compared with elevated RL, the relationships between low CL (less than -2 SD) and the same neonatal characteristics were less significant; in particular, there was no strong link between low CL and hyaline membrane disease. Finally, birth before 30 weeks gestation was an index of severity.

Immunological characteristics of malaria antibodies in two regions of Madagascar

Antibodies directed against antigens of the asexual blood stages of Plasmodium falciparum were studied in the plasma of 29 individuals infected with P. falciparum and living in two areas of Madagascar. These plasma samples were investigated by four immunological methods: indirect fluorescence, immunoprecipitation of radiolabeled P. falciparum polypeptides, inhibition of the in vitro growth of P. falciparum, and double diffusion in a gelose plate. A multifactorial correspondence analysis of the results obtained for each sample revealed that the nature of several of the antibodies varied according to the age and place of residence of the subjects. In comparison with plasma samples from older individuals, specimens from young children had a higher immunofluorescence titer, immunoprecipitated several additional peptides (90, 110, and 118 kilodaltons), revealed more precipitation lines in the Ouchterlony plate technique, and did not inhibit the in vitro growth of P. falciparum to the same extent. Furthermore, as opposed to plasma samples from individuals living in the high central plateau, plasma samples from individuals living on the east coast of the island inhibited the penetration of erythrocytes by merozoites of one of the two studied P. falciparum strains and preferentially immunoprecipitated low-, rather than high-, molecular-weight peptides.

Fulminant viral hepatitis and pregnancy in Algeria and France

The relationship between fulminant viral hepatitis (FVH) and pregnancy was compared in Algeria and France. This comparison was based on the study of 22 Algerian and 77 French pregnant and non-pregnant women, aged 15 to 49 years, consecutively admitted for FVH to the Centre Hospitalier Universitaire, Constantine, Algeria, or to Hôpital Beaujon, Clichy, France. The observed and expected (calculated from demographic data) percentage of pregnant women was significantly different among the Algerian patients with FVH (45.5% v. 24.9%, P less than 0.03), but not among the French patients (3.9% v. 5.8%). Hepatitis A was the cause of FVH in none of the Algerian patients, but in eight French patients, none of whom was pregnant. Hepatitis B was the cause of FVH in one non-pregnant Algerian patient and in 49 French patients, two of whom (4.1%) were pregnant. Hepatitis non-A, non-B was the cause of FVH in 21 Algerian patients, ten of whom (47.6%, a percentage significantly higher than expected, P less than 0.04) were pregnant, and in 19 French patients, one of whom (5.3%, a percentage similar to that expected) was pregnant. In conclusion, (1) there is a relationship between FVH and pregnancy in Algeria, but not in France, and (2) this difference is mainly or exclusively attributable to infection with a non-A, non-B virus affecting the Algerian population, but which is much less common or absent in France.

Echotomographic and serologic screening for hydatidosis in a Tunisian village

Echotomographic and serologic screening for hydatidosis was carried out in 1,650 subjects aged over 5 years in a village located in a high risk region of central Tunisia. Echotomography detected liver cysts in 6 subjects (prevalence rate: 3.6 per 1,000). These 6 cases were among the 7 positive cases detected by ELISA. In all 6, the diagnosis of liver cysts was confirmed. No other localization was found in any of the subjects including one with a positive ELISA and a normal echotomographic examination. This work demonstrates the high feasibility of echotomography in the field and confirms the high prevalence rate of hydatidosis in the community.

Antibodies to HTLV-I p24 in African and Portuguese populations

Using a radioimmunoassay to detect HTLV-I protein antibodies of molecular weight 24,000, we screened populations from Algeria (140 subjects), Tunisia (442), Mali (69), Senegal (415), Uganda (135), the Central African Republic (77), the Congo (360), and Madagascar (193). Only four subjects were positive (1 from Senegal, 1 from Uganda, 2 from the Congo). This is a much lower figure than that found by others in Africa by the enzyme-linked immunosorbent assay technique. In addition, 319 Portuguese blood donors (46 of whom have lived in Angola or Mozambique) were screened using the same radioimmunoassay. All were negative.

Seroepidemiology of hepatitis B in a population of children in central Tunisia

The prevalence rate of HBV markers in the overall population was 18.0%. The prevalence rates of HBsAg and anti-HBs were 3.3% and 12.2% respectively. 2.5% of the children were negative for these markers but positive for anti-HBc alone. Of the 17 HBsAg positive children, 10 were HBeAg positive and four were anti-HBe positive. The statistical study using multifactorial correspondence analysis and the chi 2 test showed a positive relationship between the prevalence rate of anti-HBs and age, and a negative relationship between the prevalence rate of 'absence of markers' and age. The male sex and urban dwelling were related to higher prevalence rates of HBsAg and anti-HBc alone and to a lower prevalence rate of 'absence of markers'. No relationship was found between geographical zone, father's education and HBV markers. The implications of these results in terms of prevention are discussed.

Serologic survey of human hydatid disease in high risk populations from central Tunisia. Preliminary results

The annual surgical incidence rate of hydatid disease in central Tunisia varies from 11.1 to 30.1 per 100,000 population depending on the district. In order to obtain more comprehensive data, we conducted a serologic survey in the district with the highest rate, using hemagglutination-inhibition to test 480 workers from a state farm and 190 inhabitants of villages in the neighborhood. The overall prevalence rate was 1.3% (9/670). Echotomography revealed liver cysts in all cases and the diagnosis was confirmed in the eight subjects who underwent surgery. If these preliminary results are confirmed by further surveys, mass screening might be considered in high risk districts.

Arterial blood gases and acid-base status in awake rats

Arterial blood gases and acid-base balance were measured in adult rats using a cannula implanted in the aortic arch. These measurements were performed both in awake, unrestrained animals and in animals submitted to various circumstances i.e. (a) different diet: high and low sodium chloride intake, (b) anesthesia by pentobarbital or inactine and, (c) repeated blood sampling with concomitant replacement with the same volume of blood. For each group investigated the [HCO3 -]a vs. PaCO2, [H+] vs. PaCO2, PaCO2 vs. PaO2 relationships were determined. The values obtained (m +/- SD) from awake, unrestrained adult rats were respectively 7.47 +/- 0.02 for arterial pH, 34.5 +/- 3.0 Torr for PaCO2 and 90 +/- 5.5 Torr for PaO2; the calculated [HCO3 -]a concentration was 25.5 +/- 1.5 mmol . 1-1. The present results indicate that plasma bicarbonate concentration, within normal range, highly depends on the prevailing resting level of PaCO2 (n = 202; r = 0.82; P less than 10(-3)). In addition, the PaCO2 versus PaO2 relationship was highly statistically significant (n = 202; r = -0.43; P less than 10(-3). In the other experimental groups of rats, these relationships were virtually the same as above although mean values (+/- SD) for PaCO2, PaO2, pHa and [HCO3 -]a might vary with the group investigated. The mean value for whole pHi, obtained by the DMO method, reached 6.81 for pHa = 7.47 and was not correlated to PaCO2 level in normal conditions. The present data argue for the existence of a respiratory component mediating individual acid-base variations in a normal population of rats. Arterial carbon dioxide partial pressure, by determining bicarbonate ions reabsorption rate, would ensure pH regulation under normal circumstances.

Circulating immune complexes and severe sepsis: duration of infection as the main determinant

The relation between the duration of bacterial infection and circulating immune complexes (CIC) level was evaluated using the C1q binding assay in a group of patients with well defined clinical sepsis. Fifty-four patients with endocarditis and 35 with post-open heart surgery mediastinitis were prospectively studied over a period of 2 years. CIC were detected in 42% of patients studied. Interindividual variations were observed but it was found that the level of CIC increased statistically with time (P less than 0.001). CIC were statistically linked with cryoglobulinemia (P less than 0.001), rheumatoid factor (P less than 0.001) and a decreased CH50 (P less than 0.05). CIC were more frequent in patients with endocarditis (53%) than in patients with mediastinitis (24%). However, when the duration of the infection was taken into account the difference was no longer significant. No relation could be evidenced between the incidence of CIC and clinical symptoms including prognosis and renal signs. In our experience, determination of CIC does not have a critical clinical value.

Significance of intra- and extrahepatic portasystemic shunting in survival of cirrhotic patients

Survival and incidence of hemorrhage and encephalopathy were studied in 121 medically managed cirrhotic patients according to the type of naturally occurring portasystemic shunting. Three types of shunting were distinguishable using scintillation splenoportography, a method whereby morphological and hemodynamic data on portal and hepatic circulation were obtained by external detection. The three patterns were: (1) extrahepatic shunting with partial splenic blood flow diversion, (2) spontaneous total splenic blood flow diversion, and (3) intrahepatic shunting corresponding to portohepatic communications with a diameter larger than 10 mum. The probability of 4-year survival was much lower in case of portasystemic shunting (18%) than in its absence (73%, P less than 0.01). Patients with intrahepatic shunting had a survival rate not significantly different from that of patients with extrahepatic shunting. However, they had the highest incidence of hemorrhage (71%), and hemorrhage was not due to rupture of esophageal varices. The highest incidence of encephalopathy was seen in patients with total splenic blood diversion (40%), but it was not significantly different from that of other cirrhotic patients. No group of patients can be significantly identified as a high-risk group.

Respiratory frequencies of sleeping infants during the first months of life: correlations between values in different sleep states

This study was carried out on 57 normal infants: 22 full-term newborns, examined in the hospital laboratory, and 35 2-18-wk-old infants, examined in two resident nurseries. Polygraphic records, including 1-3 complete sleep cycles, were performed during the morning. The tracings were analyzed by 20-sec epochs. Three to 10% of active sleep states (AS) and 0.8-4% of quiet sleep states (QS) included greater than or equal to 3 sec respiratory pauses. There were minimal, non-significant differences between respiratory frequencies (RF) in total and in no-pause tracings. Our results confirmed that RF was higher in AS in all ages, when compared with QS (P less than 0.02). During the transition (TS) from one to another well-defined sleep state, the respiratory rate showed an intermediate level (AS greater than TS greater than QS): the transition from AS to QS showed progressive slowing of RF, while the transition from QS to AS occurred abruptly, with sudden acceleration of RF. There was a significant slowing of RF during the couse of QS, while the RF in AS was more variable without significant differences between the beginning, the middle and the end of AS state. In this material RF was higher in 2-5-wk and 6-10-wk age groups, compared to newborns and to 11-18-wk-old infants. At all ages, there was a high degree of correlation (P less than 0.01) between RF found in different sleep states for given individuals: some infants breathed more rapidly and other more slowly in all sleep states. A review of the literature showed that the differences between normal RF.

Assessment of Scholander micromethod for gas concentrations versus weighing method

Three gaseous mixtures in N2, of varying concentrations of CO2 (3.60, 5.79, and 9.36%) and O2 (22.18, 15.12, and 6.82%), respectively, were prepared by precise weighings, which may serve as absolute measures. These mixtures were analyzed with two apparatuses by the Scholander micromethod. Taking into account the influence of several factors (apparatuses, order of analyses, etc, it appears that differences between apparatuses were not significant in five of six cases and the effect of order was significant in O2 (P less than 0.01) but not in CO2 for the set of measurements. When compared with weighings, measurements differed only in one apparatus (P less than 0.02) in two of six cases and by no more than 0.02%. The relation between weighings and measurements was highly significant (P less than 10(-9) and no lack of fit to linearity occurs. Side effects of the factors considered and interactions between them are discussed. In conclusion, the micromethod of Scholander gives accurate results, in very good agreement with the reference values provided that certain technical precautions are observed.

Cardiac output measurement with a simplified thermodilution technique. Comparison with the Fick method

A simplified thermodilution technique for cardiac output measurement is compared with the Fick method in dogs, over a wide range of cardiac output values. The reproducibility of the method is satisfactory (differences less than 10 per cent for 95 per cent of the measurements). The overall correlation factor (r = 0.97) is highly significant for cardiac outputs ranging from 750 to 7,500 ml.mn(-1). The influence of hematocrit (when lower than 30%) and of the injection site of indicator are discussed. Present experiments confirm that the use of pre-set factors allow for the thermal loss inside the catheter does not obviate the accuracy of thermodilution method for cardiac output measurements. The slope of the regression line is very close to 1. Lack of fit to linearity is tested and is found not significant throughout the explored range. This technique should therefore have extensive clinical applications.