Necrotizing pulmonary aspergillosis and ventricular assist device infection: case report and review of literature

Necrotizing pulmonary aspergillosis and Aspergillus device infection are rare and have potentially fatal complications after left ventricular assist device (LVAD) implantation. To date, few cases of patients surviving Aspergillus device infection have been published, with survival reported only after device removal. We present a patient implanted with an LVAD in whom necrotizing pulmonary aspergillosis with device involvement was successfully treated by segmentectomy and prolonged antifungal treatment without device exchange or removal. Similar cases in the literature were searched for and are discussed in view of the severity of this complication.

Malaria mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites

Background

Malaria continues to be a major cause of infectious disease mortality in tropical regions. However, deaths from malaria are most often not individually documented, and as a result overall understanding of malaria epidemiology is inadequate. INDEPTH Network members maintain population surveillance in Health and Demographic Surveillance System sites across Africa and Asia, in which individual deaths are followed up with verbal autopsies.

Objective

To present patterns of malaria mortality determined by verbal autopsy from INDEPTH sites across Africa and Asia, comparing these findings with other relevant information on malaria in the same regions.

Design

From a database covering 111,910 deaths over 12,204,043 person-years in 22 sites, in which verbal autopsy data were handled according to the WHO 2012 standard and processed using the InterVA-4 model, over 6,000 deaths were attributed to malaria. The overall period covered was 1992–2012, but two-thirds of the observations related to 2006–2012. These deaths were analysed by site, time period, age group and sex to investigate epidemiological differences in malaria mortality.

Results

Rates of malaria mortality varied by 1:10,000 across the sites, with generally low rates in Asia (one site recording no malaria deaths over 0.5 million person-years) and some of the highest rates in West Africa (Nouna, Burkina Faso: 2.47 per 1,000 person-years). Childhood malaria mortality rates were strongly correlated with Malaria Atlas Project estimates of Plasmodium falciparum parasite rates for the same locations. Adult malaria mortality rates, while lower than corresponding childhood rates, were strongly correlated with childhood rates at the site level.

Conclusions

The wide variations observed in malaria mortality, which were nevertheless consistent with various other estimates, suggest that population-based registration of deaths using verbal autopsy is a useful approach to understanding the details of malaria epidemiology.

Cause-specific childhood mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites

Background

Childhood mortality, particularly in the first 5 years of life, is a major global concern and the target of Millennium Development Goal 4. Although the majority of childhood deaths occur in Africa and Asia, these are also the regions where such deaths are least likely to be registered. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering deaths and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.

Objective

To present a description of cause-specific mortality rates and fractions over the first 15 years of life as documented by INDEPTH Network sites in sub-Saharan Africa and south-east Asia.

Design

All childhood deaths at INDEPTH sites are routinely registered and followed up with verbal autopsy (VA) interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provided person-time denominators for mortality rates. Cause-specific mortality rates and cause-specific mortality fractions are presented according to WHO 2012 VA cause groups for neonatal, infant, 1–4 year and 5–14 year age groups.

Results

A total of 28,751 childhood deaths were documented during 4,387,824 person-years over 18 sites. Infant mortality ranged from 11 to 78 per 1,000 live births, with under-5 mortality from 15 to 152 per 1,000 live births. Sites in Vietnam and Kenya accounted for the lowest and highest mortality rates reported.

Conclusions

Many children continue to die from relatively preventable causes, particularly in areas with high rates of malaria and HIV/AIDS. Neonatal mortality persists at relatively high, and perhaps sometimes under-documented, rates. External causes of death are a significant childhood problem in some settings.

Pregnancy-related mortality in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System sites

Background

Women continue to die in unacceptably large numbers around the world as a result of pregnancy, particularly in sub-Saharan Africa and Asia. Part of the problem is a lack of accurate, population-based information characterising the issues and informing solutions. Population surveillance sites, such as those operated within the INDEPTH Network, have the potential to contribute to bridging the information gaps.

Objective

To describe patterns of pregnancy-related mortality at INDEPTH Network Health and Demographic Surveillance System sites in sub-Saharan Africa and southeast Asia in terms of maternal mortality ratio (MMR) and cause-specific mortality rates.

Design

Data on individual deaths among women of reproductive age (WRA) (15–49) resident in INDEPTH sites were collated into a standardised database using the INDEPTH 2013 population standard, the WHO 2012 verbal autopsy (VA) standard, and the InterVA model for assigning cause of death.

Results

These analyses are based on reports from 14 INDEPTH sites, covering 14,198 deaths among WRA over 2,595,605 person-years observed. MMRs varied between 128 and 461 per 100,000 live births, while maternal mortality rates ranged from 0.11 to 0.74 per 1,000 person-years. Detailed rates per cause are tabulated, including analyses of direct maternal, indirect maternal, and incidental pregnancy-related deaths across the 14 sites.

Conclusions

As expected, these findings confirmed unacceptably high continuing levels of maternal mortality. However, they also demonstrate the effectiveness of INDEPTH sites and of the VA methods applied to arrive at measurements of maternal mortality that are essential for planning effective solutions and monitoring programmatic impacts.

Ainsliaolide D: a new sesquiterpene lactone from Ainsliaea pertyoides

Ainsliaolide D, a new guaiane-type sesquiterpene lactone, was isolated from the roots of Ainsliaea pertyoides Fr. var. albotomentosa Beauverd. Its structure was determined based on spectral data.

[Acquired Gitelman syndrome associated with Sjögren's syndrome and scleroderma]

Tubulopathy can complicate autoimmune diseases. It is usually a distal tubular acidosis, but Fanconi syndrome or Bartter syndrome has been exceptionally reported. We report a case of acquired Gitelman syndrome in a 32-year-old male who also presented diffuse scleroderma autoimmune thyroiditis, and Sjögren's syndrome. Only three cases of Sjögren syndrome associated with Gitelman syndrome have been previously reported in literature. The absence of other cases in the family and absence of mutation SLC12A3 emphasise the relation between autoimmune disease and this tubulopathy.

Female genital mutilation and its prevention: a challenge for paediatricians

Female genital mutilation (FGM) is defined as an injury of the external female genitalia for cultural or non-therapeutic reasons. FGM is mainly performed in sub-Saharan and Eastern Africa. The western health care systems are confronted with migrants from this cultural background. The aim is to offer information on how to approach this subject. The degree of FGM can vary from excision of the prepuce and clitoris to infibulation. Infections, urinary retention, pain, lesions of neighbouring organs, bleeding, psychological trauma and even death are possible acute complications. The different long-term complications include the risk of reduced fertility and difficulties during labour, which are key arguments against FGM in the migrant community. Paediatricians often have questions on how to approach the subject. With an open, neutral approach and basic knowledge, discussions with parents are constructive. Talking about the newborn, delivery or traditions may be a good starting point. Once they feel accepted, they speak surprisingly openly. FGM is performed out of love for their daughters. We have to be aware of their arguments and fears, but we should also stress the parents' responsibility in taking a health risk for their daughters. It is important to know the family's opinion on FGM. Some may need support, especially against community pressure. As FGM is often performed on newborns or at 4-9 years of age, paediatricians should have an active role in the prevention of FGM, especially as they have repeated close contact with those concerned and medical consequences are the main arguments against FGM.

Die Blauzungenkrankheit in Deutschland – eine neue Herausforderung für die Veterinärverwaltung

Nach der Bestätigung des Ausbruchs der Blauzungenkrankheit des Serotyps 8 zuerst in den Niederlanden und folgend auch in angrenzenden Gebieten in Belgien, Deutschland und Frankreich Mitte August 2006 kam auf die Veterinärverwaltung eine ganz neue Herausforderung zu. Bis zu diesem Zeitpunkt galt die anzeigepflichtige und hauptsächlich durch bestimmte Mückenarten (Culicoidesspp.) übertragbare Seuche als „exotisch”; sie trat nie zuvor in Mitteleuropa auf. Sofort leiteten die betroffenen Länder Maßnahmen zum Schutz vor der Blauzungenkrankheit ein. Es wurden ein Gefährdungsgebiet (20 km um einen Ausbruchsbetrieb) und ein Beobachtungsgebiet (150 km um einen Ausbruchsbetrieb) eingerichtet, in denen Untersuchungsmaßnahmen und ein eingeschränktes Verbringen empfänglicher Tiere durchgesetzt wurde. Aktuell sind vor allem Rinder und Schafe betroffen. Das klinische Bild umfasst bei beiden Tierarten vor allem schleimig-eitrigen Nasenausfluss, Gingivitis und Temperaturerhöhung, bei Rindern auch Rötungen und Erosionen an Euter und insbesondere den Zitzen. Die Zahl der erkrankten Tiere steigt zur Zeit noch, doch bleibt die Hoffnung auf ein „Totlaufen” der Infektion in den Wintermonaten durch das Sterben exotischer Mückenvektoren. Allerdings sind dann in diesem Zusammenhang alle Maßnahmen zur Verhinderung einer iatrogenen Öbertragung von großer Bedeutung.

Usefulness of midodrine in patients with severely symptomatic neurocardiogenic syncope: a randomized control study

INTRODUCTION

The efficacy of midodrine for the management of patients with neurocardiogenic syncope was assessed prospectively in a randomized control study.

METHODS AND RESULTS

Patients who had at least monthly occurrences of syncope and a positive tilt-table test were included in the study. A total of 61 patients were randomly allocated to treatment either with midodrine or with fluid, salt tablets, and counseling. Midodrine was given at a starting dose of 5 mg three times a day and increased up to a dose of 15 mg three times a day when required. Midodrine was given during the daytime every 6 hours. Thirty-one patients were assigned to treatment with midodrine; the other 30 patients were advised to increase their fluid intake and were instructed to recognize their prodromes and abort the progression to syncope. Patients were followed-up for at least 6 months. A quality-of-life questionnaire was administered at the time of randomization and 6 months after. At the 6-month follow-up, 25 (81%) of 31 midodrine-treated patients and 4 (13%) of the 30 fluid-therapy patients had remained asymptomatic (P < 0.001). One patient had to discontinue taking midodrine due to severe side effects and another six patients experienced minor side effects that did not require drug discontinuation.

CONCLUSION

Midodrine appeared to provide a significant benefit in patients with neurocardiogenic syncope. To prevent recurrence of symptoms, dose adjustments were required in about one third of patients.

Prospective validation of a diagnosis model as an aid to therapeutic decision-making in acute meningitis

The aim of this study was to validate a diagnosis model that provides pABM, the probability of bacterial versus viral meningitis, based on four parameters collected at the time of first lumbar tap: cerebrospinal fluid protein level, cerebrospinal fluid polymorphonuclear cell count, blood glucose level, and leucocyte count. The model was evaluated prospectively as an aid to therapeutic decision-making in 109 consecutive patients with acute meningitis and negative cerebrospinal fluid Gram stain. In each case pABM was computed before a therapeutic decision and three diagnoses were established successively: (i) clinical evaluation, i.e. before pABM computation (bacterial meningitis, viral meningitis, or meningitis of undetermined origin); (ii) computation of pABM (viral meningitis if pABM< 0.1, bacterial meningitis otherwise); and (iii) determination of definitive diagnosis (bacterial meningitis: positive cerebrospinal fluid culture; viral meningitis: negative cerebrospinal fluid culture, no other aetiology and no treatment; meningitis of undetermined origin: cases fitting neither of the first two diagnoses). The computed diagnosis was viral meningitis in 78 of the 80 cases diagnosed definitively as viral meningitis, and bacterial meningitis in four of the five cases diagnosed definitively as bacterial meningitis. Negative and positive predictive values and accuracy of the model were 98.7%, 66.7%, and 96.5%, respectively. The clinical diagnosis was undetermined in 22 cases, 15 of which were diagnosed definitively as viral cases; in all of these 15 cases, the computed diagnosis was viral meningitis, leading the physician to refrain from starting antibiotics in all of them. The results confirm that the model evaluated is reliable and aids in the identification of patients in whom antibiotics can be safely avoided.

Validation of a diagnosis model for differentiating bacterial from viral meningitis in infants and children under 3.5 years of age

The aim of this study was to validate, in a population of infants and children under 3.5 years of age, a diagnosis model that provides a figure for the probability of bacterial meningitis (pABM), based on four parameters collected at the time of the first lumbar tap: the cerebrospinal fluid (CSF) protein level, CSF polymorphonuclear cell count, blood glucose level, and leucocyte count. The best cut-off value for distinguishing between bacterial and viral meningitis was previously found to be 0.1, since 99% of meningitides associated with pABM<0.1 were viral. The charts of 103 consecutive children aged 0.1-3.5 years who had been hospitalised for acute meningitis were reviewed. Each case was sorted into the following three categories for aetiology: bacterial (positive CSF culture, n=48); viral (negative CSF culture and no other aetiology, and no antibiotic treatment after diagnosis, n=36); and undetermined (fitting neither of the first two definitions, n=19). After computation of pABM values in each case, the predictive values of the model were calculated for different pABM cut-off values. The results confirmed that the best cut-off pABM value was 0.1, for which the positive and negative predictive values in this model were 96% and 97%, respectively. Only one case of bacterial meningitis (lumbar tap performed early in an infant with meningococcal purpura fulminans with negative CSF culture) was associated with a pABM value of <0.1. This model is quite reliable for differentiating between bacterial and viral meningitis in children under 3.5 years of age, and it may enable physicians to withhold antibiotics in cases of meningitis of uncertain aetiology.

[Autoimmunity: a concept to be revisited?]

Autoimmunity is thought to be a defect in immunologic tolerance, resulting in the activation and expansion of self antigen-specific T and B lymphocyte clones and the production of circulating antibodies, and a myriad of cytokines and other inflammatory mediators. This hypothesis, which speculates on an aberrant response of the immune system to normal self antigens has exerced a powerful influence on clinical investigations and therapeutic researches. Although much information has accumulated, the mechanism of autoimmune disease remains poorly understood and little attention has been paid to the hypothesis that autoimmune diseases might be caused by a conventional immunological response against self antigens for which tolerance has never been established. Clinical practice would undoubtedly get a lot out of it, as well as new therapeutic measures.

Changes in left ventricular volume during head-up tilt in patients with vasovagal syncope: an echocardiographic study

We tested the hypothesis that patients who have vasovagal syncope during head-up tilt have a greater decrease in their left ventricular volume in response to tilt than do normal subjects. Measurements were done in the supine position and during graded tilt by using two-dimensional echocardiography. We compared seven patients with vasovagal syncope with nine normal volunteers. The rate of reduction of end-diastolic volume index during tilt was faster in the vasovagal group than in normal subjects. A more significant reduction of stroke index and ejection fraction during tilt was found in the vasovagal group than in normal subjects, possibly because of more peripheral translocation of blood volume in the venous system during tilt and an early vagal effect on ventricular contraction.

[Way, aim, state and perspective of the Aujeszky's disease (AD) eradication program in North Rhine Westphalia]

In August 1991 a program to eliminate Aujeszky's disease from the whole pig herds in North Rhine Westphalia within six years was initiated. The wide area vaccination program combined with the eradicating program was so successful that most farms in North Rhine Westphalia were free of infection till February 1995, only 1% of the farms have not taken part in this program. As a consequence of the different situation of the control of the Aujeszky's disease in other states changes of the decree which has the objectives of eradicating Aujeszky's disease are planned. The changes should allow to transport pigs from herds which are not free of infection after April 1, 1995 too under certain circumstances. To keep the present eradicating success in North Rhine Westphalia special protection measures are necessary. This includes especially the decree of the state protection decree which came into effect on April 1, 1995.

Head-up tilt and hemodynamic changes during orthostatic hypotension in patients with supine hypertension

OBJECTIVES

This study assessed the mechanism(s) of the decrease in upright blood pressure in patients with supine hypertension by using the tilt test and a hemodynamic approach.

BACKGROUND

Orthostatic hypotension in patients with supine hypertension creates a pathophysiologic and therapeutic dilemma.

METHODS

We studied 28 consecutive patients with history of orthostatic intolerance amounting to recurrent syncope in 13 of them (15 men, 13 women; mean [SD] age 65 +/- 11 years). They all had supine hypertension (systolic blood pressure > 160 mm Hg) and orthostatic hypotension (found to be a decrease in systolic blood pressure > 30 mm Hg during tilt test). Cardiac output, cardiopulmonary volume and systemic resistance were assessed by radionuclide first-pass technique (technetium-99m red blood cell tagging). Total blood volume was determined by radioiodinated serum albumin, and the ratio of cardiopulmonary to total blood volume was used as an index of venous capacitance.

RESULTS

Twenty-one patients had accentuated venous pooling defined as a tilt-induced decrease in cardiopulmonary volume/total blood volume ratio > 15% from baseline or a supine ratio < 14% (normal 16% to 18%), or both. Seven of the 28 patients had autonomic insufficiency; 6 of the 7 also had venous pooling; 1 patient had autonomic insufficiency only. Neither clinical history nor changes during tilt differentiated the subgroups. Plasma catecholamine levels increased during head-up tilt in all subgroups, and differences in their increase were not significant between patients with venous pooling and those with autonomic insufficiency. However, radionuclide hemodynamic variables revealed that patients with venous pooling compensated for the decrease in stroke volume by increasing peripheral resistance, whereas patients with autonomic dysfunction did not.

CONCLUSIONS

Orthostatic hypotension in patients with supine hypertension may have multiple etiologies. Hemodynamic assessment with determination of cardiopulmonary volume and systemic vascular resistance differentiated between venous pooling and autonomic insufficiency in these patients; head-up tilt and plasma catecholamine levels did not. These findings may have important therapeutic implications.

Sensitivity and specificity of the tilt table test in young patients with unexplained syncope

The usefulness of the head-up tilt testing (HUT) has been previously addressed in diagnosing vasovagal neuroregulatory syncope in the teenage population. However, data concerning sensitivity and specificity is deficient due to the lack of control groups. We compared the response to HUT in young patients referred because of syncope or near syncope (n = 44, mean age 16 +/- 3 years SD) to healthy young volunteers with a normal physical examination and no previous history of syncope (n = 18, mean age 16 +/- 2 years) and to determine the sensitivity and specificity of HUT. The graded tilt protocol was performed at 15 degrees, 30 degrees, and 45 degrees (each for 2 min), and then 60 degrees for 20 minutes. Cuff blood pressure was measured every minute and lead II ECG was continuously monitored.

RESULTS

25 of the 44 patients (57%) developed a vasovagal response or became symptomatic after 13.8 +/- 5.7 minutes of HUT. Three of the 18 volunteers (17%) had a vasovagal response and became symptomatic after 9 +/- 3 minutes of HUT. There was no statistical difference among the four groups (with and without tilt induced vasovagal response) in terms of age and baseline hemodynamic data. The sensitivity of 20 minutes HUT was 57% and its specificity was 83%. The presyncopal hemodynamic response in patients with history of syncope that was characterized by a significant decrease in systolic blood pressure and lack of increase of diastolic blood pressure as compared with baseline and with other groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Veterinary administration in the Rhineland--yesterday and today]

The public veterinary administration was founded in July 1817 by the "Supreme Act" and developed from the public medical administration during the first half of the 19th century to finally an adequate position in 1913. In the beginning prior objectives were animal disease campaigns and participation in animal breeding activities. Towards the end of the last century the public veterinary administration also dealt with hygiene control concerning food of animal origin and meat hygiene. Further fields of activities followed, for example the control of the disposal of animal carcases, trade with animal drugs, vaccines and feedstuff, protection of animals and poultry meat hygiene. It was of special importance to the medium level of the public veterinary administration when in 1981 a chemist engaged in the supervision of food for human consumption was employed by the "Regierungspräsident" Cologne. It was then possible to lump together both control in the complete field of supervision of food for human consumption and public veterinary administration.

[Results of distraction by way of external metacarporadial fixation in fracture of the distal end of the radius. Apropos of 97 cases]

104 fractures cases were treated over 5 years using this method, which is reserved for the most critical cases (less than one fourth the total number of fractures of the distal end of the radius); 97 of those were reviewed by an impartial observer. The technique consists in distractive reduction, maintained by a small external holding device interconnecting two pins inside the radius and two pins in the 2nd metacarpal bone. Usually, the device is removed after 45 days. Subjective results were rated "very good" in 62.8% of cases, while post-mobilization, radiological and overall findings rated likewise in 61.8%, 40.2% and 63.9% of cases, respectively. Half the patients presented secondary displacement, which although usually minimal, did necessitate in 6 cases a new reduction (using the same device). Algodystrophy occurred in 17 cases and constituted the main source of complications. It increased in frequency proportionally to the degree of distraction applied. At long term, important finger stiffness persisted only in 3 cases. Thus, the quality of results obtained makes external fixator distraction a choice therapeutic method in hard-to-manage fractures.

Isolation of recombinant partial gag gene product p18 (HIV-1Bru) from Escherichia coli

The membrane-associated structural protein, p18, of the human immunodeficiency virus (HIV-1), has been expressed in Escherichia coli. The recombinant protein was purified by cation-exchange chromatography on S Sepharose followed by cation-exchange high-performance liquid chromatography (HPLC) on Sulfoethyl Aspartamide. The isolation of 28.7 mg of recombinant p18 from 16.71 of cell culture represents an overall yield of ca. 20%. Recombinant p18 was characterized by sodium dodecyl sulphate polyacrylamide gel electrophoresis, reversed-phase HPLC, amino acid composition and amino acid sequence analysis of the N-terminus. Edman degradation of peptides generated by trypsin or Staphylococcus aureus V8 proteolytic digestion, including the C-terminus, confirmed the amino acid sequence to be that predicted from the cDNA. A C-terminally cleaved form of recombinant p18, p18LM, was separated in the cation-exchange HPLC step and was partially characterized in parallel with the intact molecule. By Western blotting it was shown that recombinant p18 in addition to the cleaved form p18LM is recognized by a monoclonal antibody which was generated against the natural protein from HIV-1.

Complete characterization of the human IGF-I nucleotide sequence isolated from a newly constructed adult liver cDNA library

A full-size cDNA sequence coding for insulin-like growth factor I (IGF-I) was isolated from a human liver library. For the construction of this bank, a new method was developed which anneals dG-tailed cDNA with a synthetic adaptor 5'-AATTCCCCCCCCCCC-3' followed by ligation into the EcoRI site of a lambda immunity-insertion vector. Based on the sequence analysis of the complete IGF-I messenger we concluded that the protein is synthesized as a precursor containing a signal peptide of 22 or 25 amino acid residues. In addition, the sequence extended in the 3'-direction and showed the presence of multiple polyadenylation sites in the IGF-I message.