Use of Tobacco Products, Alcohol, and Other Substances Among High School Students During the COVID-19 Pandemic - Adolescent Behaviors and Experiences Survey, United States, January-June 2021

The COVID-19 pandemic has been associated with established risk factors for adolescent substance use, including social isolation, boredom, grief, trauma, and stress. However, little is known about adolescent substance use patterns during the pandemic. CDC analyzed data from the Adolescent Behaviors and Experiences Survey, an online survey of a probability-based, nationally representative sample of public- and private-school students in grades 9–12 (N = 7,705), to examine the prevalence of current use of tobacco products, alcohol, and other substances among U.S. high school students. Prevalence was examined by demographic characteristics and instructional models of the students’ schools (in-person, virtual, or hybrid). During January–June 2021, 31.6% of high school students reported current use of any tobacco product, alcohol, or marijuana or current misuse of prescription opioids. Current alcohol use (19.5%), electronic vapor product (EVP) use (15.4%), and marijuana use (12.8%) were more prevalent than prescription opioid misuse (4.3%), current cigarette smoking (3.3%), cigar smoking (2.3%), and smokeless tobacco use (1.9%). Approximately one third of students who used EVPs did so daily, and 22.4% of students who drank alcohol did so ≥6 times per month. Approximately one in three students who ever used alcohol or other drugs reported using these substances more during the pandemic. The prevalence of substance use was typically higher among non-Hispanic American Indian or Alaska Native students, older students, and gay, lesbian, or bisexual students than among students of other racial or ethnic groups, younger students, and heterosexual students. The prevalence of alcohol use also was higher among non-Hispanic White students than those of other racial or ethnic groups. Students only attending school virtually had a lower prevalence of using most of the substances examined than did students attending schools with in-person or hybrid models. These findings characterizing youth substance use during the pandemic can help inform public health interventions and messaging to address these health risks during and after the COVID-19 pandemic.

Use of Tobacco Products, Alcohol, and Other Substances Among High School Students During the COVID-19 Pandemic - Adolescent Behaviors and Experiences Survey, United States, January-June 2021

The COVID-19 pandemic has been associated with established risk factors for adolescent substance use, including social isolation, boredom, grief, trauma, and stress. However, little is known about adolescent substance use patterns during the pandemic. CDC analyzed data from the Adolescent Behaviors and Experiences Survey, an online survey of a probability-based, nationally representative sample of public- and private-school students in grades 9-12 (N = 7,705), to examine the prevalence of current use of tobacco products, alcohol, and other substances among U.S. high school students. Prevalence was examined by demographic characteristics and instructional models of the students' schools (in-person, virtual, or hybrid). During January-June 2021, 31.6% of high school students reported current use of any tobacco product, alcohol, or marijuana or current misuse of prescription opioids. Current alcohol use (19.5%), electronic vapor product (EVP) use (15.4%), and marijuana use (12.8%) were more prevalent than prescription opioid misuse (4.3%), current cigarette smoking (3.3%), cigar smoking (2.3%), and smokeless tobacco use (1.9%). Approximately one third of students who used EVPs did so daily, and 22.4% of students who drank alcohol did so ≥6 times per month. Approximately one in three students who ever used alcohol or other drugs reported using these substances more during the pandemic. The prevalence of substance use was typically higher among non-Hispanic American Indian or Alaska Native students, older students, and gay, lesbian, or bisexual students than among students of other racial or ethnic groups, younger students, and heterosexual students. The prevalence of alcohol use also was higher among non-Hispanic White students than those of other racial or ethnic groups. Students only attending school virtually had a lower prevalence of using most of the substances examined than did students attending schools with in-person or hybrid models. These findings characterizing youth substance use during the pandemic can help inform public health interventions and messaging to address these health risks during and after the COVID-19 pandemic.

Perceived Racism and Demographic, Mental Health, and Behavioral Characteristics Among High School Students During the COVID-19 Pandemic - Adolescent Behaviors and Experiences Survey, United States, January-June 2021

Perceived racism in school (i.e., a student’s report of being treated badly or unfairly because of their race or ethnicity) is an important yet understudied determinant of adolescent health and well-being. Knowing how perceived racism influences adolescent health can help reduce health inequities. CDC’s 2021 Adolescent Behaviors and Experiences Survey (ABES), an online survey of a probability-based, nationally representative sample of U.S. public- and private-school students in grades 9–12 (N = 7,705), was conducted during January–June 2021 to assess student behaviors during the COVID-19 pandemic. CDC analyzed data from ABES to measure perceived racism and the extent to which perceptions of racism are associated with demographic, mental health, and behavioral characteristics. Mental health and behavioral characteristics analyzed included mental health status; virtual connection with others outside of school; serious difficulty concentrating, remembering, or making decisions; and feeling close to persons at school. Demographic characteristics analyzed included sex, race and ethnicity, and grade. Prevalence of perceived racism and associations between perceived racism and demographic, mental health, and behavioral characteristics are reported overall and stratified by race and ethnicity. Approximately one third (35.6%) of U.S. high school students reported perceived racism. Perceived racism was highest among Asian (63.9%), Black (55.2%), and multiracial students (54.5%). Students who reported perceived racism had higher prevalences of poor mental health (38.1%); difficulty concentrating, remembering, or making decisions (44.1%); and not feeling close to persons at school (40.7%). Perceived racism was higher among those students who reported poor mental health than those who did not report poor mental health during the pandemic among Asian (67.9% versus 40.5%), Black (62.1% versus 38.5%), Hispanic (45.7% and 22.9%), and White students (24.5% versus 12.7%). A better understanding of how negative health outcomes are associated with student experiences of racism can guide training for staff and students to promote cultural awareness and antiracist and inclusivity interventions, which are critical for promoting safe school environments for all students.

Estimated SARS-CoV-2 Seroprevalence in the US as of September 2020

IMPORTANCE

Case-based surveillance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection likely underestimates the true prevalence of infections. Large-scale seroprevalence surveys can better estimate infection across many geographic regions.

OBJECTIVE

To estimate the prevalence of persons with SARS-CoV-2 antibodies using residual sera from commercial laboratories across the US and assess changes over time.

DESIGN, SETTING, AND PARTICIPANTS

This repeated, cross-sectional study conducted across all 50 states, the District of Columbia, and Puerto Rico used a convenience sample of residual serum specimens provided by persons of all ages that were originally submitted for routine screening or clinical management from 2 private clinical commercial laboratories. Samples were obtained during 4 collection periods: July 27 to August 13, August 10 to August 27, August 24 to September 10, and September 7 to September 24, 2020.

EXPOSURES

Infection with SARS-CoV-2.

MAIN OUTCOMES AND MEASURES

The proportion of persons previously infected with SARS-CoV-2 as measured by the presence of antibodies to SARS-CoV-2 by 1 of 3 chemiluminescent immunoassays. Iterative poststratification was used to adjust seroprevalence estimates to the demographic profile and urbanicity of each jurisdiction. Seroprevalence was estimated by jurisdiction, sex, age group (0-17, 18-49, 50-64, and ≥65 years), and metropolitan/nonmetropolitan status.

RESULTS

Of 177 919 serum samples tested, 103 771 (58.3%) were from women, 26 716 (15.0%) from persons 17 years or younger, 47 513 (26.7%) from persons 65 years or older, and 26 290 (14.8%) from individuals living in nonmetropolitan areas. Jurisdiction-level seroprevalence over 4 collection periods ranged from less than 1% to 23%. In 42 of 49 jurisdictions with sufficient samples to estimate seroprevalence across all periods, fewer than 10% of people had detectable SARS-CoV-2 antibodies. Seroprevalence estimates varied between sexes, across age groups, and between metropolitan/nonmetropolitan areas. Changes from period 1 to 4 were less than 7 percentage points in all jurisdictions and varied across sites.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that as of September 2020, most persons in the US did not have serologic evidence of previous SARS-CoV-2 infection, although prevalence varied widely by jurisdiction. Biweekly nationwide testing of commercial clinical laboratory sera can play an important role in helping track the spread of SARS-CoV-2 in the US.

Neuropeptide Y-like signalling and nutritionally mediated gene expression and behaviour in the honey bee

Previous research has led to the idea that derived traits can arise through the evolution of novel roles for conserved genes. We explored whether neuropeptide Y (NPY)-like signalling, a conserved pathway that regulates food-related behaviour, is involved in a derived, nutritionally-related trait, the division of labour in worker honey bees. Transcripts encoding two NPY-like peptides were expressed in separate populations of brain neurosecretory cells, consistent with endocrine functions. NPY-related genes were upregulated in the brains of older foragers compared with younger bees performing brood care ('nurses'). A subset of these changes can be attributed to nutrition, but neuropeptide F peptide treatments did not influence sugar intake. These results contrast with recent reports of more robust associations between division of labour and the related insulin-signalling pathway and suggest that some elements of molecular pathways associated with feeding behaviour may be more evolutionarily labile than others.

A tool to evaluate rapidly the quality of clinical trials on topical acne treatment

Practicing dermatologists rarely evaluate therapeutic trials. This study was designed to build a simple evaluation tool, use it to evaluate the quality of published trials and thereby consider their applicability. Reports on 146 therapeutic trials, published from 1969 to 2004, were selected. A 50-item list was used for an initial assessment. After comparison with existing grids, a shortened nine-item list was established and used for this analysis. The results were analyzed item by item (logistic regression) and globally (principal component analysis). An index was then established and validated using Cronbach's coefficient alpha. The overall quality of trials was poor: 9% to 73% positive response range. This rate increased after 1990 for six items. Two factors explained almost 60% of the total variance: factor 1 summing six items concerning the formal content of the articles and factor 2 its underlying basis. Using the sum of these six variables, Cronbach's coefficient alpha reached 0.716; their mean sum improved from 1969 to 1970-2001-2005. The significantly improved quality of trials, based on the mean sum over time, supports well-founded basis of this tool. Regarding the application of evidence-based medicine in clinical practice, this tool is user friendly and should facilitate the updating of our knowledge.

[Lithium gluconate 8% in the treatment of seborrheic dermatitis]

Seborrheic dermatitis is a chronic from of inflammatory dermatitis characterized by erythema and desquamation with predominant localization on the face (nasolabial folds, eyebrows, hair-line and ears). It appears to be caused by proliferation of Malassezia yeasts. Lithium gluconate 8% gel (Lithioderm 8% gel) is the only drug containing topical lithium salt commercially available in France for the treatment of seborrheic dermatitis. The mechanism of action of topical lithium is not well known; it may act through anti-inflammatory and antifungal action. Efficacy and safety were assessed in 2 clinical studies, one versus placebo and the other versus ketoconazole 2% foaming gel using the same principal criterion defined as the rate of patients showing complete remission after 2 months of treatment (complete disappearance of both erythema and desquamation). Lithium gluconate 8% was significantly more effective than placebo and than ketoconazole 2% foaming gel and was well tolerated. Adverse events observed were cutaneous (burning sensation, erythema and pruritus), for the most part of mild severity. No cutaneous side effects contributed to those reported with the use of systemic lithium in psychiatric disorders were noted. Pharmacokinetic studies have shown that systemic absorption after topical application is low. Lithioderm 8% gel is applied twice daily over a recommended period of 2 months. It constitutes a new alternative in the treatment of facial seborrheic dermatitis, regardless of severity.

Effect of selenium intake on the prevention of cutaneous epithelial lesions in organ transplant recipients

Organ graft recipients have a high rate of pre-malignant and malignant epithelial lesions. Selenium directly influences the number of Langer-hans cells. In several studies selenium has shown its role in preventing various carcinomas, it was worth investigating whether it could prevent skin cancer linked to human papilloma virus (HPV). A multicentre, randomised, placebo-controlled, parallel group study in 184 recent organ transplant recipients was undertaken. Patients were treated for 3 years with 200 mug/day selenium (91 patients) or a matching placebo (93 patients), and then monitored for 2 years. Occurrence rates of warts and various keratoses (main criterion) and of skin cancers (secondary criterion) were compared in the two groups, using Kaplan-Meyer analyses. There was no difference between the two groups for the main criterion (odds-ratio 1.09, p = 0.72) or the secondary criterion (odds-ratio 3.08; p = 0.15). When both arms were pooled, phenotype and age were not found to be discriminatory factors, whereas a previous history of an actinic keratosis significantly increased the risk of developing a skin cancer by 17.5%. Safety was good and similar in both groups. Selenium was not shown to prevent the occurrence of skin lesions linked to HPV. The occurrence of skin cancer was higher if there had been a previous actinic keratosis, highlighting the importance of early dermatological follow-up of the transplanted population. This was demonstrated by the high rate of epithelial lesions detected, which was more than twice the rate usually reported in the literature.

Efficacité et tolérance de l’imiquimod crème 5 % dans le traitement des condylomes acuminés externes : résultats d’un suivi à 6 mois

INTRODUCTION

One of the main issues raised by the management of external genital warts is their potential risk of recurrence. However, nearly all studies assessing recurrences have been conducted with a 3 month follow-up. Since the latency of the human papillomavirus is long, such 3 month follow-up might be too short to detect the true recurrence rate. We therefore conducted a study evaluating patients with external genital warts, treated with an immune response modifier, 5% imiquimod cream, and followed up to 6 months after total clearance.

METHODS

This was an open, non comparative, multicenter study conducted in 51 private or hospital practices in France. 5% imiquimod cream was applied 3 times per week until the clearance of external genital warts, with a maximum application period of 16 weeks. Patients were followed-up for 6 months after complete clearance.

RESULTS

One hundred ninety-one patients (103 males and 88 females), with a mean age of 31.4 years (18.1-70.4) were included in this study, between November 29 1999 and February 1st 2001. Complete clearance of external genital warts was noted in the ITT analysis in 103/191 cases (54 p. 100; CI95 p. 100: 40-61). Fifteen out of 92 (16 p. 100; CI95 p. 100: 9.4-25.5) had a recurrence within the 6 months follow-up period, 13 of these 15 recurrences were noted at the 3 month follow-up visit.

CONCLUSION

The rate of recurrence of external genital warts at 6 months was similar to the rate noted at 3 months, suggesting that after the 3-month period, the risk of developing a recurrence was low. The mode of action of imiquimod through the induction of cytokines and the stimulation of the local immune response could explain these results.

Prothèse acoustique et bruiteur conjoint pour des sujets hypoacousiques et acouphéniques

INTRODUCTION

Sound therapy has been studied in a group of 30 patients experiencing hearing loss and tinnitus.

MATERIAL AND METHODS

Patients wore a BTE hearing-aid (TCI-COMBI by Siemens), which, in addition to acoustic amplification, can generate a broadband noise. Comparison of self-questionnaires completed by the patients during a 12 week period with amplification alone to a 12 week period with amplification and noise.

RESULTS AND CONCLUSIONS

His study demonstrates that the level of suffering is significantly reduced during the period with added noise.

Lithium gluconate 8% vs ketoconazole 2% in the treatment of seborrhoeic dermatitis: a multicentre, randomized study

BACKGROUND

Lithium significantly improved seborrhoeic dermatitis symptoms in comparison with placebo. Objectives This randomized controlled trial was designed to show a non-inferiority of 15% (primary end-point) of lithium gluconate 8% ointment compared with ketoconazole 2% emulsion.

METHODS

The study population comprised out-patients who had facial seborrhoeic dermatitis for at least 2 months, with moderate to severe erythema and desquamation at inclusion. The primary end-point was complete remission, defined as the disappearance of both erythema and desquamation. The non-inferiority of lithium was assessed on the 95% confidence interval (CI) of the difference between treatments.

RESULTS

The intent-to-treat analysis (ITT) involved 288 patients and the per protocol (PP) analysis 269 patients. Treatment groups were comparable at baseline on age, sex, disease duration and symptoms. For the main criterion, the success rate was 52.0% (lithium) vs. 30.1% (ketoconazole) in the ITT population and 53.2% (lithium) vs. 30.7% (ketoconazole) in the PP population. The non-inferiority of lithium was demonstrated with differences of 21.9% (95% CI 10.0-33.7%) and 22.5% (95% CI 10.2-34.8%), respectively, in the ITT and PP population. As the lower limit of the 95% CI was > 0, the superiority of lithium was shown. Lithium also showed better results on other symptoms: burning and dryness. Adverse events were reported by 26.3% (lithium) and 25% (ketoconazole) of patients.

CONCLUSIONS

Lithium was 22% more effective than ketoconazole in giving complete remission of seborrhoeic dermatitis, with comparable safety.

Multicenter randomized comparative double-blind controlled clinical trial of the safety and efficacy of zinc gluconate versus minocycline hydrochloride in the treatment of inflammatory acne vulgaris

BACKGROUND

In addition to tetracyclines, zinc may constitute an alternative treatment in inflammatory lesions of acne.

OBJECTIVE

To evaluate the place of zinc gluconate in relation to antibiotics in the treatment of acne vulgaris.

METHODS

Zinc was compared to minocycline in a multicenter randomized double-blind trial. 332 patients received either 30 mg elemental zinc or 100 mg minocycline over 3 months. The primary endpoint was defined as the percentage of the clinical success rate on day 90 (i.e. more than 2/3 decrease in inflammatory lesions, i.e. papules and pustules).

RESULTS

This clinical success rate was 31.2% for zinc and 63.4% for minocycline. Minocycline nevertheless showed a 9% superiority in action at 1 month and one of 17% at 3 months, with respect to the mean change in lesion count. Regarding safety, the majority of the adverse effects of zinc gluconate and of minocycline concerned the gastrointestinal system and were moderate (5 dropouts with zinc gluconate and 4 with minocycline).

CONCLUSION

Minocycline and zinc gluconate are both effective in the treatment of inflammatory acne, but minocycline has a superior effect evaluated to be 17% in our study.

Erythromycin-resistance of cutaneous bacterial flora in acne

Some studies have raised the problem of an increase of bacterial resistance in acne patients. This study was carried out in France, where no previous studies about resistance to erythromycin has been performed, on 40 patients with mild to moderately severe acne. Microbiological samples were obtained by using Williamson and Kligman method. This study showed that the prevalence of bacterial resistance to erythromycin was 95% for Staphylococcus epidermidis strains and 52% for Propionibacterium acnes strains. Resistant strains were more frequent in patients with predominantly inflammatory lesions (papules and pustules). The influence of previous or current treatment with erythromycin was also studied and showed that even patients without any previous use of erythromycin had resistant strains for Propionibacterium acnes (42%). In addition the minimum inhibitory concentrations (MIC) for zinc were evaluated. All the Propionibacterium acnes strains tested were inhibited at concentrations less or equal to 512 mug/ml of zinc. However, zinc combined with erythromycin in vitro did not modify the erythromycin MIC. This first French study on bacterial resistance to erythromycin in acne patients confirms the results of studies performed in other countries.

Differential effects of nifedipine and co-amilozide on the progression of early carotid wall changes

BACKGROUND

Common carotid artery intima-media thickness (IMT) progression was compared between 4 years of treatment with nifedipine and diuretic.

METHODS AND RESULTS

This study, ancillary to the International Nifedipine GITS Study: Intervention as a Goal in Hypertension Treatment (INSIGHT), involved nifedipine 30 mg or co-amilozide (hydrochlorothiazide 25 mg and amiloride 2.5 mg) with optional subsequent titration. Among 439 randomized hypertensive patients, 324 had >/=1 year of follow-up (intent-to-treat group), and 242 completed follow-up (until-end-of-study group). Ultrasonography was performed at baseline, 4 months later, and then every year. Central computerized reading provided far-wall IMT, diameter, and cross-sectional area IMT (CSA-IMT). The primary outcome was IMT progression rate (slope of IMT-time regression). Secondary outcomes were changes from baseline (Delta) in IMT, diameter, and CSA-IMT. In the until-end-of-study population, between-treatment differences existed in IMT progression rate (P=0.002), Delta IMT (P=0.001), and Delta CSA-IMT (P=0.006), because IMT progressed on co-amilozide but not on nifedipine. In the intent-to-treat population, treatment differences existed in Delta IMT (P=0.004) and Delta CSA-IMT (P=0.04) but not in IMT progression rate (P=0.09). Patients with >/=2, 3, or 4 years of follow-up showed treatment differences in IMT progression rate (P=0.04, 0.004, 0.007, respectively), Delta IMT (P=0.005, 0.001, 0.005), and Delta CSA-IMT (P=0.025, 0.013, 0.015). Diameter decreased more on co-amilozide than on nifedipine in the intent-to-treat population (P<0.05), whereas blood pressure decreased similarly on both treatments.

CONCLUSIONS

A difference in early carotid wall changes is shown between 2 equally effective antihypertensive treatments.

Prognostic value of MIBG imaging in idiopathic dilated cardiomyopathy

Alterations of cardiac sympathetic innervation are likely to contribute to fatal outcomes in patients with heart failure. These alterations can be evaluated noninvasively by 123I-metaiodoben-zylguanidine (MIBG) imaging.

METHODS

The hypothesis that impaired cardiac sympathetic innervation, as assessed using MIBG imaging, is related to adverse outcomes was tested in 112 patients with heart failure resulting from idiopathic cardiomyopathy. Main inclusion criteria were New York Heart Association classes II-IV and radionuclide left ventricular ejection fraction (LVEF) < 40%. Patients were assessed for cardiac MIBG uptake, circulating norepinephrine concentration, LVEF, peak Vo2, x-ray cardiothoracic ratio, M-mode echographic end-diastolic diameter and right-sided heart catheterization parameters.

RESULTS

During a mean follow-up of 27 +/- 20 mo, 19 patients had transplants, 25 died of cardiac death (8 sudden deaths), 2 died of noncardiac death and 66 survived without transplantation. The only independent predictors for mortality were low MIBG uptake (P < 0.001) and LVEF (P = 0.02) when using multivariate discriminant analysis. Moreover, MIBG uptake (P < 0.001) and circulating norepinephrine concentration (P = 0.001) were the only independent predictors for life duration when using multivariate life table analysis.

CONCLUSION

Impaired cardiac adrenergic innervation as assessed by MIBG imaging is strongly related to mortality. MIBG imaging may help risk stratify patients with heart failure resulting from idiopathic dilated cardiomyopathy.

[Per os desensitization in nickel contact eczema: a double-blind placebo-controlled clinico-biological study]

BACKGROUND

Ingestion of nickel (Ni) has been demonstrated to induce a specific state of tolerance in the guinea pig and mouse. In a pilot study conducted in 10 patients, we demonstrated that per os administration of Ni leads to reduced proliferation of specific lymphocytes and a lower number of responding lymphocytes in blood. The aim of this study was to evaluate the clinical and biological changes induced by the ingestion of Ni in a double-blinded placebo-controlled study.

PATIENTS AND METHODS

Patients with nickel contact hypersensitivity were given a capsule of nickel sulfate containing 5 mg Ni (group A) or an identical placebo (group B) once a week for 7 weeks. Clinical criteria were assessed 49 days after study onset: objective measurement of lesion extent and intensity and quantitative patch tests at concentrations 2.4-0.8-0.2 and 0.05 p. 100. Likewise stimulation of specific lymphocyte proliferation and the number of circulating lymphocytes responding to Ni at limit dilutions were determined.

RESULTS

Thirty patients with nickel contact eczema were included in the study, 28 women and 2 men. There was no statistical difference between the two groups for the intensity of skin lesions or their clinical course, quantitative patch tests and lymphocyte stimulation tests. Conversely, the number of circulating lymphocytes responding to Ni was significantly lower in group A than in group B at study end (p < 0.05).

DISCUSSION

This double-blind placebo-controlled study confirmed that per os nickel can induce a significant reduction in the number of circulating lymphocytes responding to Ni. No other effect could be demonstrated for the clinical and biological parameters studied. These preliminary results should prompt a multicentric controlled trial including a larger number of patients with more severe lesions at inclusion and with a longer treatment duration.

[Treatment of adjustment disorder with anxiety: efficacy and tolerance of etifoxine in a double-blind controlled study]

Adjustment disorder with anxiety is defined as a clinically significant anxiety that occurs within 3 months after the onset of an identifiable psychological stressor. Recent studies indicate that this disorder is not uncommon and must be quickly identified and treated. However, few therapeutic trials have been done in relation with this disorder. According to the criteria set by DSM IV, 170 patients with a primary diagnosis of adjustment disorder with anxiety have been enrolled in a double blind multicenter controlled trial. Patients were treated for 4 weeks with etifoxine (150-200 mg/d), or buspirone (15-20 mg/d). Also both etifoxine and buspirone show clinical efficacy and safety, the two treatments are not equivalent. The global improvement score and the efficacy index are significantly improved in the etifoxine group. These results show the interest of using etifoxine in the treatment of adjustment disorder with anxiety and should be confirmed by further studies.

Saccharomyces boulardii prevents diarrhea in critically ill tube-fed patients. A multicenter, randomized, double-blind placebo-controlled trial

OBJECTIVE

To assess the preventive effect of Saccharomyces boulardii on diarrhea in critically ill tube-fed patients and to evaluate risk factors for diarrhea.

DESIGN

Prospective, multicenter, randomized, double-blind placebo-controlled study.

SETTING

Eleven intensive care units in teaching and general hospitals.

PATIENTS

Critically ill patients whose need for enteral nutrition was expected to exceed 6 days.

INTERVENTION

S. boulardii 500 mg four times a day versus placebo.

MEASUREMENTS AND RESULTS

Diarrhea was defined by a semiquantitative score based on the volume and consistency of stools. A total of 128 patients were studied, 64 in each group. Treatment with S. boulardii reduced the mean percentage of days with diarrhea per feeding days from 18.9 to 14.2% [odds ratio (OR) = 0.67, 95% confidence interval (CI) = 0.50-0.90, P = 0.0069]. In the control group, nine risk factors were significantly associated with diarrhea: nonsterile administration of nutrients in open containers, previous suspension of oral feeding, malnutrition, hypoalbuminemia, sepsis syndrome, multiple organ failure, presence of an infection site, fever or hypothermia, and use of antibiotics. Five independent factors were associated with diarrhea in a multivariate analysis: fever or hypothermia, malnutrition, hypoalbuminemia, previous suspension of oral feeding, and presence of an infection site. After adjustment for these factors, the preventive effect of S. boulardii on diarrhea was even more significant (OR = 0.61, 95% CI = 0.44-0.84, P < 0.0023).

CONCLUSIONS

S. boulardii prevents diarrhea in critically ill tube-fed patients, especially in patients with risk factors for diarrhea.

Prognostic value of cardiac metaiodobenzylguanidine imaging in patients with heart failure

The prognostic value of 123I-metaiodobenzylguanidine (MIBG) imaging was compared with that of other noninvasive cardiac imaging indices in ninety patients (mean age = 52 +/- 7 yr) suffering from either ischemic (n = 24) or idiopathic (n = 66) cardiomyopathy. Patients had different measurements taken: cardiac MIBG uptake, radionuclide left ventricular ejection fraction, x-ray cardiothoracic ratio and echographic M-Mode data. Cardiac MIBG uptake was assessed as the heart-to-mediastinum activity ratio measured on the chest anterior view image obtained 4 hr after intravenous injection. The patients then had follow-up for 1-27 mo, at which time 10 patients had transplants, 22 had died and 58 were still alive. Data from patients with transplants were not used in the analysis, in which multivariate stepwise regression discriminant analysis showed that cardiac MIBG uptake was more potent to predict survival than other indices: H/M (p less than 0.0001), x-ray cardiothoracic ratio (p = 0.0017), echographic end-diastolic diameter (p = 0.0264) and radionuclide left ventricular ejection fraction (p = 0.0301). Moreover, multivariate life table analysis showed that cardiac MIBG uptake was also the best predictor for life duration: H/M (p = 0.0001), radionuclide left ventricular ejection fraction (p = 0.0098) and x-ray cardiothoracic ratio (p = 0.0139); echographic data were not useful. Thus, cardiac MIBG imaging may be helpful for heart transplantation decision making in patients with heart failure.

Prolonged duration of blood pressure response to enalkiren, the novel dipeptide renin inhibitor, in essential hypertension

The effects of sustained renin inhibition by repeated administration of enalkiren (A-64662), the novel dipeptide renin inhibitor, were evaluated in a randomized, double-blind, placebo-controlled, parallel-group study of 32 inpatients (eight per group) with essential hypertension who were maintained on a diet containing 60 meq/day sodium. Three different dosage regimens of enalkiren were studied: 1) 1.2 mg/kg quotid., 2) 0.3 mg/kg q.i.d., and 3) 0.1 mg/kg q.i.d. Each patient received an intravenous infusion every 6 hours for 1 week. Placebo infusions were used to mimic the 4 times/day dosing schedule. Blood pressure was measured periodically via 24-hour automated monitoring equipment. Mean plasma renin activity in the patient groups ranged from 1.58 to 2.68 ng angiotensin I/ml/hr. Plasma renin activity was promptly suppressed in all groups receiving enalkiren. Prolonged duration of plasma renin activity suppression (greater than or equal to 24 hours) was demonstrated after the administration of 1.2 mg/kg enalkiren. The 0.3 mg/kg q.i.d. and 1.2 mg/kg quotid. regimens produced statistically significant reductions (p less than or equal to 0.05) in systolic and diastolic blood pressures with clear evidence of persistent antihypertensive activity for 12 hours or more when compared with the placebo group. Despite relatively large reductions in mean systolic and diastolic blood pressure, mean pulse rates were essentially unchanged. The prolonged reduction in blood pressure with enalkiren without evidence of tachyphylaxis after 1 week of treatment suggests that renin inhibitors may emerge as useful therapeutic agents for the treatment of hypertension.

Effect of xamoterol on haemodynamics and plasma catecholamines in chronic heart failure

The effects of xamoterol on haemodynamics and plasma catecholamines were studied at rest and after exercise in patients with mild to moderate heart failure, using a symptom-limited exercise test. Exercise duration and myocardial efficiency were significantly increased, and heart rate on maximal exercise was reduced despite increased catecholamine levels.

[Determination of variability factors of arterial pressure using 3843 self-measurements of blood pressure in 34 active hypertensives]

To assess the role of physical activity, stress and treatment on BP variations in working hypertensives we used repeated self measurements of BP which are cheaper and more simple than ambulatory BP measurements but allow for a smaller number of measurements. 34 working hypertensives self measured daily life BP, at home and at workplace, 7 times a day, for at least one week, before and 6 weeks after beta-blockade with metoprolol 200 to 400 mg daily. They used a Spengler SP9 electronic sphygmometer and specified on 4 grades scales their physical activity and stress just before measurement. The time for self measurement of BP was settled according to occupations more than to clocktime. The equipment was standardized at each visit by measuring BP with a mercury manometer then with the electronic sphygmometer. There were no significant differences neither for SBP nor for DBP and the two measures correlate closely (r = 0.91), P = 0.0001). Analysis of variance on SBP exhibits the role of time (p (0.001) and stress (p (0.0001). Physical activity does not interfere (p = 0.19). There is no difference between work days and sundays (p = 0.17). Treatment effect was very strong (p (0.0001) but there was no interaction neither with physical activity nor stress. Analysis of variance on DBP exhibits similar results except that BP on workdays is significantly higher than on sundays (p = 0.03). We conclude that: Repeated self measurement of BP is able to display variation of BP with occupations and stress. Beta-blockade lowers BP but does not interfere with variability.

Accuracy of gated equilibrium radioventriculography in measuring left ventricular function in dogs

To assess the precision of gated equilibrium radioventriculography in measuring changes in left ventricular stroke volume (LVSV), we studied five dogs each with a chronically implanted electromagnetic flowmeter on the ascending aorta. Per cent changes in left ventricular stroke counts (LVSC) were compared to those in LVSV following acute changes induced by positive end respiratory pressure. We have compared LVSCs calculated in five different ways: (1) Manual outlining of LV region of interest (LVROI), either single fixed enddiastolic (ED) ROI or ED and endsystolic (ES) ROIs with the aid of functional images (first harmonic of Fourier analysis); (2-5) automatic outlining of LV ROI (the algorithm generated 30 profiles on which the maximum of second derivative delineated the LV edges) was performed either on ED image or both ED and ES images. For these four methods a crescent-shaped ROI for background correction was manually drawn at the border of the LV ROI. The fifth method used an automatically drawn single fixed LVED ROI with interpolative background substraction (IBS) between LV and RV edges. LVSC changes, calculated with the IBS method correlated better with LVSV changes than the other four methods. Thus assessment of small LVSC changes is highly processing-dependent.

Peripheral hemodynamic effects of short-term nadolol administration in essential hypertension

A study of forearm arterial and venous hemodynamics by pulsed Doppler velocimetry and plethysmography was performed in 21 patients with essential hypertension, aged 16 to 54 years, before and after short-term nadolol administration at a dose of 0.05 mg/kg. Because of a large intersubject variability in the responses of the hemodynamic parameters to nadolol, an unconventional statistic approach was used to divide the overall population of patients into two homogeneous groups. The first included nine patients (group 1) and the second 12 patients (group 2). In patients of group 1, nadolol significantly decreased the systolic blood pressure (p less than 0.001), venous tone (p less than 0.01), and brachial artery flow (p less than 0.05). In patients of group 2, nadolol did not affect any forearm parameters. Each group of patients was compared to an age- and pressure-matched group of patients receiving propranolol at equiblocking doses. Contrary to nadolol, propranolol was found to increase significantly the forearm vascular resistance in patients of groups 1 and 2 (90 +/- 19%, p less than 0.001; 63 +/- 10%, p less than 0.001, respectively). Thus the hemodynamic beta-blocking effects of nadolol in the forearm were less marked than those of propranolol, suggesting that the effects of acute beta blockade by nadolol could be offset by other effects, such as a peripheral partial-agonist effect.

Effects of intravenous diltiazem on sinus node function and atrioventricular conduction in patients

We studied the electrophysiologic effects of injectable diltiazem (dosage: bolus of 0.15 mg/kg, maintenance infusion of 0.3 mg/kg/h for 20 min) on sinus node function and atrioventricular function in 33 patients (22 men and 11 women, mean age 63.6 +/- 15.8 years). Seventeen patients had an electrophysiological exploration considered as normal, eight had sinus node dysfunction (corrected sinus recovery time greater than 525 ms), and eight had AV nodal block (PH greater than 160 ms and/or a Wenckebach point less than 125/min). Effects of the drug were assessed 20 min after the beginning of the infusion, which was continued until the end of examination. In normal subjects diltiazem lengthened corrected sinus node recovery time (305 +/- 115 ms leads to 451 +/- 283 ms) and slightly depressed AV nodal conduction (Wenckebach point: 163 +/- 23 leads to 147 +/- 25). In patients with sinus node dysfunction diltiazem provoked a bradycardia without significant changes in corrected sinus node recovery time or in estimated atrio-sino-atrial conduction time. In patients with AV nodal block diltiazem provoked a lowering of the Wenckebach point (137 +/- 47 leads to 122 +/- 38). There was no effect on hissian or infrahissian conduction, even when this was abnormal in the basal state. These data suggest that diltiazem must be utilized with caution in patients with sinus node dysfunction and AV nodal block.