Improved adherence to statins following pictorial intervention. Sub study of visualization of subclinical atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA)

Introduction

VIPVIZA is a prospective, randomised controlled trial with open label and masked evaluators, integrated in Västerbotten intervention programme (VIP), a population-based CVD screening and prevention programme examining 40,50,60-year-olds. In VIPVIZA subclinical atherosclerosis was identified by ultrasound and pictorial information about carotid plaque presence, carotid thickness and risk assessment was provided to participants and their physicians. After examination, participants were randomized to pictorial information (intervention) or as usual care (control). Previous studies from VIPVIZA have shown that the time to initiation of statins is lower and the proportion of statin users is higher in the intervention group.

Purpose

To study whether the pictorial risk information intervention made participants with pre intervention prescription of statins more adherent to statin treatment.

Method

During 2013–2016, 3532 participants in VIPVIZA were screened by carotid ultrasound examination, of which 46% had plaque, 546 had expedited prescriptions of statins (ATC codes: C10AAxx, C10B, C10BA, C10BX) prior to inclusion. Participants were followed from inclusion until 3-year follow-up examination. Adherence calculations were based on Swedish prescription drug registry (PDR).

For adherence calculations we assumed that medication is used as prescribed. Dose change of same medication is considered, and number of days' supply is recalculated if a dispensing event contains a change of dose. The new dose comes into effect the day of dispensing a prescription with a dose change. For the follow-up period the number of days with potential use (based on supply) is divided by days from baseline examination until 3-year examination, yielding a value in the interval [0,1] where 0 is non adherent and 1 perfect adherence. Remaining supply of medication at the end of follow-up period is disregarded. Adherence was also dichotomised at 0.8.

Results

The average adherence to statins was higher in the intervention group for participants with carotid plaque, 0.844 vs 0.773, confidence interval 95% for mean difference (−0.125, −0.018), p=0.009. The intervention group with carotid plaque had the best adherence of all subgroups, but the difference in adherence within the intervention group (plaque vs no plaque) was non-significant. With respect to sex the difference in mean adherence between intervention and control for males was 0.826–0.795 while for females 0.815–0.742. With dichotomised adherence the increase in the intervention group is significant for females, p=0.027. See table 1.

Conclusion

Providing information about subclinical atherosclerosis increases adherence to statins, especially in participants with plaque and females.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swedish Research Council

Is the Effect of a High-Intensity Functional Exercise Program on Functional Balance Influenced by Applicability and Motivation among Older People with Dementia in Nursing Homes?

BACKGROUND AND OBJECTIVES

Exercise can be an important way of maintaining balance function in people with dementia, but further investigation is needed to determine the optimal way of exercising. The objective was to evaluate whether exercise applicability (i.e., attendance, exercise intensity, and adverse events) and motivation were associated with the effect on functional balance of a high-intensity functional exercise program for older people with dementia in nursing homes.

DESIGN, SETTING AND PARTICIPANTS

Exercise intervention participants (n = 81; 60 women, 21 men) from a randomized controlled trial (UMDEX) were included. Their mean age was 84 and mean Mini-Mental State Examination score was 15.

INTERVENTION

Groups of 3-8 participants participated in the High-Intensity Functional Exercise (HIFE) Program, with 5 sessions per 2-week period, for 4 months (total, 40 sessions).

MEASUREMENTS

Outcome was the Berg Balance Scale (BBS), assessed at baseline and follow up, and the score difference, dichotomized to classify participants into two groups: responders (≥5-point increase) and non-responders (<5-point increase). Target variables were measures of applicability and motivation. Associations between each target variable and the outcome were analyzed using multivariable logistic regression. Baseline characteristics and new medical conditions developing during the intervention period were compared between responders and non-responders and included in the analyses when p < 0.10.

RESULTS

The BBS score was 28.6 ± 14.3 at baseline and 31.2 ± 15.3 at follow up, with the difference between follow-up and baseline scores ranging from -35 to 24. Twenty-nine (35.8%) participants were responders. The multivariable models showed no significant association between responders vs. non-responders and any target variable.

CONCLUSION

Participation in a 4-month high-intensity functional exercise program can improve balance in many individuals with dementia in nursing homes, despite the progressiveness of dementia disorders and several co-existing medical conditions. Predicting balance exercise response based on applicability and motivation seem not to be possible, which lends no support for excluding this group from functional exercise, even when exercise intensity or motivation is not high.

Patient-reported rates of chronic pain and recurrence after groin hernia repair

Background

The effectiveness of different procedures in routine surgical practice for hernia repair with respect to chronic postoperative pain and reoperation rates is not clear.

Methods

This was prospective cohort study based on a unique combination of patient-reported outcomes and national registry data. Virtually all patients with a groin hernia repair in Sweden between September 2012 and April 2015 were sent a questionnaire 1 year after surgery. Persistent pain, defined as at least ‘pain present, cannot be ignored, and interferes with concentration on everyday activities’ in the past week was the primary outcome. Reoperation for recurrence recorded in the register was the secondary outcome.

Results

In total, 22 917 patients (response rate 75·5 per cent) who had an elective unilateral groin hernia repair were analysed. Persistent pain present 1 year after hernia repair was reported by 15·2 per cent of patients. The risk was least for endoscopic total extraperitoneal (TEP) repair (adjusted odds ratio (OR) 0·84, 95 per cent c.i. 0·74 to 0·96), compared with open anterior mesh repair. TEP repair had an increased risk of reoperation for recurrence (adjusted OR 2·14, 1·52 to 2·98), as did open preperitoneal mesh repair (adjusted OR 2·34, 1·42 to 3·71) at 2·5-year follow-up. No other methods of repair differed significantly from open anterior mesh repair.

Conclusion

The risk of significant pain 1 year after groin hernia repair in routine surgical practice was 15·2 per cent. This figure was lower in patients who had surgery by an endoscopic technique, but at the price of a significantly higher risk of reoperation for recurrence.

Risk factors for injuries associated with damage claims following groin hernia repair

PURPOSE

Surgical repair of groin hernia should be carried out with minimal complication rates, and it is important to have regular quality control and accurate means of assessment. The Swedish healthcare system has a mutual insurance company (LÖF) that receives claims from patients who have suffered healthcare-related damage or malpractice. The Swedish Hernia Register (SHR) currently covers around 98% of all Swedish groin hernia operations. The aim of this study was to analyse damage claims following groin hernia repair surgery and link these with entries in the SHR, in order to identify risk factors and causes of injuries and malpractice associated with hernia repair.

METHODS

Data on all 48,574 groin hernia operations registered in the SHR between 2008 and 2010 were compared and linked with data on claims made to the Swedish National Patient Injury Insurance (LÖF).

RESULTS

Of the 130 damage claims received by LÖF, 26 dealt with bleeding, 20 with testicular injury and 7 with intestinal lesions. Eighty (62%) of the complications were considered malpractice according to the Swedish Patient Injury Act. Acute and recurrent surgery, sutured repair and general anaesthesia were associated with a significantly increased risk for a damage claim independently the patients were compensated or not. Females filed claims in greater proportion than males. There was no significant difference in background factors between claims accepted by LÖF and compensated and those who were rejected compensation.

CONCLUSION

Risk factors for filing a damage claim included acute surgery, operation for recurrence, sutured repair and general anaesthesia, whereas local anaesthesia reduced the risk.

Location of recurrent groin hernias at TEP after Lichtenstein repair: a study based on the Swedish Hernia Register

PURPOSE

To investigate which type of hernia that has the highest risk of a recurrence after a primary Lichtenstein repair.

METHODS

Male patients operated on with a Lichtenstein repair for a primary direct or indirect inguinal hernia and with a TEP for a later recurrence, with both operations recorded in the Swedish Hernia Register (SHR), were included in the study. The study period was 1994-2014.

RESULTS

Under the study period, 130,037 male patients with a primary indirect or direct inguinal hernia were operated on with a Lichtenstein repair. A second operation in the SHR was registered in 2236 of these patients (reoperation rate 1.7 %). TEP was the chosen operation in 737 in this latter cohort. The most likely location for a recurrence was the same as the primary location. If the recurrences change location from the primary place, we recognized that direct hernias had a RR of 1.51 to having a recurrent indirect hernia compared to having a direct recurrence after an indirect primary hernia repair.

CONCLUSIONS

Recurrent hernias after Lichtenstein are more common on the same location as the primary one, compared to changing the location.

Risk factors for hip fracture in very old people: a population-based study

SUMMARY

Knowledge of risk factors for hip fracture among very old people is limited. Walking indoors with help from ≤1 person, Parkinson's disease, currently smoking, delirium in the previous month, underweight, and age were associated with increased risk of hip fracture and could be important for preventive strategy development.

INTRODUCTION

The purpose of this study is to investigate risk factors for hip fracture among a representative sample of very old people.

METHODS

In total, 953 participants from the Umeå 85+/Gerontological Regional Database population-based cohort study were interviewed and assessed during home visits. Associations of baseline characteristics with hip fracture during the maximum 5-year follow-up period were analyzed using Cox proportional hazards regression.

RESULTS

Participants had a mean age of 89.3 ± 4.7 years; 65.8% were women, 36.8% lived in residential care facilities, 33.6% had dementia, and 20.4% had histories of hip fracture. During a mean follow-up period of 2.7 years, 96 (10.1%) individuals sustained hip fracture. Walking indoors with help from no more than one person (hazard ratio [HR] = 8.57; 95% confidence interval [CI], 1.90-38.71), Parkinson's disease (HR = 5.12; 95% CI, 1.82-14.44), currently smoking (HR = 4.38; 95% CI 2.06-9.33), delirium in the previous month (HR = 2.01; 95% CI, 1.15-3.49), underweight (body mass index <22; HR = 1.74, 95% CI, 1.09-2.77), and age (HR = 1.09; 95% CI, 1.04-1.14) were associated independently with an increased risk of hip fracture. Hip prosthesis at baseline decreased the risk of hip fracture (HR = 0.37; 95% CI, 0.15-0.91), but only for those with bilateral hip prostheses.

CONCLUSIONS

Seven factors were associated independently with incident hip fracture during follow-up in this sample of very old people. These factors could have important clinical implications in identifying persons at high risk of hip fracture, as well as in the development of effective preventive strategies.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Usefulness of real-time PCR for lytA, ply, and Spn9802 on plasma samples for the diagnosis of pneumococcal pneumonia

In the present study, we evaluated rapid real-time PCR assays for ply, Spn9802, and lytA applied to plasma samples for the detection of Streptococcus pneumoniae in patients with community-acquired pneumonia (CAP). In a prospective study of CAP aetiology, an EDTA plasma sample was collected together with blood culture in 92 adult CAP patients and 91 adult controls. Among the 92 CAP patients, lytA PCR was positive in eight (9%), Spn9802 PCR was positive in 11 (12%) and ply PCR was positive in 19 (21%) cases. Of 91 controls, the ply PCR was positive in eight cases (9%), but no positive cases were noted by Spn9802 or lytA PCRs. Ten CAP patients had pneumococcal bacteraemia. Compared to blood culture, PCR for lytA, Spn9802 and ply had sensitivities of 70% (7/10), 60% (6/10) and 70% (7/10), and specificities of 96% (79/82), 94% (77/82) and 85% (70/82) respectively. With blood culture and/or culture of representative sputum, and/or urinary antigen detection, S. pneumoniae was identified in 31 CAP patients. Compared to these tests in combination, PCR for lytA, Spn9802 and ply showed sensitivities of 26% (8/31), 32% (10/31) and 42% (13/31), and specificities of 100% (61/61), 98% (60/61) and 90% (55/61) respectively. We conclude that Spn9802 and lytA PCRs may be useful for the rapid detection of bacteraemic pneumococcal pneumonia, whereas ply PCR is not specific enough for routine use and blood PCR with small plasma volumes is not useful for the detection of nonbacteraemic pneumococcal pneumonia.

Antibody response to insulin in children and adolescents with newly diagnosed Type 1 diabetes

AIMS

To compare levels of insulin antibodies in children and adolescents after initiation of insulin therapy using either insulin aspart (IAsp) or human insulin (HI) in combination with Neutral Protamine Hagedorn (NPH) insulin, and to investigate the relationships between insulin antibodies and HbA(1c) and insulin dose.

METHODS

IAsp-specific antibodies (IAsp-Ab) and antibodies cross-reacting with HI and IAsp (HI-cross-Ab) were analysed by radioimmunoassay at diagnosis of diabetes and every 3-6 months for 30 months. Seventy-two patients (HI = 30, IAsp = 42) with Type 1 diabetes, aged 2-17 years were included. Data on HbA(1c), insulin dose and serious adverse events (SAEs) were collected retrospectively.

RESULTS

IAsp-Ab levels remained low throughout the study. After 9 months, the level of HI-cross-Ab increased [mean (SD) HI, 48.8% (21.53); IAsp, 40.2% (17.92)] and remained elevated. Repeated measurement analysis of HI-cross-Ab levels showed no significant difference between treatments (P = 0.16). HI-cross-Ab were significantly associated with total insulin dose (U/kg) (P = 0.001) and time (P < 0.0001), but not with HbA(1c) (P = 0.24). Mean (+/- SD) HbA(1c) was similar at diagnosis (HI 9.5 +/- 1.97%; IAsp 9.6 +/- 1.62%); HbA(1c) then decreased and stabilized to about 6.0% in both groups. Few SAEs were reported, the majority being hypoglycaemic episodes.

CONCLUSIONS

Treatment with IAsp and with HI was associated with an increase in HI-cross-Ab in insulin-naive children, but this did not influence treatment efficacy or safety. These results support the safe use of IAsp in children and adolescents with Type 1 diabetes.

Classification of motor commands using a modified self-organising feature map

In this paper, a control system for an advanced prosthesis is proposed and has been investigated in two different biological systems: (1) the spinal withdrawal reflex system of a rat and (2) voluntary movements in two human males: one normal subject and one subject with a traumatic hand amputation. The small-animal system was used as a model system to test different processing methods for the prosthetic control system. The best methods were then validated in the human set-up. The recorded EMGs were classified using different ANN algorithms, and it was found that a modified self-organising feature map (SOFM) composed of a combination of a Kohonen network and the conscience mechanism algorithm (KNC) was superior in performance to the reference networks (e.g. multi-layer perceptrons) as regards training time, low memory consumption, and simplicity in finding optimal training parameters and architecture. The KNC network classified both experimental set-ups with high accuracy, including five movements for the animal set-up and seven for the human set-up.

Microbiological etiology in clinically diagnosed community-acquired pneumonia in primary care in Orebro, Sweden

OBJECTIVE

To study the etiology of clinically diagnosed community-acquired pneumonia (CAP) in antibiotically naive patients attending a primary care center and treated at their homes.

METHODS

A three-year prospective study was carried out, and 177 patients presenting with clinical signs of CAP were included. All patients had chest X-rays after inclusion, and 82 (46%) showed infiltrates. Nasopharyngeal swab culture was performed on all patients, and 51% produced a representative sputum sample. Paired sera were obtained from 176 patients.

RESULTS

Among the 82 patients with radiographically proven CAP, Streptococcus pneumoniae was detected in 26 patients (32%), Haemophilus influenzae in 23 (28%), Mycoplasma pneumoniae in 15 (18%), and Chlamydia pneumoniae in four (5%). Serologic evidence of a viral infection was found in 13 patients (16%). Among the 95 patients without infiltrates, S. pneumoniae was found in 21 (22%), H. influenzae in 14 (15%), M. pneumoniae in two (2%), and C. pneumoniae in five (5%). Viral infection was detected in 19 (20%) of these 95 patients.

CONCLUSION

In primary care in Sweden, the initial antibiotic treatment in any patient with pneumonia should be effective against S. pneumonia and H. influenzae. In addition, M. pneumoniae should be targeted during recurrent epidemics. C. pneumoniae, and especially Legionella, seem to be uncommon in primary care.

Clinical significance of nested polymerase chain reaction and immunofluorescence for detection of Pneumocystis carinii pneumonia

OBJECTIVE

To study the clinical significance of a nested polymerase chain reaction (PCR) method compared to immunofluorescence (IF) for detection of Pneumocystis carinii.

METHODS

The medical records of 89 patients with 91 episodes of pneumonia were scrutinised retrospectively. The pneumonia episodes were divided into categories according to the likelihood that the patient had had clinical Pneumocystis carinii pneumonia (PCP). All respiratory tract samples from the 89 patients (34 broncho-alveolar lavage (BAL) and 57 sputa) were tested for Pneumocystis carinii by IF and nested PCR.

RESULTS

Fifteen episodes, as diagnosed by IF, were classified as true PCP (combination of the groups with definite and probable PCP; sensitivity 60%, specificity 97%). Among the P. carinii DNA-positive episodes, detected with nested PCR, 24 were classified as true PCP (combination of the groups with definite and probable PCP; sensitivity 96%, specificity 59%), since all IF-positive samples were nested PCR positive. Only one pneumonia episode classified as a probable PCP, was negative with both methods, as applied to a BAL sample.

CONCLUSIONS

IF applied to BAL or sputum seems to be the most specific method for diagnosis of clinical PCP. Additional clinical cases can be found by nested PCR, although this then gives a high risk of detecting subclinical colonisation of P. carinii.

Functional connections are established in the deafferented rat spinal cord by peripherally transplanted human embryonic sensory neurons

Functionally useful repair of the mature spinal cord following injury requires axon growth and the re-establishment of specific synaptic connections. We have shown previously that axons from peripherally grafted human embryonic dorsal root ganglion cells grow for long distances in adult host rat dorsal roots, traverse the interface between the peripheral and central nervous system, and enter the spinal cord to arborize in the dorsal horn. Here we show that these transplants mediate synaptic activity in the host spinal cord. Dorsal root ganglia from human embryonic donors were transplanted in place of native adult rat ganglia. Two to three months after transplantation the recipient rats were examined anatomically and physiologically. Human fibres labelled with a human-specific axon marker were distributed in superficial as well as deep laminae of the recipient rat spinal cord. About 36% of the grafted neurons were double labelled following injections of the fluorescent tracers MiniRuby into the sciatic and Fluoro-Gold into the lower lumbar spinal cord, indicating that some of the grafted neurons had grown processes into the spinal cord as well as towards the denervated peripheral targets. Electrophysiological recordings demonstrated that the transplanted human dorsal roots conducted impulses that evoked postsynaptic activity in dorsal horn neurons and polysynaptic reflexes in ipsilateral ventral roots. The time course of the synaptic activation indicated that the human fibres were non-myelinated or thinly myelinated. Our findings show that growing human sensory nerve fibres which enter the adult deafferentated rat spinal cord become anatomically and physiologically integrated into functional spinal circuits.

Cytokine responses in patients with pneumonia caused by Chlamydia or Mycoplasma

The serum concentrations of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), and interferon-gamma (IFN-gamma) were measured by enzyme immunoassays in 44 patients with Chlamydia (n = 13) or Mycoplasma (n = 14) pneumonia or influenza A infection (n = 17) and in 20 control subjects. The levels of IFN-gamma were raised in 29/44 patients. The concentrations of IL-6 were raised in 32/44 patients. Raised levels of TNF-alpha were seen in 26/44 but there was no significant difference between the levels of the different groups of patients. All three cytokines indicated clinical recovery when acute and convalescent samples from 10 patients with Chlamydia pneumonia were analyzed. IFN-gamma, IL6 and TNF-alpha are present in the circulation in the majority of patients with Chlamydia and Mycoplasma pneumonia and in influenza A infection. We suggest that repeated measurement of cytokines, such as IL-6, IFN-gamma and TNF-alpha, may be useful in the management of lower respiratory tract infections but further studies are needed to define the value of cytokine measurements in acute pneumonia.

Developmental tuning in a spinal nociceptive system: effects of neonatal spinalization

Recent studies indicate a modular organization of the nociceptive withdrawal reflex system. Each module has a characteristic receptive field, closely matching the withdrawal movement caused by its effector muscle. In the rat, the strength of the sensory input to each module is tuned during the first postnatal weeks, i.e., erroneous spinal connections are depressed, and adequate connections are strengthened. To clarify if this tuning is dependent on supraspinal structures, the effect of a complete neonatal spinal cord transection on the postnatal tuning of withdrawal reflexes was studied. The nociceptive receptive fields of single hindlimb muscles and compound withdrawal reflexes were examined in decerebrate unanesthetized and awake rats, respectively. Noxious thermal CO(2) laser stimulation was used to evoke reflex responses. Neonatal spinal cord transection resulted in a disrupted reflex organization in the adult rat, resembling that previously found in neonatal rats. The receptive fields of single hindlimb muscles exhibited abnormal distribution of sensitivity not matching the withdrawal action of the effector muscles. Likewise, the composite nocifensive movements, as documented in the awake rat, often resulted in erroneous movements toward the stimulus. It is concluded that withdrawal reflexes do not become functionally adapted in rats spinalized at birth. These findings suggest a critical role for supraspinal systems in the postnatal tuning of spinal nociceptive systems.

Perforated silicon nerve chips with doped registration electrodes: in vitro performance and in vivo operation

An in vitro model was developed for the study of signal transduction between a Cu-wire, miming a neural signal source, and recording electrodes on perforated silicon chips. Phosphorous doped electrodes were used to achieve an all silicon device. The model was used to study signal amplitude as a function of the spatial position, and distance to the signal source. Recordings of the signal crosstalk to neighboring electrodes on the chips were made. It was found that the amplitude decreased by a factor of two at a distance of 50 microns between the electrode surface and the signal source. The chip electrode signal crosstalk was found to be 6 dB using an external reference electrode. Improvements were accomplished with an on chip reference electrode giving a crosstalk suppression of 20 dB. Impedance analysis showed that doped silicon electrodes displayed similar characteristics as Cu-electrodes at frequencies above 3 kHz. Sieve electrodes were implanted in the rat sciatic nerve and following a 10-week nerve regeneration period the dorsal and ventral (L5) roots in the spinal cord were stimulated. Compound action potentials were recorded via the chip. Stimulating the regenerated sciatic nerve via the sieve electrode also induced lower leg muscle contraction activity.

Secretion of IL-6, IL-8 and G-CSF by human endothelial cells in vitro in response to Staphylococcus aureus and staphylococcal exotoxins

The capacity of endothelial cells to produce and release cytokines (IL-6, IL-8 and G-CSF) in response to exposure to Staphylococcus aureus strains or staphylococcal exotoxins (alpha-toxin, enterotoxin A and TSST-1) was investigated. An endothelial cell culture model of human umbilical vein endothelial cells (HUVEC) was used. Five out of ten clinical isolates of S. aureus were found to induce cytokine production and release from endothelial cells. Four of the five isolates that induce cytokine release produced enterotoxin A, B, C, D and/or TSST-1, compared with two of those that did not induce release. Purified staphylococcal exotoxins (1 pg/ml-1 microg/ml) did not act as primary stimuli and induced no detectable cytokine secretion. When endothelial cells were prestimulated with IL-1beta or TNF alpha at a concentration of 1 ng/ml for 2 h, IL-1beta served as a potent primary stimulus for IL-6, IL-8 and G-CSF production, whereas TNF alpha did not induce any significant cytokine release during the subsequent 24 h. A further increase in IL-6 and G-CSF release, but not of IL-8, was observed when IL-1beta prestimulated cells were exposed to alpha-toxin or TSST-1. However, to potentiate cytokine production (IL-6 and IL-8) by SEA, both IL-1beta and the toxin had to be present simultaneously. Our data show that S. aureus, but not staphylococcal exotoxins, have the capacity to act as primary stimuli of endothelial cells and induce production and release of cytokines. IL-1beta may prime HUVEC to release IL-6, IL-8 and G-CSF prior to subsequent stimulation with staphylococcal exotoxins.

Economic evaluation of screening for prostate cancer: a randomized population based programme during a 10-year period in Sweden

Prostate cancer is a growing health problem representing considerable costs. Screening and early curative treatment may reduce morbidity and possibly prevent future escalating costs. However, population screening programmes are generally not well accepted at present due to uncertainty about whether screening for prostate cancer can result in reduced mortality. Evidence from large, randomized, controlled trials is still lacking. The objective of this study was to calculate clinical and economic consequences of general prostate cancer screening based on a limited screening trial in a Swedish community and a decision-tree model. A random selection of 1492 men (50-69 years) were invited to repeated screening in 1987. They have been examined every third year (four rounds). The other 7679 men in the population act as controls. The results show that the total incremental health care costs for prostate cancer will increase by 179 million SEK per year with screening compared to no-screening. The number of detected cases of localized cancer will increase by about 1000, which represents an additional cost of about 158,000 SEK per case. In conclusion, general screening for prostate cancer can be performed with a reasonable cost per detected localized cancer. Information on the long-term effect on life quality and cancer mortality is unknown.

Impact on health service costs of medical technologies used in management of prostatic cancer

The aim of the study was to calculate the direct costs for the management of prostatic cancer throughout the need for care period. The impact of new medical technologies was analysed on the basis of an earlier cost study. The records of all 128 men in a defined population who died in 1992-93 and had been diagnosed with prostatic adenocarcinoma were retrospectively reviewed from diagnosis to death. The median cost per case, SEK 86,400, was significantly lower than the average cost per case, SEK 135,000, largely because of a few high-cost patients (in 20% of cases the cost exceeded SEK 250,000). Analysis of cost distribution throughout the need for care period showed that about 84% of the total cost per case was incurred during the the 3 years up to death. Estimated total direct care costs due to prostatic cancer in Sweden in the mid-1980s and early 1990s rose from approx. SEK 550 million to approx. SEK 780 million (1993 prices).

Community-acquired pneumonia in adults

Efforts to reduce hospitalization or the length of stay are common topics in papers published last year. Chlamydia pneumoniae is now recognized worldwide as a common pathogen in community-acquired pneumonia. A great variation in the frequency of various pathogens is found in different countries, stressing the importance of ascertaining the aetiological and epidemiological situation in each respective country.

Antibody response in Staphylococcus aureus septicaemia--a prospective study

Formation of serum antibodies against alpha-toxin, teichoic acid and lipase was followed in 63 patients with Staphylococcus aureus septicaemia in 240 consecutive serum samples. Control subjects comprised 23 patients with septicaemia due to other causes and 21 febrile patients without septicaemia. An antibody response against alpha-toxin, measured by ELISA, was most common (40%) in the initial serum, but antibody to teichoic acid was present in the highest number of positive patients (60%) when samples were drawn between 0 and 30 days: 74% of the patients showed a positive antibody response to at least one of the three antigens. When complicated versus uncomplicated septicaemia was compared (samples taken 8-14 days), 14 (45%) of 31 patients had a positive response against alpha-toxin versus 12 (75%) of 16, against teichoic acid 16 (51%) of 31 versus 12 (75%) of 16 and against lipase 15 (48%) of 31 versus 8 (50%) of 16. Patients with low initial antibody levels displayed a poorer antibody response than those with higher initial antibody levels. This phenomenon was observed with all three antigens, but was most pronounced with alpha-toxin. The initial antibody levels may predict the antibody response during the course of the disease. ELISA titres against alpha-toxin correlated (r=0.87) with biological neutralising activity of the antisera. The results may indicate a biological role of serum antibodies in staphylococcal septicaemia.

Evaluation of Alcaligenes eutrophus cells as an NADH regenerating catalyst in organic-aqueous two-phase system

A soluble NAD-dependent hydrogenase contained in Alcaligenes eutrophus was evaluated as a coenzyme regenerating catalyst in an organic-aqueous two-phase (predominantly organic) system. The horse-liver alcohol-dehydrogenase (HLADH) catalyzed reduction of cyclohexanone to cyclohexanol was used as a model reaction. The impact of different solvents (selected to span a large variety of principal properties) on the stability and activity of the HLADH, using substrate-driven regeneration, was studied. Solvents suitable for the HLADH were then selected for an evaluation of the hydrogenase-driven coenzyme regeneration. Hydrophobic solvents such as heptane, toluene, and 1,1,1-trichloroethane were found to be suitable for the coupled reactions catalyzed by HLADH and hydrogenase. Nonimmobilized cells, permeabilized with cetyl-trimethyl-ammonium bromide, were the most efficient preparation for the regeneration of NADH. The use of this preparation in heptane (10% water) was optimized with respect to the yield obtained in the HLADH-catalyzed reduction of cyclohexanone. Using the optimized conditions, yields of 99% cyclohexanol were obtained.

Developmental adaptation of rat nociceptive withdrawal reflexes after neonatal tendon transfer

Nociceptive withdrawal reflexes (NWRs) were studied in adult rats in which the movement patterns produced by single muscles had been altered by neonatal tendon transfer. NWRs evoked by cutaneous noxious mechanical and thermal (CO2-laser) stimulation were recorded using electromyography in a decerebrate spinal preparation. The sensitivity distribution within the receptive fields of the NWRs of the extensor digitorum longus and the peronei muscles exhibited changes corresponding to the altered movement patterns. No detectable change of NWRs was found in normal muscles whose receptive fields overlapped that of the modified muscle. Furthermore, NWRs of muscles that regained an essentially normal function after neonatal tendon transfer did not differ from normal. It is proposed that a developmental experience-dependent mechanism, which takes into account the hindlimb movement pattern caused by contraction of single muscles, underlies the functionally adapted organization of adult NWRs.

Bottle-blowing in hospital-treated patients with community-acquired pneumonia

A study was carried out to determine whether bottle-blowing has any positive effects in patients with pneumonia. In a prospective open study 145 adults with untreated community-acquired pneumonia requiring hospitalization were randomized to early mobilization (group A), to sit up and take 20 deep breaths on 10 occasions daily (group B), or to sit up and to blow bubbles in a bottle containing 10 cm water through a plastic tube 20 times on 10 occasions daily (group C). Peak expiratory flow (PEF), vital capacity (VC), forced expiratory volume in 1 sec (FEV1) and serum concentration of C-reactive protein (CRP) were determined on admission, and on days 4 and 42. Fever duration and hospital stay were recorded. In a subset of 16 patients, single breath diffusion capacity of carbon monoxide was measured on 3 occasions. The patients in group A were hospitalized for a mean of 5.3 days, group B for 4.6 days and group C for 3.9 days. Treatment was a significant factor (p = 0.037) in a Cox regression model, with group C significantly better than group A (p = 0.01). The number of days with fever was 2.3, 1.7 and 1.6 in groups A, B and C respectively. These differences were not significant (p = 0.28). No significant differences were found between the groups regarding CRP, PEF, VC, FEV1, or diffusion capacity. Intensive bottle-blowing shortens the hospital stay in patients with pneumonia. The underlying mechanism is not clear.

Developmental adaptation of withdrawal reflexes to early alteration of peripheral innervation in the rat

1. In adult decerebrate spinal rats whose plantar nerves (PLN) had been transected at either postnatal day 1 (P1) or P21 the nociceptive withdrawal reflexes (NWR) of musculi extensor digitorum longus (EDL), peroneus longus (PER) and semitendinosus (ST) were characterized with respect to receptive field (RF) organization, magnitude and time course, using electromyography. Thermal (short CO2 laser pulses) and mechanical (calibrated pinch) stimulation were used. The innervation patterns in normal and lesioned adult rats were assessed by acute nerve lesions. 2. The spatial organization of the mean mechano- and thermonociceptive RFs of all the muscles studied was similar to normal in both P1- and P21-lesioned rats, although in some P21-lesioned rats atypical EDL RFs were encountered. 3. In P1-lesioned rats thermo-NWR of PER and EDL had normal magnitudes, while mechano-NWR were reduced. In P21-lesioned rats both thermo- and mechano-NWR of these muscles had reduced magnitudes. Except for thermo-NWR of ST in P1-lesioned rats, which were increased, NWR of ST had normal magnitudes in both P1- and P21-lesioned rats. The time course of thermonociceptive NWR of the muscles studied were near normal in both P1- and P21-lesioned rats. 4. Acute nerve lesions in adult P1-lesioned rats revealed an essentially abolished contribution to NWR from the PLN. Instead, the contribution to NWR from other hindpaw nerves, such as the superficial and deep peroneal nerves, was dramatically increased. By contrast, in P21-lesioned rats, the regenerated PLN contributed significantly to the NWR. 5. It is concluded that despite profound alterations of plantar hindpaw innervation induced by early PLN transection the cutaneous nociceptive input to NWR attained an essentially normal spatial organization. An experience-dependent mechanism is suggested to be instrumental in adapting the reflex connectivity to the peripheral innervation.

Postnatal development of the nociceptive withdrawal reflexes in the rat: a behavioural and electromyographic study

1. The postnatal development of nociceptive withdrawal reflexes was studied. In awake intact rats, forelimb, hindlimb and tail reflexes were recorded on videotape. In decerebrate spinal rats, electromyography (EMG) was used to record nociceptive withdrawal reflexes in musculi extensor digitorum longus (EDL), peronei, gastrocnemius-soleus (G-S) and biceps posterior-semitendinosus (BP-ST). Thermal (short-lasting CO2 laser pulses) and mechanical stimulation were used. 2. In adults, nociceptive withdrawal reflexes were typically well directed and reflex pathways to single hindlimb muscles had functionally adapted receptive fields. By contrast, at postnatal day (P) 1-7, the nociceptive withdrawal reflexes were often inappropriate, sometimes producing movements towards the stimulation, and EMG recordings revealed unadapted variable receptive fields. With increasing age, the nociceptive withdrawal reflexes progressively became well directed, thus producing localized withdrawal. Both withdrawal movements and spatial organization of the receptive fields were adult-like at P20-25. 3. Up to P25, reflex thresholds were more or less constant in both intact awake rats and spinal decerebrate rats, except in G-S in which no nociceptive withdrawal reflexes were evoked from P20 on. After P25, mechanical, but not thermal, thresholds increased dramatically. 4. EMG recordings revealed that during the first three postnatal weeks, the latency of the CO2 laser-evoked nociceptive withdrawal reflexes decreased significantly in peronei and BP-ST, but not in EDL, and thereafter increased significantly in peronei, BP-ST and EDL. The magnitude of the nociceptive withdrawal reflexes in these muscles increased markedly between P7 and P20 and showed little change thereafter. 5. Possible mechanisms underlying the postnatal tuning of the nociceptive withdrawal reflexes are discussed.

Serum antibody response to Staphylococcus aureus enterotoxins and TSST-1 in patients with septicaemia

The prevalence of enterotoxins and toxic shock syndrome toxin (TSST-1) production in strains isolated from patients with Staphylococcus aureus septicaemia, and the serum antibody response in relation to toxin production in vitro of each isolate, were investigated. Among 63 strains of S. aureus isolated from the blood of patients with septicaemia, 51 from patients with superficial wounds and 49 from nasal carriers, 50-60% produced at least one of the enterotoxins A-D or TSST-1. The most frequent toxins produced were enterotoxins A and C and TSST-1. Among the 63 patients with staphylococcal septicaemia, 51 (81%) had a significant rise or a high antibody titre, or both, to at least one of the toxins. A positive serological response to toxin A was found in 78%, to enterotoxin B in 83%, to enterotoxin C in 80%, to enterotoxin D in 86% and to TSST-1 in 92% of the patients from whom the isolated strain produced the respective toxin. Antibodies against enterotoxins A, B, C and D and TSST-1 were also seen in 35%, 16%, 32%, 59% and 10%, respectively, in patients infected by strains that did not produce the specific toxin. Immunological cross-reactions between the toxins were demonstrated both in hyperimmune sera obtained from rabbits and in patients' sera, particularly between enterotoxins B and C. It is concluded that these potent toxins with superantigenic properties are produced in vivo during S. aureus septicaemia. No differences with regard to enterotoxin or TSST-1 production or antibody response were noted between patients with complicated versus uncomplicated septicaemia.

Dynamics of blood cytokine concentrations in patients with bacteremic infections

Cytokines play a major role in the pathophysiology of sepsis and septic shock. Using enzyme immunoassays the acute serum levels of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), granulocyte-colony stimulating factor (G-CSF), interleukin-8 (IL-8), and leukemia inhibitory factor (LIF) were investigated in 90 patients with positive blood cultures and clinical signs of infection. In 27 patients samples were obtained on admission, after 1, 4, 12, 18, and 24 h, and then daily. The acute serum levels of IL-6, TNF-alpha, G-CSF, and IL-8 were significantly higher among patients with severe sepsis. Patients with Gram-negative infection had significantly higher levels of TNF-alpha on admission than did patients with Gram-positive infections (p = 0.0008). The levels of IL-6, G-CSF and, to some extent, TNF-alpha decreased rapidly in survivors within the first 24 h of admission to hospital and institution of treatment. LIF was detected in 8/90 in both survivors and nonsurvivors.

Diagnostic value of blood cytokine concentrations in acute pneumonia

BACKGROUND

The role of cytokines in the pathogenesis of pneumonia is still poorly understood. In a previous study the diagnostic value of measuring blood concentrations of interleukin 6 and interferon gamma was established. In the present study the value of blood concentrations of interleukin 8, granulocyte-colony stimulating factor, and lactoferrin as markers of bacteraemic pneumonia is evaluated.

METHODS

The circulating concentrations of interleukin 8 (IL-8), granulocyte-colony stimulating factor (G-CSF), and lactoferrin were measured in 14 patients with bacteraemic pneumococcal pneumonia and 49 patients with atypical pneumonia or influenza A infection using enzyme immunoassays.

RESULTS

Serum G-CSF concentrations were higher in the group with bacteraemic pneumococcal pneumonia, and G-CSF values correlated with the white blood cell count and levels of C-reactive protein (CRP). The levels of IL-8 were higher in the group with bacteraemic pneumococcal pneumonia than the groups with Chlamydia pneumonia, Legionella pneumonia, or influenza A infection, but there was no difference when compared with the group with Mycoplasma pneumonia. A white blood cell count of > 15 x 10(9)/l was highly suggestive of bacteraemic pneumonia. The concentrations of lactoferrin were raised in all groups except those with influenza A infection, but no difference was found between the different aetiological groups. A correlation was found between lactoferrin and white blood cell counts.

CONCLUSIONS

Serum G-CSF and IL-8 concentrations are potential markers of bacteraemic pneumonia.

A survey of spinal dorsal horn neurones encoding the spatial organization of withdrawal reflexes in the rat

The withdrawal reflex pathways to hindlimb muscles have an elaborate spatial organization in the rat. In short, the distribution of sensitivity within the cutaneous receptive field of a single muscle has a spatial pattern that is a mirror image of the spatial pattern of the withdrawal of the skin surface ensuing on contraction in the respective muscle. In the present study, a search for neurones encoding the specific spatial input-output relationship of withdrawal reflexes to single muscles was made in the lumbosacral spinal cord in halothane/nitrous oxide-anaesthetized rats. The cutaneous receptive fields of 147 dorsal horn neurones in the L4-5 segments receiving a nociceptive input and a convergent input from A and C fibres from the hindpaw were studied. The spatial pattern of the response amplitude within the receptive fields of 118 neurones was quantitatively compared with those of withdrawal reflexes to single muscles. Response patterns exhibiting a high similarity to those of withdrawal reflexes to single muscles were found in 27 neurones located in the deep dorsal horn. Twenty-six of these belonged to class 2 (responding to tactile and nociceptive input) and one belonged to class 3 (responding only to nociceptive input). None of the neurones tested (n = 20) with reflex-like response patterns could be antidromically driven from the upper cervical cord, suggesting that they were spinal interneurones. With some overlap, putative interneurones of the withdrawal reflexes to the plantar flexors of the digits, the plantar flexors of the ankle, the pronators, the dorsiflexors of the ankle, and a flexor of the knee, were found in succession in a mediolateral direction.(ABSTRACT TRUNCATED AT 250 WORDS)

Interleukin-6, C-reactive protein, lactoferrin and white blood cell count in patients with S. aureus septicemia

In a prospective study of 65 patients with S. aureus septicemia, the clinical value of measuring serum IL-6 and lactoferrin levels was assessed and compared with CRP levels and WBC count. 20/65 (31%) patients had a CRP value < or = 100 mg/l on admission and 10 (50%) and 11 (55%) of these had serum levels of IL-6 > 100 pg/ml or lactoferrin > 2.0 mg/l, respectively. 41/64 (64%) patients had a WBC count < or = 15.0 x 10(9)/l and the corresponding figures for increased IL-6 and lactoferrin values were 29 (71%) and 21 (51%) patients, respectively. The high concentrations of IL-6 and lactoferrin on admission decreased rapidly during the hospital stay, better reflecting the clinical course than CRP and WBC count. Patients with endocarditis showed higher IL-6 levels and body temperatures both on admission and during the first days of hospitalization compared with patients without endocarditis.

Serum concentrations of interleukin-6, tumour necrosis factor-alpha, and C-reactive protein in patients undergoing major operations

OBJECTIVE

To investigate the kinetics of interleukin-6 (IL-6), tumour necrosis factor-alpha (TNF-alpha) and C-reactive protein after a surgical operation.

DESIGN

Prospective study.

SETTING

Teaching hospital, Sweden.

SUBJECTS

28 patients undergoing cardiac operations, joint replacement, or gastric restrictive operations.

INTERVENTIONS

Samples of serum were taken before operation; at 0, 6, and 12 hours; and then daily for six days.

OUTCOME MEASURES

IL-6, TNF-alpha, and C-reactive protein concentrations at specified time points, and their correlation with complications and outcome.

RESULTS

The IL-6 concentration peaked soon after operation, and that of C-reactive protein 48-96 hours later. Serum IL-6 concentrations were highest in the eight patients undergoing cardiac operations. In one patient an infective complication occurred resulting in secondary peaks of IL-6 and C-reactive protein. Three patients who developed postoperative circulatory and respiratory instability had no additional changes in cytokine concentrations. The overall concentrations of IL-6 were raised above 100 pg/ml for a mean of 36 hours after operation and those of C-reactive protein were over 100 mg/l for a mean of 106 hours (p < 0.0001). Serum TNF-alpha concentrations were low in all patients.

CONCLUSION

The maximum serum concentrations of IL-6 and C-reactive protein after surgical operations were comparable to those in patients with sepsis. If IL-6 and C-reactive protein analyses are used in the diagnosis of infective complications, evaluation of the results should be related to the length of time between the operation and sampling, and to the clinical findings. The shorter period during which IL-6 was raised compared with C-reactive protein indicates that IL-6 may be a more useful marker of postoperative infective complications.

Modular Organization of Spinal Nociceptive Reflexes: A New Hypothesis

Recent experimental studies suggest that the nociceptive withdrawal reflex system essentially has a "modular" organization, with each module concerned with the control of a single or a small group of muscles. This organizational principle appears to apply also to some spinoolivocerebellar pathways.

Improving the implementation of cost recovery for health: lessons from Zimbabwe

In the current debate over health financing policy in developing countries, governments are increasingly focusing on cost recovery--having patients pay part or all of their health care costs--as a way to mobilize more resources for health, improve equity by selectively charging the wealthy, and increase efficiency by encouraging reinvestment of fee revenues into cost-effective primary care. Zimbabwe offers an important example of a country with a tradition of levying fees in government health facilities, but where enforcement became lax in the 1980s. In 1991, policymakers resolved to resuscitate and strengthen cost recovery, as part of a broader economic reform program. This paper discusses the strengths and weaknesses of Zimbabwe's cost recovery system, its potential for improvement, and the obstacles to change in revising the fee structure and billing and collection procedures. It argues that cost recovery can help to achieve Zimbabwe's health objectives, but only in conjunction with other measures to redirect public spending to essential public health and clinic care and improve the efficiency of government services. The paper finds that during the 1980s, the fee schedule became badly misaligned with actual medical care costs and created distortions in patient referral patterns. Billing and collection were also weak, because of deficiencies in personnel and information systems and lack of incentives for revenue generation. The paper concludes that if key steps were taken to raise the collections-to-billings ratio, recover fees from privately-insured patients, and adjust fees in line with medical cost inflation, recoveries could increase fourfold, from 5% to 20% of government spending for clinical care. At the same time, access to government health services for the poor could be maintained by improving exemption procedures.

A programme for assigning target values for external quality assessment schemes in countries with no authorized reference laboratories. Annex. Experiences with deviating results on Ektachem 700 XR

The use of consensus values in external quality assessment schemes (EQAS) involves several problems and should preferably be replaced with target values obtained by methods of high metrological level. However, such values are difficult to obtain. In the present study we transferred values from the NIST (former NBS) certified reference serum SRM 909 to lyophilized and frozen test sera for various inorganic components using flame absorption or flame emission spectrometry. Enzyme values were assigned by laboratories of members of the former Scandinavian Enzyme Committee. The assignment was based on 2-4 determinations each day through 3 days of experiment. A total of 10 laboratories participated in the work. The results were utilized in a Danish EQAS. One practical concern is the fairly long time (9 months) which was needed for production, collection and compiling all data. To get an impression of how much dry chemistry analysers, e.g, could influence consensus values a Kodak Ektachem 700 XR was studied using lyophilized and frozen sera. The results are reported in the annex. On NIST SRM 909 the values found for sodium(I) were 6% too high even though the findings on frozen human sera were accurate. For aspartate aminotransferase a result three times the target values was found on a human lyophilized serum, while the values on the frozen sera only were slightly too high.

Functional organization of the nociceptive withdrawal reflexes. II. Changes of excitability and receptive fields after spinalization in the rat

The spatial organization of the cutaneous input to hindlimb withdrawal reflexes was studied in spinalized, decerebrated, unanesthetized rats. Reflex activity in plantar flexors of the digits, pronators of the foot, dorsiflexors of the digits, and/or the ankle and flexors of the knee was recorded with electromyographic techniques for up to 12 h after spinalization. Graded mechanical (pinch) and thermal stimulation (CO2 laser) of the skin were used. Reflexes were absent ("spinal shock") during approximately 10-20 min after spinalization. The reflex thresholds for pinch and CO2 laser stimulation then decreased considerably during the following 5-8 h. After this time, even mild pressure (less than 0.1 N/mm2) on the skin was sufficient to evoke a reflex in most muscles. During the period from about 0.5-3 h after spinalization, the nociceptive receptive field of each muscle usually corresponded to the area of the skin withdrawn by the muscle. Maximal responses were evoked from the area of the receptive field maximally withdrawn. During this period, responses to innocuous pinch were evoked mainly from the most sensitive area of the receptive fields. Concomitant with the decrease in reflex thresholds, the nociceptive receptive fields expanded for all muscles, often to include areas of the skin not withdrawn by the muscles. For most muscles, reflexes on tactile stimuli were eventually elicited from the entire receptive fields. The receptive fields for thermonociceptive and mechanonociceptive inputs were similar in most muscles. The interossei muscles were exceptional in that they responded very weakly to thermal stimulation. It is concluded that there are neuronal networks in the spinal cord that translate cutaneous nociceptive and tactile input into a withdrawal. However, the control exerted by descending pathways is necessary to maintain a functionally adequate excitability in these reflex pathways and an appropriate size for their receptive fields.

Streptococcal myositis

Streptococcal myositis (SM), is a very serious condition with a high mortality rate. The port of entry of the infection is often unknown. We present here a case report concerning a 68-year-old patient with fulminant SM preceded by symptoms of an upper respiratory tract infection. Haemolytic streptococci of group A were found in the blood, muscle tissue and throat. The patient survived after massive therapeutic interventions including intensive care with intravenous antibiotics, fasciotomy, plasma exchange, controlled respiratory ventilation and exarticulation through the shoulder. The patient's wife fell ill at the same time with a sore throat and the same type of streptococci (T-type 3) was found in both patients.

Regional differences of Chlamydia pneumoniae as causative agent of pneumonia in Sweden

A retrospective serological study was performed on sera from 1982-83 and 1989 to investigate the incidence of Chlamydia pneumoniae infection in hospital treated patients with pneumonia in Orebro County. Paired sera from 231 patients were available and 3 cases (1.3%) of C. pneumoniae infection were documented by microimmunofluorescence. The results differ from those reported by others implying regional differences of C. pneumoniae as causative agent of pneumonia. The findings from Orebro County do not support any change in current antibiotic policy and we still regard penicillin as the first drug of choice in community-acquired pneumonia.