Prevalence of epilepsy in rural Bolivia: a door-to-door survey

OBJECTIVE

To carry out a door-to-door survey in rural areas of the Cordillera Province, Santa Cruz Department, Bolivia, to determine the prevalence of neurologic diseases (epilepsy, stroke, parkinsonism, and peripheral neuropathy) in a sample of approximately 10,000 inhabitants.

METHODS

A team of nondoctor health workers administered a standard screening instrument for neurologic diseases-a slightly modified version of the World Health Organization protocol. All subjects found positive during the screening underwent a neurologic examination.

RESULTS

On screening, the authors found 1,130 positive subjects, of whom 1,027 were then investigated by neurologists. On the basis of the definition proposed by the International League Against Epilepsy, we detected 124 epileptic patients (prevalence, 12.3/1,000), 112 of whom had active epilepsy (prevalence, 11.1/1,000) on the prevalence day (November 1, 1994). Peak age-specific prevalence occurred in the 15 to 24-year age group (20.4/1,000). Sex-specific prevalence was higher in women (13.1/1,000) than men (11.4/1,000). Eighty-nine patients (71.8%) underwent a standard EEG recording. Considering both EEG and clinical data, partial seizures were the most common type (53.2%) based on the classification of the International League Against Epilepsy. The mean age at onset was 20.7 years for partial seizures and 13.6 years for generalized seizures. Only 10.5% of patients had received specific treatment for more than 2 months of their life.

CONCLUSION

This report on epilepsy prevalence in Bolivia confirms that epilepsy is a major health problem in rural areas of developing countries.

Epilepsy, cysticercosis, and toxocariasis: a population-based case-control study in rural Bolivia

OBJECTIVE

To assess the relationship between epilepsy and infection with Taenia solium and Toxocara canis with a case-control study, in the rural area of the Cordillera Province, Bolivia.

METHODS

A preliminary two-phase door-to-door prevalence survey determined the prevalence of epilepsy and identified cases and control subjects. At least two control subjects per case were selected, matching on sex, age, and community of residence. Cases and control subjects were assessed serologically for antibodies against T. canis by ELISA and against T. solium by enzyme-linked immunoelectrotransfer blot (EITB).

RESULTS

The prevalence survey found 130 confirmed cases of epilepsy, of which 113 were eligible for the case-control study (59 partial seizures and 54 generalized seizures). Two hundred thirty-three control subjects were selected. Multivariable analysis for a matched case-control study was carried out. There was an association between EITB positivity for T. solium and epilepsy with an OR of 1.85 (95% CI 0.99 to 3.4) for all cases. A stronger association was found in those with partial epilepsy with a late onset of disease (15 years and older), where the OR was 3.66 (95% CI 1.10 to 12.10). A positive association was also found with T. canis for all cases with an OR of 2.70 (95% CI 1.41 to 5.19). This increased for those with late-onset partial epilepsy to an OR of 18.22 (95% CI 2.10 to 158.10).

CONCLUSION

This finding suggests that both neurocysticercosis and toxocariasis may in part explain the higher prevalence of epilepsy, particularly partial epilepsy, in developing countries.

Patterns of antimicrobial use and antimicrobial resistance among healthy children in Bolivia

OBJECTIVE

To determine the incidence of antimicrobial-resistant, nonpathogenic Escherichia coli among healthy children aged 6-72 months in Camiri town and a rural village, Javillo, in south-eastern Bolivia.

METHOD

A community-based survey: stool samples were obtained from 296 healthy children selected by modified cluster sampling in Camiri and all 25 eligible children in Javillo. E. coli isolates were tested for antimicrobial susceptibility according to the standard disc diffusion method. By a questionnaire survey of 12 pharmacies and by using simulated patients, we investigated the antimicrobial availability and the usage patterns in Camiri town.

RESULTS

In Camiri, over 90%, and in Javillo over 70% of children carried E. coli resistant to ampicillin, trimethoprim-sulphamethoxazole (TMP/SMX) or tetracycline. Overall, 63% of children carried E. coli with multiple resistance to ampicillin, TMP/SMX, tetracycline and chloramphenicol. In the simulated patients study, antimicrobials were dispensed inappropriately for 92% of adults and 40% of children with watery diarrhoea, and were under-prescribed for males with urethral discharge (67%) or females with fever and dysuria (58%). The dose and/or duration of antimicrobials dispensed was almost always too low.

CONCLUSION

Our study showed a disturbingly high prevalence of carriage of nonpathogenic E. coli resistant to antimicrobials. The prevalence of resistance to ampicillin and TMP/SMX was higher than that previously reported in developing countries. The existence of a large reservoir of resistance genes in healthy individuals in developing countries represents a threat to the success of antimicrobial therapy throughout the world. Programmes to improve rational and effective drug use in developing countries are urgently needed.

In-vitro activity of nisin against clinical isolates of Clostridium difficile

Nisin is a cationic peptide produced by Lactococcus lactis. Its activity against clinical isolates of Clostridium difficile was compared to that of vancomycin and metronidazole by minimum inhibitory concentration (MIC), minimum bactericidal concentration (MBC) and time-kill studies. Nisin was more active than the other agents, with a MIC90 of 0.256 mg/L and strong bactericidal activity. Nisin may be a promising agent for the management of C. difficile associated diarrhea.

Antistaphylococcal (MSSA, MRSA, MSSE, MRSE) antibiotics

S. aureus and coagulase-negative staphylococci such as S. epidermidis are important causes of infection of the bloodstream, cardiac valves, implanted devices, and skin, with repercussions on mortality and increased economic costs. Treatment of staphylococcal infections is made difficult by the increasing emergence of resistance to beta-lactams and other antimicrobials, including reduced susceptibility to glycopeptides. Penicillin must be used for infrequent penicillin-susceptible isolates, oxacillin and nafcillin are to be considered the major option for penicillin-resistant staphylococci, and glycopeptides are the drugs of choice for infections caused by methicillin-resistant strains. Co-trimoxazole, lincosamides, macrolides, tetracyclines, and fluoroquinolones are alternative agents, primarily in subjects allergic to beta-lactams. Newly introduced or experimental drugs, such as streptogramins (quinupristin-dalfopristin), oxazolidinones (linezolid), carbapenems (LY 333328), everninomicins (SCH 27899), and derivatives of tetracyclines (glycylcyclines), could be useful for therapy of infections caused by multiresistant staphylococci.

Urosepsis in the critical care unit

Critical care unit patients show a higher risk of developing a bloodstream infection than ward patients. The urinary tract is the main source of hospital-acquired secondary bloodstream infection. Nosocomial urinary tract infection is promoted by bladder catheterization in the vast majority of cases. Aerobic gram-negative bacilli are the prevalent agents of bloodstream infection secondary to a nosocomial urinary tract infection. Sepsis and septic shock are severe complications of these infections in the critical care patient. Management of patients with a septic process of urinary source calls for the combination of adequate life-supporting care, an appropriate antibiotic therapy, and innovative adjunctive measures. Accurate catheter care is the best measure to adopt for the prevention of urosepsis.

Prevalence of antibodies against hepatitis A and E viruses among rural populations of the Chaco region, south-eastern Bolivia

We conducted a cross-sectional study to determine the seroprevalence of antibodies against hepatitis A and hepatitis E viruses (HAV and HEV) in the population of two rural areas, Camiri and Villa Montes, of the Chaco region, south-eastern Bolivia. HAV antibodies were detected in 461 (94.1%) of 490 serum samples tested, not differing significantly between sexes and study areas. The HAV seropositivity rate (64.7%) was high even in the youngest age group (1-5 years). The prevalence of HEV was 7.3%, with no significant differences between sexes. The prevalence of HEV antibodies in the population of the Camiri area (10.4%) was significantly higher than in the Villa Montes area (4.4%), possibly due to the better quality of drinking water in the Villa Montes area. In the population </= 30 years of age, the HEV seropositivity rate (4.4%) was significantly lower than in the >/= 31 year-old group. This is consistent with findings in other countries. This is the first report of the prevalence of HEV infection in Bolivia.

Haloferax volcanii for biotechnology applications: challenges, current state and perspectives

Haloferax volcanii is an obligate halophilic archaeon with its origin in the Dead Sea. Simple laboratory culture conditions and a wide range of genetic tools have made it a model organism for studying haloarchaeal cell biology. Halophilic enzymes of potential interest to biotechnology have opened up the application of this organism in biocatalysis, bioremediation, nanobiotechnology, bioplastics and the biofuel industry. Functionally active halophilic proteins can be easily expressed in a halophilic environment, and an extensive genetic toolkit with options for regulated protein overexpression has allowed the purification of biotechnologically important enzymes from different halophiles in H. volcanii. However, corrosion mediated damage caused to stainless-steel bioreactors by high salt concentrations and a tendency to form biofilms when cultured in high volume are some of the challenges of applying H. volcanii in biotechnology. The ability to employ expressed active proteins in immobilized cells within a porous biocompatible matrix offers new avenues for exploiting H. volcanii in biotechnology. This review critically evaluates the various application potentials, challenges and toolkits available for using this extreme halophilic organism in biotechnology.

Proposal of an improved score method for the diagnosis of pulmonary tuberculosis in childhood in developing countries

210 children aged less than 5 years, referred to the Arua Regional TB Centre (Uganda) for suspected pulmonary tuberculosis (PTB), were examined by anamnesis, clinical examination, Mantoux test, gastric washing, chest X-ray. The response to treatment criterion was applied to the patients treated. According to the score method suggested by Ghidey and Habte, 31 children were diagnosed as PTB patients. 30 of the 31 children with PTB tested positive for alcohol acid-fast bacilli (AAFB) in the aspirated juice. The Mantoux test and X-rays gave a minor contribution to diagnosis. The clinical results are commented. A statistical analysis was carried out to evaluate the role of gastric washing in the diagnosis of PTB in children under 5 years of age (sensitivity, 96.8%; specificity, 92.2%; positive predictive value, 68.2%; negative predictive value, 99.4%). The response to treatment was also evaluated. A modified enlarged score method (based on gastric washing and including response to treatment) is proposed to be applied in developing countries where chest X-ray and other facilities are often lacking.

Clinical and microbiologic efficacy and safety profile of linezolid, a new oxazolidinone antibiotic

Gram-positive cocci are important causes of infection both in the community and in the hospital, with repercussions on mortality and increased economic costs. Treatment of these infections is made difficult by the increasing emergence of multi-resistant organisms, primarily among Gram-positive cocci, such as vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus and coagulase-negative staphylococci, and penicillin-resistant pneumococci. Linezolid, a member of the new class of synthetic antimicrobials named oxazolidinones, has several favourable characteristics including high activity against multiresistant Gram-positive cocci. In a number of clinical trials, linezolid showed good clinical and microbiologic efficacy in the therapy of infections caused by these organisms. It can be considered a valid option for treating both community- and hospital-acquired infections due to multiresistant Gram-positive cocci.

Streptococcus pneumoniae as an agent of nosocomial infection: treatment in the era of penicillin-resistant strains

Streptococcus pneumoniae is a well-known agent of community-acquired infections such as sinusitis, otitis media, pneumonia, bacterial meningitis, bacteremia and acute exacerbations of chronic bronchitis. However, the role of S. pneumoniae as a cause of nosocomial infections of respiratory tract, bloodstream and central nervous system is more and more recognized, primarily in high-risk patients with depression of their immune function. Therapy of pneumococcal infections is made difficult by the emergence and spread of bacterial resistance to penicillin and other beta-lactams as well as to a number of antimicrobials such as macrolides, chloramphenicol, tetracyclines and sulfonamides. This epidemiological situation is a cause for concern world-wide, but it primarily affects some European countries, North America, South Africa and the Far East. The main consequence on therapeutic grounds is that in severe infections such as bacterial meningitis, the addition of vancomycin to a third-generation cephalosporin is advisable while awaiting laboratory test results, even in areas with low prevalence of penicillin-resistant pneumococci. However, a beta-lactam agent can also be a valid choice in the presence of potentially lethal infections such as pneumonia or in the case of penicillin intermediately resistant isolates. In recent years, new alternative molecules have been introduced into clinical practice for therapy of infections caused by penicillin-resistant pneumococci. In both in vivo and in vitro studies, drugs of the classes of fluoroquinolones (levofloxacin, moxifloxacin, gatifloxacin), streptogramins (quinupristin/dalfopristin) and oxazolidinones (linezolid) have shown good microbiologic and clinical efficacy against penicillin-resistant pneumococci. In this era of world-wide spread of penicillin-resistant pneumococci, use of polysaccaride or conjugated vaccines is highly recommended.

Parasitological observations on three Bolivian localities including rural communities, cities and institutions

Three hundred of 381 subjects examined from the Camiri, Boyuibe and Gutierrez areas (Santa Cruz Department) harboured one to six species of intestinal helminths and/or protozoa. High infection rates were found in Camiri in the orphanage (43 of 44 persons) and in the Military Hospital (10 of 10 persons), as well as in Itanambicua (97.4%), a rural community close to the city (38 of 39 persons). No significant differences were noted between the overall parasitic prevalences observed in rural and urban environments, but the frequency of species was different. Indiscriminate defaecation, the habit of living in close association with animals, overcrowding, and especially lack of health education, are some of the factors responsible for the parasitic situation observed.

A neuroepidemiological survey in rural Bolivia: background and methods

A door-to-door survey was carried out in rural areas of the Cordillera province, Santa Cruz Department, Bolivia. A cluster sample of 10,124 inhabitants was selected. The aim was to determine the prevalence of the most common neurological diseases (epilepsy, stroke, parkinsonism and peripheral neuropathy) in this population using a modification of the World Health Organization screening instrument. 1,130 subjects screened positive and were then investigated by neurologists. In this paper we describe the background and methods of the survey and the characteristics of the population.

Infections in multiple myeloma

Multiple myeloma is a relatively rare but severe hematologic malignancy. Marked depression in production of normal immunoglobulins, mild neutropenia, and alkylant/steroid therapy or BMT/SCT all produce major suppression of the immune system in the totality of patients. Recurrent bacterial, fungal, and viral infections are an important cause of morbidity and the most common cause of death in these subjects. Prompt diagnosis and appropriate anti-infective chemotherapy are essential in order to reduce the risk of mortality.

The influence of some metabolic inhibitors on phagocytic activity of mouse macrophages in vitro

The action of different metabolic inhibitors on phagocytosis by macrophages from mouse peritoneal exudate cultured in vitro was studied. The following metabolic inhibitors were tested: sodium iodoacetate, sodium fluoride, sodium fluoroacetate, sodium malonate, 2-4-dinitrophenol, sodium azide, ouabain and cycloheximide, all at the concentration of 10(-3) M. Iodoacetate caused a strong inhibitory effect on phagocytosis; this observation confirms that glycolysis is the main source of energy for the phagocytic process. On the contrary, fluoride, although it is an effective inhibitor of glycolysis, did not exert any effect. This difference may be explained by the fact that sodium fluoride blocks anaerobic glycolysis only in vitro at an unphysiological temperature (0 degrees C). Fluoroacetate and malonate, two compounds which interfere with the Krebs cycle, did not inhibit phagocytosis, but it is known that the Krebs cycle activity is poorly developed in the macrophagic cells. Sodium azide and 2-4-dinitrophenol, two inhibitors of oxidative phosphorylation, showed an effect on phagocytosis only after 3 h of contact with the cell cultures. Ouabain blocks Na+ and K+ transport across the plasma membrane and, probably, it inhibited phagocytosis by interfering with the movements of the cell membrane. Finally, the mode of action of cycloheximide on phagocytosis is uncertain. This compound inhibits the protein synthesis and, perhaps, it can act by preventing the renewal of the cell membrane.

Skeletal tuberculosis and other granulomatous infections

After several decades of steadily decreasing incidence, tuberculosis has had a resurgence in the past 15 years, not only in the lungs, but also in extrapulmonary sites. This is primarily a result of the AIDS pandemic, considering that HIV specifically affects cellular immunity, which is the first-line defence against tuberculosis. The generally non-specific clinical and radiological patterns of skeletal tuberculosis make it similar to other bacterial, fungal, inflammatory and neoplastic diseases of the bones and joints. Physicians must not omit tuberculosis in the differential diagnosis of any osteo-articular inflammatory process so that specific treatment may be initiated as soon as possible. Anti-tuberculous therapy is beset by important factors that limit its efficacy, such as the emergence of drug toxicity and of resistant or multiresistant mycobacterial strains. Surgical treatment may be indicated in selected cases where medical therapy alone is not sufficient to eradicate the problem.

In-vitro differentiation of human monocytes into mature macrophages during long-term cultures

A method is described which allows human peripheral blood monocytes from any given donor to differentiate in vitro into mature macrophages. About 90% of the starting monocytes are maintained during the long-term culture and are matured to macrophages. Thus cell loss is minimal and the resulting population of mature macrophages can be regarded as representative for all possible macrophage subpopulations present in peripheral blood. These cultures represent a standardized model for in-vitro studies on the role of mature macrophages in various immunological reactions.

Distribution and antibiotic resistance of isolates from lower respiratory tract and blood cultures from patients in three Italian intensive care units: a 2-year comparison

The distribution and antibiotic resistance of major pathogens isolated from patients in ICUs were studied by three Italian microbiological laboratories. Consecutive aerobic strains were collected over two different time periods from protected brushing bronchoscopy, broncho-alveolar lavage and blood cultures. A total of 420 strains were isolated during the first period (47.3% gram-negative and 52.7% gram-positive) and 412 over the second period (50.5% gram-negative and 49.5% gram-positive). Pseudomonas aeruginosa was the most frequently isolated organism from the respiratory tract followed by Staphylococcus aureus. Methicillin resistance was 47.9 and 44.5% in S. aureus and 63.0 and 65.1% in coagulase-negative staphylococci over the two periods. No glycopeptide-resistance was found in gram-positive organisms. Ceftazidime-resistance in Klebsiella pneumoniae was very high.

Haloferax volcanii as immobilised whole cell biocatalyst: new applications for halophilic systems

Enzyme-mediated synthesis of pharmaceutical compounds is a 'green' alternative to traditional synthetic chemistry, and microbial engineering opens up the possibility of using whole cells as mini-factories. Whole-cell biocatalysis reduces cost by eliminating expensive enzyme purification and cofactor addition steps, as well as resulting in increased enzyme stability. Haloferax volcanii is a model halophilic archaeon encoding highly salt and organic solvent tolerant enzymes such as alcohol dehydrogenase (HvADH2), which catalyses the reduction of aldehydes and ketone in the presence of NADPH/NADH cofactor. A H. volcanii strain for constitutive HvADH2 expression was generated using a strong synthetic promoter (p.syn). The strain was immobilised in calcium alginate beads and repeatedly used as a whole-cell biocatalyst. The reduction of acetophenone, used as test substrate, was very successful and high yields were detected from immobilised whole cells over repeated biotransformation cycles. The immobilised H. volcanii retained stability and high product yields after 1 month of storage at room temperature. This newly developed system offers halophilic enzyme expression in its native environment, high product yield, stability and reusability without the addition of any expensive NADPH/NADH cofactor. This is the first report of whole cell-mediated biocatalysis by the halophilic archaeon H. volcanii.

Nosocomial bacterial and fungal meningitis in children; an eight year national survey reporting 101 cases. Pediatric Nosocomial Meningitis Study Group

One hundred and one cases of nosocomial meningitis in children from a national survey over 8 years have been analyzed for risk factors and outcome. From 101 cases, 115 organisms were isolated. Seventy six were Gram-positive bacteria, 29 were Gram-negative and there were ten fungal isolates. Major risk factors for acquisition of nosocomial meningitis were neurosurgery (70.2%), ventriculoperitoneal shunt (42.9%), prior therapy with broad spectrum antibiotics (64.1%), central venous catheter (94.5%), premature neonates with very low birth weight (32.8%) and total parenteral nutrition (68.8%). Overall attributable mortality was 14. 9%; in bacterial infection it was 13.2% and in fungal nosocomial meningitis, 30.0%. Higher mortality was significantly related to perinatal pathology with CNS abnormality, prematurity polymicrobial infection with Enterobacteriaceae and concomitant bacteraemia. Prematurity in neonates, very low birth weight and infection with Enterobacteriaceae were significantly associated with a worse outcome.

Which prophylactic regimen for which surgical procedure?

For optimal prevention of infection subsequent to a surgical intervention, it is necessary to follow a series of general principles, including the classification of the type of surgical intervention, the characteristics of the antibiotic used, and the route and the time of its administration. Moreover, with reference to the different types of surgery, other factors assume importance: the etiology of the infection and the ability of the antibiotic to achieve adequate levels in the tissues at the beginning of the infective process. In general abdominal, biliary, and obstetric-gynecologic surgery, which covers many clean-contaminated and contaminated interventions for which antibiotic prophylaxis has been shown to be the most effective, the etiology is often mixed (aerobic and anaerobic flora) with a predominance of gram-negative microorganisms. Thus, an appropriate prophylactic regimen must consider a third-generation cephalosporin, such as cefotaxime, that is effective against most gram-negative bacteria, in particular against Klebsiella pneumoniae. Acylureido penicillins can also be used because of their activity against enterococci, gram-positive microorganisms that are also causes of infection in this area of surgical intervention. Combining an antimicrobial such as clindamycin or metronidazole, which are particularly active against anaerobes, may be recommended as well. In urologic surgery, most infections are caused by Enterobacteriaceae; in addition to the antimicrobial spectrum, the ability of the antibiotic to concentrate adequately in the urine and renal tissue must also be considered. Beta-lactam antibiotics are the agents of choice, in particular, third-generation cephalosporins, aztreonam, and acylureido penicillins. In cardiac, orthopedic, and partially in neurologic surgery, where most infections are due to gram-positive bacteria (primarily methicillin-resistant staphylococci), antibiotic prophylaxis should include a glycopeptide agent (teicoplanin, vancomycin). In the field of surgical prophylaxis, more experience has been accumulated with cefotaxime, used as a short-course regimen or as a convenient single dose, than with any other newer cephalosporin. Cefotaxime's broad spectrum of action provides coverage against most potential pathogens and, when used as a single dose, is both convenient and cost-effective.

The influence of some metabolic inhibitors on in vitro phagocytizing macrophages. I. The behaviour of human macrophages

In the present work the uptake of foreign materials by macrophages has been studied in order to elucidate its possible energy-dependent mechanisms. We used monolayer cultures of macrophages from human peripheral venous blood, treated with the following metabolic inhibitors: iodoacetic acid, fluoroacetic acid, sodium fluoride, sodium malonate, sodium azide, 2-4-dinitrophenol, cycloheximide, and ouabain. The test assay was performed by using a zymosan particles suspension in Mc Coy 5 A medium supplemented as follows. The quantitation of phagocytosis was obtained by direct count of intracellular zymosan particles by oil 100X microscopy and the results were submitted to a statistical evaluation. The most effective inhibitor we found was iodoacetate, an inhibitor of anaerobic glycolysis, but fluoride, which acts on the same metabolic pathway at a different site, was quite ineffective. The same ineffectiveness we found for fluoracetate and malonate which act on the Krebs cycle. On the contrary, dinitrophenol (uncoupler of oxidative phosphorylation), azide (inhibitor of cytochrome linked-phosphorylation), ouabain (inhibitor of membrane ATPase activity) and cycloheximide (inhibitor of protein synthesis) give a remarkable decrease of index of phagocytosis after a 3h incubation. In conclusion, we can suppose that the energy-dependent phagocytosis is first depending on transport across the cell membrane (ATPase activity and protein synthesis) and second both on anaerobic glycolysis and oxidative phosphorylation.