Multilocus genotyping of human Giardia isolates suggests limited zoonotic transmission and association between assemblage B and flatulence in children

BACKGROUND

Giardia intestinalis is one of the most common diarrhea-related parasites in humans, where infection ranges from asymptomatic to acute or chronic disease. G. intestinalis consists of eight genetically distinct genotypes or assemblages, designated A-H, and assemblages A and B can infect humans. Giardiasis has been classified as a possible zoonotic disease but the role of animals in human disease transmission still needs to be proven. We tried to link different assemblages and sub-assemblages of G. intestinalis isolates from Swedish human patients to clinical symptoms and zoonotic transmission.

METHODOLOGY/PRINCIPAL FINDINGS

Multilocus sequence-based genotyping of 207 human Giardia isolates using three gene loci: ß-giardin, glutamate dehydrogenase (gdh), and triose phosphate isomerase (tpi) was combined with assemblage-specific tpi PCRs. This analysis identified 73 patients infected with assemblage A, 128 with assemblage B, and six with mixed assemblages A+B. Multilocus genotypes (MLGs) were easily determined for the assemblage A isolates, and most patients with this genotype had apparently been infected through anthroponotic transmission. However, we also found evidence of limited zoonotic transmission of Giardia in Sweden, since a few domestic human infections involved the same assemblage A MLGs previously reported in Swedish cats and ruminants. Assemblage B was detected more frequently than assemblage A and it was also more common in patients with suspected treatment failure. However, a large genetic variability made determination of assemblage B MLGs problematic. Correlation between symptoms and assemblages was found only for flatulence, which was significantly more common in children less than six years of age infected with assemblage B.

CONCLUSIONS/SIGNIFICANCE

This study shows that certain assemblage A subtypes are potentially zoonotic and that flatulence is connected to assemblage B infections in young children. Determination of MLGs from assemblages A and B can be a valuable tool in outbreak situations and to help identify possible zoonotic transmission.

Water intoxication associated with non-steroidal anti-inflammatory drug therapy

Two cases of rheumatoid arthritis, who developed severe hyponatremia after treatment with non-steroidal anti-inflammatory drugs (NSAID) are presented. Early diagnosis was followed by rapid correction with hypertonic saline. It is suggested that NSAIDs, like piroxicam, diclofenac and indomethacin, may be added to the list of drugs which can induce syndrome of inappropriate antidiuretic hormone (SIADH).

The study of women in Gothenburg 1968-1969. Intake of energy and nutrients in five age groups

Women from five age groups (38, 46, 50, 54, and 60 years), participating in the population study "Women in Gothenburg 1968-1969", were subjected to a 24-hour recall dietary interview (n = 1361). In a randomized subsample (n = 418), a dietary history was obtained and individuals in another randomized subsample (n = 755) submitted a 24-hour urine specimen for nitrogen analyses. There were significant differences between the 24-hour recall and dietary history figures in all five age groups with respect to energy and all nutrients. The mean protein intake calculated indirectly from the urinary nitrogen excretion came close to the figures calculated from the dietary histories in four out of five age groups. The energy intake and, consequently, the intake of most nutrients calculated from the dietary histories were higher than generally ascribed to Swedish women, as most previous data have been obtained by 24-hour dietary recall interviews. Most women (71-89% in the different age groups) consumed too much fat and most women of fertile age (80-92%) consumed too little iron. A significant decrease in the mean energy intake was apparent only in the age group 60, i.e. 1870 kcal versus 1965--2 105 in the other groups.

Is late stent thrombosis in drug-eluting stents a real clinical issue? A single-center experience and review of the literature

BACKGROUND

Randomized studies have not found an increased rate of late stent thrombosis (LAST) in drug-eluting stents (DES) compared with bare metal stents (BMS) but those studies were statistically not powered to show such a difference. At the same time there is an increasing number of reports of LAST in DES patients in the current literature.

PATIENTS AND METHODS

We tried to describe the incidence of LAST in an unselected DES and BMS patient population. All patients who underwent stenting in our hospital between October 2003 and March 2006 were included in the study (n=1377). A total of 424 (30.1%) patients were treated with only BMS stents, 520 (37.8%) with paclitaxel-eluting stents (PES), 384 (27.9%) with sirolimus-eluting stents (SES) and 49 (3.6%) with BMS and DES. Long-term follow-up of all patients was used to determine the incidence of LAST as defined by angiographically proven stent thrombosis associated with acute symptoms more than 30 days after stent implantation. Followup was between 1 month and 2 years 7 months (mean 12 months). Patients treated with DES were younger (66+/-11 years) than BMS patients (72+/-10 years; p<0.001) and more often had diabetes (24.2% vs 17.4%; p < 0.001). A previous PCI had been performed in 27.1% of DES patients vs 13.9% of BMS patients (p < 0.001).

RESULTS

There were 9 cases of LAST: 2 with SES (at 6 and 11 months after implantation), 6 with PES (at 6, 9 (2x), 10, 16 and 26 months), and one with BMS (at 22 months). All patients with LAST presented with STEMI and without an angina history that suggested restenosis. Two cases were related to complete cessation of antiplatelet therapy, one because of patient non-compliance (SES), one after aspirin was stopped for orthopedic surgery (BMS). Two cases occurred within 1 month of cessation of clopidogrel therapy and while these patients were on aspirin therapy. Five cases occurred on aspirin monotherapy 2, 3, 4, 10 and 20 months, respectively after planned cessation of clopidogrel. None of the cases occurred under dual antiplatelet therapy. All patients underwent primary PCI; none died.

CONCLUSION

Angiographically proven LAST occurred in our unselected patient population with an incidence of 0.84% in patients treated with DES and 0.21% in BMS patients within a mean follow-up of 12 months (p = 0.36). LAST may indeed occur in clinically stable patients while on aspirin monotherapy. Since LAST led in all patients to STEMI it seems to be a serious clinical issue that prompts further investigation and discussion of length of dual platelet therapy.

[Leflunomide--the first specific disease-modifying drug against rheumatoid arthritis]

Rheumatoid arthritis (RA) is a disabling disorder with chronic inflammation leading to significant disability and pain if not treated early and effectively. Leflunomide is the first drug developed and registered specifically for modifying disease course in RA, and is a good complement to other forms of drug therapy currently in use. In clinical trials, leflunomide has been proven to exert an effect on clinical parameters of RA-inflammation superior to placebo and equal to methotrexate and sulphasalazine, while clinical response evidently begins somewhat earlier than on these other drugs. There appears to be a retarding effect on radiographic progression over 13 months comparable to that of methotrexate and sulphasalazine. The very long elimination half-life as well as side effects including nausea, diarrhea, and elevated liver enzymes (almost as frequent as with methotrexate) hamper its usefulness, and its definitive place in modern RA-therapy remains to be established.

Functional capacity and early radiographic osteoarthritis in middle-aged people with chronic knee pain

BACKGROUND AND PURPOSE

In order to improve the physiotherapeutic treatment of patients with long-standing knee pain, it is important to identify osteoarthritis (OA) of the knee at an early stage. The aim of the present study was to test the value of single functional measurement variables with the focus on the lower extremities for the association to early radiographic signs of OA of the knee. The classification by Ahlbäck grade I (joint space narrowing) was used in a cohort of 204 individuals aged 35-54 years with long-standing knee pain.

METHODS

The following five selected tests were employed: three tests of static and dynamic balance (Balance I-III); one test of muscle strength (one-leg-rising-test, OLR); and one test of walking ability (time for walking 300 m indoors). Odds ratios (ORs) were calculated with a 95% confidence interval.

RESULTS AND CONCLUSIONS

Results revealed that the selected tests of functional capacity due to rather low sensitivity (0.15-0.81), specificity (0.21-0.86) and inconclusive odds ratios (0.78-1.62) are probably of limited value as assessment tools to find radiographic knee OA in a younger population with mild OA. However, it is also possible to conclude that in middle-aged individuals with chronic knee pain, the diagnosis of radiographic OA is not related to the functional capacity as measured in the present study.

[Pain analysis is vital in rheumatic diseases. Pain often causes much worry to patients]

The article consists of a synthesis of a rheumatic pain symposium held at the annual meeting of the Swedish Medical Association in 1996. Various aspects of pain in rheumatic diseases were discussed, such as physiological, neurohumoral and neurogenic mechanisms, sensory stimulation treatment, differentiation of mechanical and inflammatory pain, quality enhancement by improved co-operation between primary and tertiary care facilities, pharmacological treatment with (centrally and peripherally acting) opioids, selective cyclo-oxygenase inhibitors, and NMDA (N-methyl-D-aspartate) receptor antagonists. For patients with rheumatic disorders exacerbated by pain problems, as for other patients, a pain diagnosis is of fundamental importance. This can be achieved by analysis of the social, psychological, physiological and medical factors contributing to the cause and degree of pain and to pain behaviour, and of the extent to which the pain may be nociceptive (i.e., inflammatory, mechanical, or ischaemic in origin), neurogenic or idiopathic. Pain analysis should be followed by individualised treatment focused on the patient's most crucial problems, thus enhancing the prospect of optimal treatment outcome.

[Pain analysis is vital in rheumatic diseases. The pain is often the patient's worst problem]

The article consists of a synthesis of a rheumatic pain symposium held at the annual meeting of the Swedish Medical Association in 1996. Various aspects of pain in rheumatic diseases were discussed, such as physiological, neurohumoral and neurogenic mechanisms, sensory stimulation treatment, differentiation of mechanical and inflammatory pain, quality enhancement by improved cooperation between primary and tertiary care facilities, pharmacological treatment with (centrally and peripherally acting) opioids, selective cyclo-oxygenase inhibitors, and NMDA (N-methyl-D-aspartate) receptor antagonists. The aim of the symposium, with its focus on the manifest pain problem, was to improve our knowledge and skill in the understanding and treatment of this large patient category. For patients with rheumatic disorders exacerbated by pain problems, as for other patients, a pain diagnosis is of fundamental importance. This can be achieved by analysis of the social, psychological, physiological and medical factors contributing to the cause and degree of pain and to pain behaviour, and of the extent to which the pain may be nociceptive (i.e., inflammatory, mechanical, or ischaemic in origin), neurogenic or idiopathic. Pain analysis should be followed by individualised treatment focused on the patient's most crucial problems, thus enhancing the prospect of optimal treatment outcome.

Gadolinium-DTPA-enhanced MR imaging in asymptomatic knees

PURPOSE

To evaluate the occurrence and extent of Gd-DTPA-enhanced synovial structures in asymptomatic knee joints of middle-aged healthy individuals.

MATERIAL AND METHODS

MR imaging of the knee joint was performed in 10 healthy subjects aged 40-61 years. The study included a sagittal T1-weighted SE sequence before and after i.v. injection of 0.1 mmol Gd-DTPA/kg b.w.

RESULTS

Contrast-enhanced synovial structures were found in all knees. The extent of the synovial structures was usually not uniform within the examined joint. In the intercondylar fossa, the thickness of synovial structures was more often pronounced. In the suprapatellar recess, synovial thickness was constant and minimal.

CONCLUSION

The presence and the varying extent and thickness of synovial structures in asymptomatic knees in middle-aged individuals must be considered in the evaluation of early and mild synovitis of the knee joint with Gd-enhanced MR imaging in this age group.

Dynamic training and circulating neuropeptides in patients with rheumatoid arthritis: a comparative study with healthy subjects

This study aimed at evaluating the effects of a dynamic physical training programme on circulating levels of corticotropin-releasing hormone (CRH), beta-lipotropin (beta-LPH), and beta-endorphin (beta-EP) after high-intensity training for 6 weeks (60 min twice a week) and after low-intensity training (home-training) for another 6 months in patients with rheumatoid arthritis (RA) and in healthy subjects. Additionally, differences in neuropeptide levels between the two groups were studied. A total of 30 patients with RA were randomly allocated to the study, 15 in the training group (TG) and 15 in the control group (CG). In addition, 20 healthy subjects (10 in TG; 10 in CG) participated. In addition to the biochemical analyses, the following variables were assessed for the RA group: pain and disability (Stanford health assessment questionnaire), joint tenderness (Ritchie articular index), disease activity, muscle function, aerobic capacity, sociodemographic data and attitudes. The results obtained at the start revealed significant differences (p < 0.05) between RA patients and healthy subjects concerning CRH levels, RA patients showing the lower levels (RA-group Md = 24 pmol/L, healthy group Md = 29 pmol/L). No significant differences concerning beta-LPH and beta-EP were found here. After the high-intensity training period, a significant increase of the CRH levels were found for the RA-TG (pretest Md = 24 pmol/L, after 6 weeks Md = 27 pmol/L, p < 0.05). No such results were found for the healthy-TG or the control groups. Concerning beta-EP, significant differences between the RA-TG and healthy-TG were found after the training. RA patients generally showing higher levels as compared with the healthy (RA-group Md = 42 pmol/L, healthy group Md = 36 pmol/L, p < 0.05). The same pattern was found for the beta-LPH levels. In conclusion, the effects of physical training on circulating neuropeptides remain still incompletely examined, and there is no definite answer to the question whether increased beta-EP levels are good or bad.

Podophyllum derivatives (CPH 82) compared with placebo in the treatment of rheumatoid arthritis

The efficacy, tolerance, and safety of CPH 82 (semisynthetic lignan glycosides) (Conpharm AB) for patients with rheumatoid arthritis (RA) were assessed in a 12-week double-blind placebo-controlled study. Thirteen patients out of 15 in the CPH 82 group and 10 out of 15 in the placebo group completed the study. No improvement was seen in placebo treated patients. Patients treated with CPH 82 showed a statistically significant improvement in most clinical and immunological variables. Some patients treated with CPH 82 reported gastrointestinal discomfort (diarrhoea and abdominal pain).

A study on liquid diet in geriatric patients

The intake of energy and nutrients was studied during 16 days in nine geriatrics immobilized patients who had received a conventional liquid diet for an extended period of time. The intake of energy averaged only 870 kcal/24 h. Fat intake was very low, averaging 16 g/24 h, which corresponds to 17 per cent of the total energy intake. The mean protein intake was 33 g/24 h. To improve the energy and nutrient content a food supplementation was added to the liquid diet. During the following 16 days the intake of energy increased to a daily mean of 1380 kcal. Fat and protein intake increased to 38 and 73 g/24 h, respectively. No essential change in the volume consumed after addition of the food supplementation was observed. Urinary nitrogen excretion was analyzed during the study. A positive nitrogen balance occurred after the patients had received the food supplementation.