Suspected leptospiral meningitis in adults: report of four cases and review of the literature

BACKGROUND

Leptospirosis is a widespread zoonotic disease characterised by headache and fever. These symptoms are often suggestive of meningitis, but only a proportion of patients have leptospiral meningitis.

METHODS

We report episodes of leptospiral meningitis in patients admitted to a tertiary referral centre in the Netherlands, in whom lumbar puncture was performed, and conducted a literature search of adult cases of leptospiral meningitis to describe clinical characteristics and outcome.

RESULTS

Between 2011 and 2014, 19 patients with leptospirosis were identified. Seven underwent a lumbar puncture for suspected meningitis (37%), of which six had been in contact with fresh water in a tropical area. Four patients with suspected meningitis (57%) had cerebrospinal fluid pleocytosis indicative of leptospiral meningitis and presented with headache, fever and neck stiffness. In a review of the literature we identified 366 patients with leptospiral meningitis with a median age of 33 years (range 17-77). Risk factors for leptospirosis were identified in 32 of 33 patients. Typical cerebrospinal fluid abnormalities consisted of a mildly elevated leukocyte count (median 206 leukocytes/mm3, range 6-2072) with a lymphocytic predominance (median 95%). Outcome was generally favourable, with a mortality rate of 3% and neurological sequelae in 5% of the survivors.

CONCLUSION

Leptospirosis in the Netherlands has a low incidence. In the case of suspected meningitis and a history of visiting tropical areas or direct or indirect contact with animal urine, leptospiral meningitis should be considered. Cerebrospinal fluid examination is vital for the differential diagnosis of leptospirosis. Outcome is generally favourable in patients with leptospiral meningitis treated with antibiotics.

Roll to roll fabrication of thin film silicon solar cells on nano-textured substrates

ECN is developing a novel fabrication process for thin film silicon solar cells on steel foil. Key features in this process are: (1) application of an insulating barrier layer which enables monolithic interconnection and texturization of the rear contact with submicron structures for light trapping; (2) Si deposition with remote, linear PECVD; (3) series interconnection by laser scribing and printing after deposition of all layers, which reduces the total number of process steps. The barrier layer is essential for the monolithic series interconnection of cells, but we show that it also enables optimum light trapping in the solar cells. We can fabricate any arbitrary sub-micron surface profile by hot embossing the barrier layer. For deposition of doped and intrinsic silicon layers we use novel remote, linear plasma sources, which are excellently suited for continuous roll-to-roll processing. We have been able to fabricate device-quality amorphous and microcrystalline silicon layers with these sources. The first nip a-Si cells were made on steel substrates with flat barrier layer and had initial efficiencies of 6.3%, showing the potential of the concept.

A review of currently available vessel sealing systems

Laparoscopic surgery is rapidly expanding among urologists as a minimally invasive treatment with surgical procedures becoming increasingly challenging. Accurate haemostatis is of utmost importance in laparoscopy, as bleeding can rapidly impair the working environment conditions. We subsequently reviewed the different haemostatic tools used in laparoscopy with the focus on ultrasonic dissectors and electrothermal bipolar vessel sealer (EBVS). Briefly, there is a wide variety of haemostatic tools currently available in laparoscopy, all with their inherent advantages and limitations. The comparison of ultrasonic dissectors and EBVS shows that both systems are very attractive with similar physical properties concerning thermal spread and bursting pressure of vessels sealed. It has to be noted, however, that EBVS can handle vessels of up to 7 mm. In conclusion, haemostatic tools constitute a rapidly evolving domain with devices being developed which cause less thermal spread, while being more precise and faster. This evolution should finally allow more complex laparoscopic surgical procedures.

Impact of proficiency testing on results of the microscopic agglutination test for diagnosis of leptospirosis

A proficiency testing scheme for the leptospirosis microscopic agglutination test was provided to 37 laboratories in 23 countries in 2002 (round 1) and to 60 laboratories in 34 countries in 2003 (round 2). Thirty-four laboratories participated in both rounds. Each panel consisted of five rabbit serum samples, four of which were antisera raised against pathogenic serovars of Leptospira. One of these samples was a mixture of two different antisera. The rates of false-negative results, calculated on the basis of the assumption that serovars within a serogroup will cross-react, were 11% for round 1 and 14% for round 2. There were regional differences in the rates of false-negative results. The titers reported by laboratories testing for the same sample with the same serovar varied widely. Laboratories that had previously participated in round 1 reported fewer false-negative results in round 2 than new participants (10 and 21%, respectively [P = 0.002]) and reported 0.56 false-negative results per participant, whereas new participants reported 1.23 false-negative results per participant (P = 0.041). Laboratories that had previously participated also reported fewer false-negative results in round 2 than in round 1 when samples common to both rounds were tested (5 and 15%, respectively [P = 0.028]). The titers reported by the new participants were, on average, lower than those reported by the laboratories that had participated previously (P = 0.019) and were significantly more variable (P = 0.001). Analysis of these results suggests a positive impact of proficiency testing on the testing performance of the participating laboratories.

The predictive value of body mass index for the weight evolution in anorexia nervosa

BACKGROUND

Low body weight is considered to be an important risk factor for poor outcome in anorexia nervosa (AN).

OBJECTIVES

To study the relationship between body mass index (BMI) at the beginning of treatment and at follow-up. A BMI of 13 kg/m2 at admission was hypothesized as cut-off point for better versus worse evolution of weight after treatment.

METHOD

The BMI of 232 female AN inpatients was calculated at admission and after 6 months and 1 year.

RESULTS

An overall low correlation between BMI at admission and at 6 months (r = 0.27) and 1 year (r = 0.26) follow-up was found. A BMI value of 15 kg/m2 at admission was revealed as the best cut-off point for making predictions.

CONCLUSIONS

Patients with an admission BMI below 15 kg/m2 have a significantly greater chance to develop a lower BMI value at follow-up than those with a higher BMI.

Effects of 24 weeks of whole body vibration training on body composition and muscle strength in untrained females

The aim of this study was to investigate and to compare the effect of 24 weeks "whole body vibration" training and fitness training on body composition and on muscle strength. Forty-eight untrained females (21.3 +/- 2.0 yr) participated in the study. The whole body vibration group (N = 18) performed unloaded static and dynamic exercises on a vibration platform (35 - 40 Hz, 2.5 - 5.0 mm; Power Plate). The fitness group (N = 18) followed a standard cardiovascular (15 - 40 min) and resistance training program including dynamic leg press and leg extension exercises (20 - 8 RM). Both groups trained 3 times weekly. The control group (N = 12) did not participate in any training. Body composition was determined by means of underwater weighing. Additionally 12 skinfolds were assessed. Isometric (0 degrees /s) and isokinetic (50 degrees /s, 100 degrees /s, 150 degrees /s) knee-extensor strength was measured by means of a motor-driven dynamometer (Technogym). Over 24 weeks there were no significant changes (p > 0.05) in weight, in percentage body fat, nor in skinfold thickness in any of the groups. Fat free mass increased significantly in the whole body vibration group (+ 2.2 %) only. A significant strength gain was recorded in the whole body vibration group (24.4 +/- 5.1 %; 5.9 +/- 2.1 %; 8.3 +/- 4.4 %; 7.6 +/- 1.5 %) and in the fitness group (16.5 +/- 1.7 %; 12.0 +/- 2.7 %; 10.4 +/- 2.3 %; 10.2 +/- 1.9 %), at 0 degrees /s, 50 degrees /s, 100 degrees /s and 150 degrees /s respectively. In conclusion, 24 weeks whole body vibration training did not reduce weight, total body fat or subcutaneous fat in previously untrained females. However, whole body vibration training induces a gain in knee-extensor strength combined with a small increase in fat free mass. The gain in strength is comparable to the strength increase following a standard fitness training program consisting of cardiovascular and resistance training.

Body composition of anorexia nervosa patients assessed by underwater weighing and skinfold-thickness measurements before and after weight gain

BACKGROUND

Weight restoration is a crucial element in the treatment of patients with anorexia nervosa. Therefore, the validity of different methods for measuring body composition is important.

OBJECTIVE

We tested the concurrent validity of hydrodensitometry (underwater weighing) and anthropometry (12 skinfold thicknesses) and assessed body composition and subcutaneous fat before and after a refeeding program and a multifaceted program of therapy in a specialized inpatient unit for eating disorders.

DESIGN

The body composition of a large sample of anorexia nervosa patients (97 restricting type, 33 binging-purging type) was studied by using 2 methods both before and after weight gain. We applied a behavioral contract for weight restoration with a minimum weekly gain of 700 g and a maximum of 3 kg. Bland-Altman analysis of agreement, Pearson correlation analysis, t tests, and analysis of covariance were used.

RESULTS

There was good agreement between the results obtained by underwater weighing and by skinfold-thickness measurement (r = 0.76, P < 0.001); the results produced by the 2 methods did not differ significantly. On average, a significant weight gain (11.9 kg) was observed, composed of 6.6 kg fat and 5.3 kg fat-free mass.

CONCLUSIONS

Body fat estimation by skinfold-thickness equation appeared to be as accurate as underwater weighing. The refeeding program led to a significant increase in body weight, of which 55.5% was body fat. The mean ratio of fat-free mass to fat mass at the end of the treatment was 3.4:1.

Long-term creatine intake is beneficial to muscle performance during resistance training

The effects of oral creatine supplementation on muscle phosphocreatine (PCr) concentration, muscle strength, and body composition were investigated in young female volunteers (n = 19) during 10 wk of resistance training (3 h/wk). Compared with placebo, 4 days of high-dose creatine intake (20 g/day) increased (P < 0.05) muscle PCr concentration by 6%. Thereafter, this increase was maintained during 10 wk of training associated with low-dose creatine intake (5 g/day). Compared with placebo, maximal strength of the muscle groups trained, maximal intermittent exercise capacity of the arm flexors, and fat-free mass were increased 20-25, 10-25, and 60% more (P < 0. 05), respectively, during creatine supplementation. Muscle PCr and strength, intermittent exercise capacity, and fat-free mass subsequently remained at a higher level in the creatine group than in the placebo group during 10 wk of detraining while low-dose creatine was continued. Finally, on cessation of creatine intake, muscle PCr in the creatine group returned to normal within 4 wk. It is concluded that long-term creatine supplementation enhances the progress of muscle strength during resistance training in sedentary females.

Left ventricular ejection fraction from gated SPET myocardial perfusion studies: a method based on the radial distribution of count rate density across the myocardial wall

Left ventricular ejection fraction (LVEF) can be derived from gated single-photon emission tomographic (SPET) myocardial perfusion studies using either manual or edge detection techniques. In the presence of severe perfusion defects, however, difficulties may be encountered. In this article a method based on the assumption that the average position of the myocardial wall can be localized by means of statistical analysis of the distribution count density, and not on edge detection, is used to measure LVEF. SPET myocardial perfusion images, gated in eight time bins, were recorded in 50 patients 60 min after the injection of 925 MBq technetium-99m tetrofosmin. Masking of non-myocardial structures and thresholding resulted in images in which only myocardial walls had significant non-zero values. The distance of the wall relative to the centre of the cavity was calculated in the three-dimentional space as the first moment of the count rate distribution along radii originating in the centre of the cavity. LVEF was calculated using, for each time bin, the sum of the cube of all distances as an estimate of the cavity volume. The method required minimal operator interventions and was successful in all patients, including those with severe perfusion defects. Intraobserver and interobserver variability was excellent, with regression coefficients of 0.97 and standard deviations of 4.5% and 4.7%, respectively. For 30 patients, the measurements were validated against planar equilibrium radionuclide angiography (ERNA) that was obtained within an interval of 1 week. LVEF ranged from 12% to 88%. Agreement between the two methods was excellent (LVEFERNA=1.05+0.92 LVEFGSPET, r=0.93, P=0.023, SEE=7.06). The Bland-Altman analysis did not show any apparent trend in the differences between ERNA and gated SPET over a wide range of ejection fractions. The standard deviation of the differences was 3. 1%. In addition no relationship was found between the two methods and the severity of perfusion defects. In conclusion, accurate measurements of LVEF are obtained from gated SPET perfusion images using a method based on statistical analysis of the count rate density. This method did not deteriorate even in the presence of severe perfusion defects and could therefore be used in following patients after myocardial infarction.

Body composition in female anorexia nervosa patients

For the first time, body composition has been studied in a very large sample of female anorexia nervosa patients (n 200) using two methods: anthropometry (skinfold thickness) and densitometry (underwater weighing). The concurrent validity of both methods appeared to be good (r 0.84). Although the mean percentage of body fat (13.5) in our sample corresponds with most of the previous reports, the range (4.3-24.8) is great. Our study shows that BMI is not a good measure of fatness. Age and duration of illness were not related to body fat. Percentage fat was found to be different (t 2.76, P < 0.01) according to the diagnostic subtype of anorexia nervosa: restricters (12.9) v. bingers and/or purgers (14.7).

Treatment of hormone-refractory prostate cancer with 90Y-CYT-356 monoclonal antibody

A Phase I dose-escalation study using 90Y-CYT-356 monoclonal antibody was performed in 12 patients with hormone-refractory prostate carcinoma. Biodistribution studies using 111In-CYT-356 were performed 1 week before 90Y-CYT-356 administration. Of the 12 patients, 58% had at least one site of disease imaged after administration of 111In-CYT-356. The dose of 90Y ranged from 1.83-12 mCi/m2. Both 111In and 90Y-CYT-356 were tolerated well, without significant nonhematological toxicity. Myelosuppression was the dose-limiting toxicity and occurred at dose levels of 4.5-12 mCi/m2. Of the patients receiving </=9 mCi/m2, 55% had grade 1 or 2 leukopenia and/or thrombocytopenia. Two of three patients treated with 12 mCi/m2 experienced grade 3 thrombocytopenia and leukopenia. One patient treated with 12 mCi/m2 had grade 4 neutropenia. The maximum tolerated dose of 90Y-CYT-356 was 9 mCi/m2. Only one patient developed a human anti-mouse antibody 4 weeks after treatment. No patient attained a complete or partial response based on prostate-specific antigen and/or radiological criteria. Three patients had transient subjective improvement in the symptomatology of their disease. In addition, patients treated with 12 mCi/m2 of 90Y-CYT-356 had a slightly longer freedom from disease progression than patients treated with doses of 90Y-CYT-356 </=9 mCi/m2.

Influence of high-resistance and high-velocity training on sprint performance

The purpose of this study is to analyze the effect of high-resistance (HR) and high-velocity (HV) training on the different phases of 100-m sprint performance. Two training groups (HR and HV) were compared with two control groups (RUN and PAS). The HR (N = 22) and HV group (N = 21) trained 3 d.wk-1 for 9 wk: two strength training sessions (HR or HV) and one running session. There was a run control group (RUN, N = 12) that also participated in the running sessions (1 d.wk-1) and a passive control group (PAS, N = 11). Running speed over a 100-m sprint was recorded every 2 m. By means of a principal component analysis on all speed variables, three phases were distinguished: initial acceleration (0-10 m), building-up running speed to a maximum (10-36 m), and maintaining maximum speed in the second part of the run (36-100 m). HV training resulted in improved initial acceleration (P < 0.05 compared with RUN, PAS, and HR), a higher maximum speed (P < 0.05 compared with PAS), and a decreased speed endurance (P < 0.05 compared to RUN and PAS). The HV group improved significantly in total 100 m time (P < 0.05 compared with the RUN and PAS groups). The HR program resulted in an improved initial acceleration phase (P < 0.05 compared with PAS).

Prevalence and clinical presentation of glucose-6-phosphate dehydrogenase deficiency in Pakistani Pathan and Afghan refugee communities in Pakistan; implications for the use of primaquine in regional malaria control programmes

Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency surveys in Afghan refugees and a local community in the North-West Frontier Province, Pakistan, showed that this trait was most common among Pathan and Uzbak refugees (15.8% and 9.1% respectively). The prevalence among Pakistani Pathans was 7.0%, and that in Tajik and Turkoman refugees was 2.9% and 2.1% respectively. Hospital studies showed that the type of G-6-PD deficiency in Pathans could cause severe haemolytic crises. The potentially fatal side effects of primaquine treatment in the Pathan communities, and the high risk of re-infection, render the anti-relapse treatment policy for Plasmodium vivax obsolete. However, epidemic conditions of P. falciparum malaria may justify the use of primaquine as a gametocidal drug, administered as a single dose, during the transmission season. These findings necessitate revision of the recommendations for the use of primaquine in the area.

Body image assessment in anorexia nervosa patients and university students by means of video distortion: a reliability study

It is well known that anorexia nervosa is characterized by a disturbed body image. The video distortion method is one of the many methods to systematically study the perceptual aspect of this body image. Using a distorted image of her own appearance, the subject is asked to reconstruct the 'exact' measures of her body and to indicate her ideal image. The reliability of this method has been assessed in a study involving 67 anorexic patients and 105 female university students. Test--retest results within the same session and over a one-week interval were sufficiently constant. Nonetheless, for both anorexics and controls, significant differences were found between estimates with a narrowed (thin) image initially and those with a widened (fat) image initially. Both groups underestimate their body measures and only significantly differ on estimates of their ideal image, with anorexics clearly less underestimating their ideal image than students.

Effect of prolonged physical exercise on intra-erythrocyte and plasma potassium

The intracellular concentrations of sodium [Na+] and potassium [K+] and the water content in human erythrocytes were investigated in 21 male runners before and after a marathon. From 2 to 5 min after the race, the intra-erythrocyte [K+] was significantly decreased (p less than 0.001) by 7% whereas the plasma [K+], intra-erythrocyte [Na+] and the erythrocyte water content were unchanged. The change in the intra-erythrocyte [K+] observed immediately after the marathon, was negatively correlated with the race time (r = -0.44; p less than 0.05). Furthermore, the change in the plasma [K+] (r = -0.64; p less than 0.001) and the amount of K+ excreted in the urine during the race (r = 0.54; p less than 0.05) were also, respectively, negatively and positively correlated with the race time. It is concluded that during prolonged physical exercise the erythrocytes could serve as a kind of K+ reservoir that is drained with increasing magnitude of body K+ loss. This might explain why in the faster marathon runners, in whom the urinary K+ loss is smaller and the K+ intake is greater than in the slower runners during race, the intra-erythrocyte [K+] is unchanged after a marathon whereas in the slower runners it is decreased.

Indicators of cell breakdown in plasma of men during and after a marathon race

Plasma indicators of muscle cell leakage and of hemolysis were studied in 23 runners before and after a marathon race. Blood samples were drawn from an antecubital vein the morning before the race (baseline), at 3 p.m., i.e., 2 h before the start, on arrival, 12 and 36 h, and 7 days later. Compared with the baseline values, the plasma creatinine phosphokinase MM and MB subfractions, aldolase and glutamicoxaloacetic transaminase activity were increased immediately after the race, rose further 12 h after the marathon, and remained elevated the race, rose further 12 h after the marathon, and remained elevated 36 h and 7 days later. The plasma lactate dehydrogenase activity and myoglobin concentration were increased on arrival and returned to the pre-race activity 7 days after the marathon. Compared with the pre-race values, the plasma haptoglobin concentration was decreased immediately and 12 h after the marathon. Our data show that indicators of muscle cell leakage and of hemolysis in plasma, withdrawn after a marathon race, remained elevated for up to 7 days after the race.

Erythrocyte 2,3-diphosphoglycerate concentration before and after a marathon in men

Erythrocyte 2,3-diphosphoglycerate (2,3-DPG) concentration was studied in 23 runners before and after a marathon race. Blood samples were drawn from an antecubital vein the morning before the race (baseline), at 3 p.m. 2 h before the start, on finishing, and 12 and 36 h later. Compared to the baseline values, erythrocyte 2,3-DPG concentration was increased (p less than 0.001) immediately after the marathon from 4.62 +/- 0.14 to 5.56 +/- 0.13 mumol.ml-1 RBC and remained elevated 12 h later (5.45 +/- 0.14 mumol.ml-1 RBC): it returned to prerace values 36 h after completion of the marathon.

Plasma atrial natriuretic peptide and cyclic nucleotide levels before and after a marathon

Plasma alpha-atrial natriuretic peptide (alpha-ANP) concentration and levels of cyclic nucleotides [guanosine 3',5'-cyclic monophosphate (cGMP) and adenosine 3',5'-cyclic monophosphate (cAMP)] were studied in 23 runners before and after a marathon race. Blood samples were drawn from an antecubital vein the morning before the race (base line), at 3 P.M. (i.e., 2 h before the start), on arrival, and 12 and 36 h and 7 days later. Compared with the base-line values of plasma alpha-ANP (5 pmol/l), cGMP (3.8 nmol/l), and cAMP (15.8 nmol/l), the plasma levels of alpha-ANP, cGMP, and cAMP were increased immediately after the marathon, respectively, to 12.0 pmol/l, 12.7 nmol/l, and 50.5 nmol/l. The increase in the plasma alpha-ANP concentration was related (r = 0.85; P less than 0.001) to the changes in plasma cGMP, plasma lactate, hematocrit, and body weight. The plasma cGMP and cAMP concentrations had returned to the prerace levels 12 h after the marathon, whereas the plasma alpha-ANP concentration was significantly lower (3.1 pmol/l) than the base-line values and increased above the prerace values 36 h (7.5 pmol/l) and 7 days (6.8 pmol/l) after the marathon. The plasma cGMP level was also higher 36 h (5.4 nmol/l) and 7 days (5.0 nmol/l) after the marathon race.

Comparison of cardiovascular response to combined static-dynamic effort, postprandial dynamic effort and dynamic effort alone in patients with chronic ischemic heart disease

The cardiovascular responses to combined static-dynamic effort, postprandial dynamic effort and dynamic effort alone were evaluated by upright bicycle ergometry during equilibrium-gated blood pool scintigraphy in 24 men, mean age 59 +/- 8 years, with chronic ischemic heart disease. Combined static-dynamic effort and the postprandial state elicited a peak cardiovascular response similar to that of dynamic effort alone; work load 643 +/- 156 and 638 +/- 161 vs 650 +/- 153 kg-m/min, respectively; heart rate 147 +/- 14 and 145 +/- 14 vs 143 +/- 17 beats/min; systolic pressure 195 +/- 26 and 200 +/- 25 vs 197 +/- 25 mm Hg; and rate-pressure product 286 +/- 48 and 292 +/- 55 vs 282 +/- 52. Heart rate, intraarterial systolic and diastolic pressures, rate-pressure product and ejection fraction were similar for the three test conditions at the onset of ischemia and at peak effort. The prevalence and extent of exercise-induced ischemic left ventricular dysfunction, ST-segment depression, angina pectoris and ventricular ectopic activity were also similar during the three test conditions. Direct and indirect measurements of systolic and diastolic blood pressure were highly correlated. The onset of ischemic ST-segment depression and angina pectoris correlated as strongly with heart rate alone as with the rate-pressure product during all three test conditions. The cardiovascular response to combined static-dynamic effort and to postprandial dynamic effort becomes more similar to that of dynamic effort alone as dynamic effort reaches a symptom limit. If significant ischemic and arrhythmic abnormalities are absent during symptom-limited dynamic exercise testing, they are unlikely to appear during combined static-dynamic or postprandial dynamic effort. This simplifies, the task of formulating guidelines for physical effort in patients with chronic ischemic heart disease, especially in providing "clearance" to perform avocational and vocational tasks involving combined static-dynamic and postprandial dynamic effort.

Reproducibility of thallium-201 myocardial imaging

Seventy-six thallium-201 myocardial perfusion studies were performed on twenty-five patients to assess their reproducibility and the effect ofvarying the level of exercise on the results of imaging. Each patient had a thallium-201 study at rest. Fourteen patients had studies on two occasions at maximum exercise, and twelve patients had studies both at light and at maximum exercise. Of 70 segments in the 14 patients assessed on each of two maximum exercise tests, 64 (91%) were reproducible. Only 53% (16/30) of the ischemic defects present at maximum exercise were seen in the light exercise study in the 12 patients assessed at two levels of exercise. Correlation of perfusion defects with arteriographically proven significant coronary stenosis was good for the left anterior descending and right coronary arteries, but not as good for circumflex artery disease. Thallium-201 myocardial imaging at maximum exercise is reproducible within acceptable limits, but careful attention to exercise technique is essential for valid comparative studies.