Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

[Don't be guided purely by numbers: false increased TSH values due to analytical interference]

BACKGROUND

Physicians are often guided by laboratory values. When a clinical presentation does not match laboratory values, one must consider the possibility that these values may be falsely increased or decreased. A common cause is analytical interference.

CASE DESCRIPTION

A 57-year-old male, presenting with fatigue and palpitations, had high TSH and normal FT4 values. Although there were no fitting clinical symptoms for these values, the patient was treated with levothyroxine assuming he had subclinical hypothyroidism. TSH levels remained high, however, whereas FT4 levels increased and the patient developed thyrotoxicosis. Eventually, it was discovered that the TSH was falsely elevated.

CONCLUSION

The patient turned out to have macro TSH, where TSH forms conjunctions with IgG into larger molecules. These conjugates cause a rarely occurring interference during laboratory analysis, resulting in a falsely increased TSH value.

Perspective: Advancing the research agenda for improving understanding of cyanobacteria in a future of global change

Harmful cyanobacterial blooms (=cyanoHABs) are an increasing feature of many waterbodies throughout the world. Many bloom-forming species produce toxins, making them of particular concern for drinking water supplies, recreation and fisheries in waterbodies along the freshwater to marine continuum. Global changes resulting from human impacts, such as climate change, over-enrichment and hydrological alterations of waterways, are major drivers of cyanoHAB proliferation and persistence. This review advocates that to better predict and manage cyanoHABs in a changing world, researchers need to leverage studies undertaken to date, but adopt a more complex and definitive suite of experiments, observations, and models which can effectively capture the temporal scales of processes driven by eutrophication and a changing climate. Better integration of laboratory culture and field experiments, as well as whole system and multiple-system studies are needed to improve confidence in models predicting impacts of climate change and anthropogenic over-enrichment and hydrological modifications. Recent studies examining adaptation of species and strains to long-term perturbations, e.g. temperature and carbon dioxide (CO₂) levels, as well as incorporating multi-species and multi-stressor approaches emphasize the limitations of approaches focused on single stressors and individual species. There are also emerging species of concern, such as toxic benthic cyanobacteria, for which the effects of global change are less well understood, and require more detailed study. This review provides approaches and examples of studies tackling the challenging issue of understanding how global changes will affect cyanoHABs, and identifies critical information needs for effective prediction and management.

Health related quality of life in Dutch infants, toddlers, and young children

Background

The purpose of this study is to provide Dutch normative data and to assess internal consistency and known-groups validity for the TNO AZL Preschool Children Quality of Life (TAPQOL) and the acute version of the generic Pediatric Quality of Life Inventory (PedsQL 4.0) in Dutch young children aged 0–7 years.

Methods

Participants were selected from a panel of a large Dutch market research agency. A sample of 794 parents (response rate 61%, 39% fathers) of children (53% boys) from the general Dutch population, completed an electronic version of the TAPQOL (N = 227 infants aged 0–1 years) or PedsQL 4.0 (N = 293 toddlers aged 2–4 years and N = 274 young children aged 5–7 years).

Results

Except for the ‘stomach’ scale (α = .39), the TAPQOL showed acceptable to excellent internal consistency (α = .60-.88). The PedsQL 4.0 showed acceptable to excellent reliability in children aged 2–4 years (α = .60–.88) and in children aged 5–7 years (α = .76–.90). Children with a chronic health condition had lower scores than healthy children on 3 out of 12 domains of the TAPQOL (p = .001–.013) and on 2 out of 6 domains of the PedsQL 4.0 for children aged 2–4 years (p = .016–.04). The PedsQL 4.0 differentiated on all domains (p < .05) between children aged 5–7 years with and without a chronic health condition.

Conclusion

In Dutch children aged 0–7 years old, HRQoL can be relialy measured with the TAPQOL and the PedsQL 4.0. However, it remains unclear whether these HRQoL instruments can distinguish between healthy children and children with a chronic health condition under the age of 5.

Farmed Atlantic salmon Salmo salar L. parr may reduce early survival of wild fish

The study examined the density-mediated effects on growth, survival and dispersal of wild and farmed Atlantic salmon Salmo salar offspring in the period immediately following emergence, using a substitutive design. In small confined stream channels, wild parr coexisting with farmed parr had a significantly poorer survival, than wild parr alone. Density did not affect this relationship. In larger unconfined stream channels, wild parr coexisting with farmed parr entered a downstream trap in higher numbers than wild parr in allopatry. The results suggests that during the earliest life stages, farmed S. salar can outcompete wild S. salar, resulting in a reduced survival of wild S. salar.

TWENTE Study: The Real-World Endeavor Resolute Versus Xience V Drug-Eluting Stent Study in Twente: study design, rationale and objectives

Background. New-generation drug-eluting stents (DES) may solve several problems encountered with first-generation DES, but there is a lack of prospective head-to-head comparisons between new-generation DES. In addition, the outcome of regulatory trials may not perfectly reflect the outcome in 'real world' patients.Objectives. To compare the efficacy and safety of two new-generation DES in a 'real world' patient population.Methods. A prospective, randomised, single-blinded clinical trial to evaluate clinical outcome after Endeavor Resolute vs. Xience V stent implantation. The primary endpoint is target vessel failure at one-year follow-up. In addition, the study comprises a two-year and an open-label five-year follow-up. (Neth Heart J 2010;18:360-4.).

Psychological outcome and quality of life in children born with congenital diaphragmatic hernia

OBJECTIVE

To assess psychological and social functioning and health related quality of life and its early determinants in children born with congenital diaphragmatic hernia (CDH).

DESIGN

Cross-sectional follow-up study.

SETTING

Outpatient clinic of a tertiary care hospital.

PARTICIPANTS

33 CDH survivors aged 6-16 years.

MAIN EXPOSURE

Patients who developed CDH associated respiratory distress within 24 h after birth.

MAIN OUTCOME MEASURE

Psychological and social functioning assessed with the Wechsler Intelligence Scale for Children (WISC-R), Bourdon-Vos test, Beery Developmental Test of Visual Motor Integration, Child Behavior Checklist (CBCL) and Teacher Report Form (TRF), and health related quality of life assessed with the Child Health Questionnaire (CHQ) and Health Utilities Index (HUI).

RESULTS

Normal mean (SD) total IQ (100.0 (13.2)) and normal visual-motor integration, but significantly lower results for sustained attention (Bourdon-Vos test, 38.8 (11.2) points) were found. Learning difficulties were reported by 30% of parents. Eight children had scores in the clinical range on the CBCL and/or TRF, indicating clinically significant behavioural problems. Except for the CHQ scale General Health, health status was not different from the reference population. No significant correlations between test results and severity of CDH were found, except for an association of general health and physical functioning with length of hospital stay.

CONCLUSION

CDH patients are at risk for subtle cognitive and behavioural problems, probably not related to CDH severity. Perception of general health is reduced compared to the reference population, indicating that CDH survivors and their parents believe their health is poor and likely to get worse.

Behavioural functioning of retinoblastoma survivors

OBJECTIVE

To assess behavioural problems in retinoblastoma (RB) survivors.

METHODS

This population-based cross-sectional study included 148 RB survivors (8-35 years), registered in the Dutch national RB register. Survivors and parents were asked to fill in behavioural questionnaires. Prevalence rates were computed, based on both self-reports and proxy reports. One-sample T-tests were applied to analyse differences compared with healthy reference samples. Multiple regression analyses were performed to identify predictors for behavioural problems within the RB sample.

RESULTS

Between-group differences varied across informants and across age groups. Parents reported significantly elevated total problem behaviour in 30% of their offspring (aged 8-17 years); this against 9% in adolescents (12-17 years) and 12% in adults (18-35 years) based on self-report. Parental reports showed significantly elevated rates of (1) internalising problems in boys and (2) somatic complaints in both girls and boys. Self-reports indicate significantly lowered levels of (1) externalising problems in adolescent and adult women and (2) thought problems in female adolescents and in adult men. Especially survivors who suffered hereditary RB, who had undergone more intensive treatment, and who came from a single-parent family were identified to be at most behavioural risk.

CONCLUSION

Perception of severity and the nature of behavioural problems seem to differ between beholder, and to vary between age groups, if not between life stages. Health professionals should be aware that especially those who are confronted with hereditary RB and who subsequently undergo intensive treatment, and who grow up in broken families, run the risk of developing behavioural difficulties.

The long-term follow-up of patients with a congenital diaphragmatic hernia: a broad spectrum of morbidity

Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly with a mortality rate of approximately 40-50%, depending on case selection. It has been suggested that new therapeutic modalities such as nitric oxide (NO), high frequency oxygenation (HFO) and extracorporal membrane oxygenation (ECMO) might decrease mortality associated with pulmonary hypertension and the sequelae of artificial ventilation. When these new therapies indeed prove to be beneficial, a larger number of children with severe forms of CDH might survive, resulting in an increase of CDH-associated complications and/or consequences. In follow-up studies of infants born with CDH, many complications including pulmonary damage, cardiovascular disease, gastro-intestinal disease, failure to thrive, neurocognitive defects and musculoskeletal abnormalities have been described. Long-term pulmonary morbidity in CDH consists of obstructive and restrictive lung function impairments due to altered lung structure and prolonged ventilatory support. CDH has also been associated with persistent pulmonary vascular abnormalities, resulting in pulmonary hypertension in the neonatal period. Long-term consequences of pulmonary hypertension are unknown. Gastro-esophageal reflux disease (GERD) is also an important contributor to overall morbidity, although the underlying mechanism has not been fully understood yet. In adult CDH survivors incidence of esophagitis is high and even Barrett's esophagus may ensue. Yet, in many CDH patients a clinical history compatible with GERD seems to be lacking, which may result in missing patients with pathologic reflux disease. Prolonged unrecognized GERD may eventually result in failure to thrive. This has been found in many young CDH patients, which may also be caused by insufficient intake due to oral aversion and increased caloric requirements due to pulmonary morbidity. Neurological outcome is determined by an increased risk of perinatal and neonatal hypoxemia in the first days of life of CDH patients. In patients treated with ECMO, the incidence of neurological deficits is even higher, probably reflecting more severe hypoxemia and the risk of ECMO associated complications. Many studies have addressed the substantial impact of the health problems described above, on the overall well-being of CDH patients, but most of them concentrate on the first years after repair and only a few studies focus on the health-related quality of life in CDH patients. Considering the scattered data indicating substantial morbidity in long-term survivors of CDH, follow-up studies that systematically assess long-term sequelae are mandatory. Based on such studies a more focused approach for routine follow-up programs may be established.

Psychosexual functioning of childhood cancer survivors

PURPOSE

The objective of the study is to explore psychosexual functioning and its relationship with quality of life in survivors of cancer in childhood.

METHODS

Sixty childhood cancer survivors completed two questionnaires: psychosexual and social functioning questionnaire and MOS-SF-36.

RESULTS

Psychosexual problems were frequent. About 20% of the survivors felt a limitation in their sexual life due to their illness. Older survivors (> or =25 years) had significantly less experience with sexual intercourse than their age-matched peers in the Dutch population (p = 0.010). Survivors treated in adolescence had a delay in achieving psychosexual milestones compared with those treated in childhood: dating (p<0.025), touching under clothes (p<0.025), masturbation (female) (p<0.05) and sexual intercourse (p<0.025). No differences were found for sexual fantasies, kissing, masturbation (male) and oral sex. The total survivor group appraised their quality of life as less positive than their Dutch peers for the subscales of general and mental health (both p<0.001), physical and social functioning (p<0.01; p<0.001), bodily pain and vitality (both p<0.001). However, quality of life was not more affected adversely in survivors with psychosexual problems compared with survivors without these problems.

CONCLUSION

In this cohort of childhood cancer survivors, psychosexual problems were frequent. Treatment in adolescence is a risk factor for a delay in psychosexual development.

Dietary supplementation of long-chain polyunsaturated fatty acids in preterm infants: effects on cerebral maturation

AIM

To study the influence of dietary-supplied long-chain polyunsaturated fatty acids on structural brain maturation in preterm infants and to investigate parameters of functional brain development, relating them to structural maturation. Other studies have suggested that dietary supplementation of long-chain polyunsaturated fatty acids in preterm infants may enhance their visual development. The influence on structural brain development has never been evaluated.

METHODS

In a prospective, double-blind study, 42 formula-fed premature infants were randomized to be fed either a standard preterm formula without long-chain polyunsaturated fatty acids or an identical formula supplemented with docosahexaenoic acid (0.015 g/100 ml) and arachidonic acid (0.031 g/100 ml). Infants with significant cerebral damage, retinopathy, chronic disease or feeding problems were excluded. Follow-up was focused on assessment of cerebral myelination by MRI. Psychomotor, mental and visual development was analysed and flash-visual evoked potentials were recorded.

RESULTS

It was found that progress of myelination, mental and motor development and latencies of visual evoked potentials were not positively influenced by supplementation of long-chain polyunsaturated fatty acids. At each test age, visual acuity was slightly better in the supplemented infants than in the non-supplemented infants, but the difference never reached significance level

CONCLUSION

Supplementation of long-chain polyunsaturated fatty acids did not have a demonstrable positive influence on structural brain maturation. Related to this finding, in this small cohort of preterm infants without significant neurological damage, sample size being restricted by strict inclusion criteria and MRI procedures, no significant positive effects were found on psychomotor, mental and visual development.

[Centenary of the Health Council of the Netherlands. IV. Infectious diseases]

Many advisory reports of the Health Council of the Netherlands in the past century have dealt, directly or indirectly, with infectious diseases. One example is vaccination against smallpox. At the start of the last century, advice on this subject was important: initially, vaccination was compulsory by law, but people became increasingly aware of the associated side effects. A second example is immunisation against acute anterior poliomyelitis, which became a reality during the fifties. The advice also contained a discussion of which vaccine should be chosen: the inactivated 'dead' (Salk) form or the attenuated 'live' form (Sabin). Due to sound national organisation and associated logistics, a high level of vaccination was (and still is) achieved and the clinical disease known as polio disappeared from the Netherlands. Food-borne infections form the third example. The effect of the advice published by the Council on this subject (from 1960 onwards) has been limited, for a large part due to the significant economic consequences of the proposals for beef farming. The developments in the field of infectious diseases, immunology and vaccinology, together with social developments make it likely that in the coming years the Council will also frequently be asked for advice in the field of infectious diseases and the fight against them.

Critical conditions for phytoplankton blooms

We motivate and analyse a reaction-advection-diffusion model for the dynamics of a phytoplankton species. The reproductive rate of the phytoplankton is determined by the local light intensity. The light intensity decreases with depth due to absorption by water and phytoplankton. Phytoplankton is transported by turbulent diffusion in a water column of given depth. Furthermore, it might be sinking or buoyant depending on its specific density. Dimensional analysis allows the reduction of the full problem to a problem with four dimensionless parameters that is fully explored. We prove that the critical parameter regime for which a stationary phytoplankton bloom ceases to exist, can be analysed by a reduced linearized equation with particular boundary conditions. This problem is mapped exactly to a Bessel function problem, which is evaluated both numerically and by asymptotic expansions. A final transformation from dimensionless parameters back to laboratory parameters results in a complete set of predictions for the conditions that allow phytoplankton bloom development. Our results show that the conditions for phytoplankton bloom development can be captured by a critical depth, a compensation depth, and zero, one or two critical values of the vertical turbulent diffusion coefficient. These experimentally testable predictions take the form of similarity laws: every plankton-water-light-system characterized by the same dimensionless parameters will show the same dynamics.

Development of specific immunoglobulin E in coughing toddlers: a medical records review of symptoms in general practice

The aim of this study was to study whether young children, originally immunoglobulin E (IgE) negative and who became sensitized to specific inhalation allergens, presented more frequently to their general practitioner (GP) with other allergy- and asthma-related symptoms than children who remained IgE negative. It was also investigated whether asthma was diagnosed more often in children who developed IgE to inhalant allergens. Coughing children, 1-5 years of age, visiting the participating GPs, were tested for IgE antibodies to mites, dogs, and cats by using radioallergosorbent testing (RAST). All IgE-negative (RAST < 0.2 IU/ml) children were re-tested after 2 years. The medical records of 162 children were reviewed on asthma- and allergy-related symptoms and on prescribed medication. After 30 months, 27 of the 162 children (17%) had become IgE positive for one or more allergens. Most children (93%) had visited their GP for treatment of respiratory symptoms during this period. However, the children who had become IgE positive had visited their GP more often than the children who remained IgE negative. Differences in visits were seen for: shortness of breath (52% IgE-positive vs. 19% IgE-negative children, respectively), wheeze (37% vs. 17%), allergic rhinitis (33% vs. 16%), and pneumonia (22% vs. 8%), but not for coughing (89% vs. 88%). The IgE-positive children were more frequently diagnosed by their GP as having asthma (48%) than were the IgE-negative children (23%). In a multivariate analysis, indicators of becoming IgE positive were: a visit for shortness of breath (odds ratio [OR] = 6.9; 95% confidence interval [CI] = 2.1-23.1) and two or more visits for wheeze (OR = 6.0; 95% CI = 1.9-19.2), adjusted for breast-feeding, age, and asthma or allergy in the family. The positive predictive value (PPV) of being IgE positive with a diagnosis of asthma was 90% (whereas the negative predictive value was 48.0%) for a child attending their GP for treatment of wheeze. For recurrent coughing (six or more visits) and shortness of breath, the PPVs were 73% and 71%, respectively. The development of sensitization to common inhalant allergens is associated with specific allergy and asthma-related symptoms in young children. IgE-positive children were more frequently diagnosed as having asthma by their GP. This implies that in general practice it is possible to detect children at high risk for developing allergic asthma early in life by their respiratory symptoms and by subsequent testing for specific IgE to inhalant allergens.

[Pertussis: current epidemiology and recommendations of the Health Council with regard to vaccination policy]

Since the second half of 1996 epidemiological data point to an increased incidence of pertussis in the Netherlands despite high levels of immunisation. This increased incidence and the availability of new, so called acellular vaccines provoked a critical reflection on the present immunisation policy against pertussis. The Dutch Health Council has recommended replacing the cellular vaccine by an acellular vaccine, and adapting the immunisation schedule.

Behaviour and school achievement in patients with early and continuously treated phenylketonuria

Thirty patients with early and continuously treated phenylketonuria (PKU) between 8 and 20 years of age were compared with 30 controls, matched individually for age, sex, and educational level of both parents, on behaviour rating scales for parents and teachers as well as a school achievement scale. PKU patients, as a group, demonstrated more problems in task-oriented behaviour and average academic performance than did matched controls. Interestingly, whereas male PKU patients were rated significantly lower on introversion by their teachers, female patients were rated significantly higher on introversion and lower on extraversion than matched controls. This sex difference was also reflected in the relationship between measures of dietary control and the behaviour clusters, suggesting that male and female patients respond differently to elevated Phe levels or the stress associated with PKU. The teacher rating on average academic performance of the PKU patients was associated with recent level of dietary control, which suggests that it might be improved by more strict adherence to the diet. In addition, academic performance correlated negatively with the behaviour cluster negative task orientation. Further studies are recommended to obtain a more complete evaluation of this relationship and to replicate the current findings on larger samples. Over the years a number of studies have examined behaviour and school achievement in patients with early treated phenylketonuria (PKU; McKusick 261600). In general, these studies have found that despite early treatment with a phenylalanine (Phe)-restricted diet, PKU patients demonstrate more behavioural and school problems than do healthy controls. The behaviour problems include both internalizing symptoms (e.g. solitary, unresponsive, anxious, depressed mood: Pietz et al 1997; Smith et al 1988; Weglage et al 1992) and externalizing symptoms (e.g. hyperactive, talkative, impulsive, restless: Hendrikx et al 1994; Kalverboer et al 1994; Realmuto et al 1986; Smith et al 1988), but not antisocial or socially negative symptoms (e.g. lying, teasing, disobedience: Kalverboer et al 1994; Pietz et al 1997; Smith et al 1988). With respect to school achievement, studies have shown that patients with early treated PKU more often repeat classes or need special tutoring (Berry et al 1979; Brunner et al 1983; Koch et al 1987; Rey et al 1996; Verkerk 1995), have to work harder than healthy controls to achieve the same results (Weglage et al 1993), or have specific deficits in arithmetic achievement scores (Azen et al 1991; Berry et al 1979; Fishler et al 1987; Koch et al 1987; Weglage et al 1993). Nevertheless, many questions regarding the behavioural and school problems of patients with early treated PKU remain unanswered. For instance, the relationship between behavioural and school problems on the one hand and levels of dietary control on the other is still relatively unclear. The few studies that examined this relationship, have focused primarily on children in primary school (Azen et al 1991; Koch et al 1987; Smith et al 1988). Furthermore, although several psychological studies have shown that the pattern of behavioural problems varies by sex (see Prior et al 1999a for a discussion), so far very few studies have examined this issue in PKU patients and results are contradictory (Kalverboer et al 1994; Pietz et al 1997; Smith et al 1988; Weglage et al 1992). In addition, so far no study has actually examined whether there is a relationship between the behavioural problems and school difficulties of PKU patients, even though this relationship has been well documented in the psychological literature (Prior et al 1999b; Richards et al 1995). The aim of the present study is therefore to examine these issues in patients with early and continuously treated PKU over a wide age range and in relation to dietary control. More specifically, school achievement as well as social and task-oriented behaviour (at home

Local tolerance, pharmacokinetics, and dynamics of ganirelix (Orgalutran) administration by Medi-Jector compared to conventional needle injections

The feasibility of administering a relatively high dose of the gonadotrophin-releasing hormone (GnRH) antagonist ganirelix by means of a needle-free injection device, which could be useful in the long-term treatment of sex-steroid-dependent disorders, was evaluated in a randomized, crossover study in 16 healthy females. Local tolerance and pharmacokinetics of ganirelix administered by MediJector versus conventional needle injections were compared. Additionally, the pharmacodynamic effect was evaluated. Two milligrams of ganirelix was administered s.c. once daily for 7 days by Medi-Jector or conventional needle in a randomized sequence, without a washout period. No apparent differences in local tolerance were observed. Most injections (87.5%) gave either no or only a mild reaction. Of the moderate reactions, swelling and redness were reported most frequently (overall 4.9 and 8.5% per injection, respectively). Administration by Medi-Jector was bioequivalent to conventional needle injection with respect to the peak concentration and area under the curve. A profound suppression of luteinizing hormone and follicle stimulating hormone was observed. Serum oestradiol and progesterone concentrations were relatively low prior to treatment and remained low during the entire study period. In conclusion, administration of a relatively high dose of ganirelix by Medi-Jector might be useful for long-term treatment of sex-steroid dependent disorders.

Unilateral thalamic lesions in premature infants: risk factors and short-term prognosis

The aim of the study was to assess incidence, risk factors, clinical symptomatology and short-term outcome of unilateral thalamic lesions in preterm infants, as detected by ultrasound. Sixteen preterm infants, born after a gestational age of less than 35 weeks, with a unilateral thalamic lesion, but without additional significant cerebral lesions, were included. Their follow-up data were compared to those of a selected control group consisting of healthy premature infants. In addition, the neonatal clinical data of the patients with a thalamic lesion were compared to data of the healthy control group and of a general control group, consisting of a non-selected year-cohort of preterm infants. During the study period, the incidence of unilateral thalamic lesions was 5.3% among preterm infants. Ultrasound was not able to distinguish between hemorrhagic and ischemic lesions. The infants with a unilateral thalamic lesion had a more complicated respiratory course and were ventilated significantly longer than infants without such a lesion. The infants with a thalamic lesion had disturbances in tone, persisting throughout infancy, while the healthy control group showed only transient disturbances in tone.

Predictive value of neonatal MRI as compared to ultrasound in premature infants with mild periventricular white matter changes

A follow-up study was performed in 42 premature infants in whom serial neonatal ultrasound and a single neonatal MRI of the brain was normal, or showed mild periventricular white matter changes. The aim of the study was to evaluate the clinical significance of periventricular signal intensity changes on MRI and to compare the predictive value of neonatal MRI with that of ultrasound. The infants underwent repeated standardised motor assessments and developmental tests. MRI was repeated at the corrected age of 12 months. Pronounced periventricular signal intensity changes on neonatal MRI and periventricular echodensities (flaring) on ultrasound were associated with a high incidence of transient motor problems during infancy. The degree of echogenicity carried the highest predictive value, as compared to duration of flaring on ultrasound and degree of periventricular signal intensity change on MRI. It is concluded that signal intensity changes on neonatal MRI represent the same ischaemic change of the periventricular white matter as flaring on ultrasound and that routine neonatal MRI screening is not warranted in premature infants without clinical evidence of neurological problems and with normal or mildly abnormal ultrasound scans. Recording of the degree of echogenicity should become a routine procedure in neonatal cerebral ultrasonography.

[Physician-assisted suicide for a patient with a psychiatric disorder: guidelines for psychiatrists. Dutch Association of Psychiatry]

In September 1998, the Dutch Association of Psychiatry published guidelines for the psychiatrist concerning cases of psychiatric patients requesting assistance with suicide. Assistance with suicide is restricted to a psychiatrist in his role as a treating physician of a patient with a psychiatric disorder. Requests for assisted suicide should primarily be considered as requests for help with life. Individual psychiatrists have no moral or legal obligation to assist in suicide. The guidelines require that the request is voluntary, explicit and well considered, the desire for death long-lasting and the suffering unbearable and hopeless. In addition an independent psychiatrist should be consulted as well as former treating physicians, general practitioner, family members and other people involved. If a somatic specialist or a general practitioner is asked to assist in suicide consultation of two psychiatrists is required. The guidelines offer psychiatrists a framework for taking great care when their patients request assisted suicide and will certainly play a part in the legal control of assisted suicide.

An epidemic of pertussis among elderly people in a religious institution in The Netherlands

An epidemic of pertussis is described among elderly people in a religious institution in the Netherlands in 1992. Subjects were evaluated for their vaccination status and for history and presence of respiratory symptoms. Specimens were collected for culture, polymerase chain reaction, and serological evaluation. None of the 75 residents and 19 of 24 nonresident personnel had been vaccinated against pertussis. The overall attack rate of clinical pertussis, defined as persistent cough lasting at least 2 weeks, was 49%. In five subjects with clinical pertussis, either culture or polymerase chain reaction or both were positive for Bordetella pertussis. A significant (at least 4-fold) change in specific antibody titre was observed in 85% (41/48) and 20% (10/49) of subjects with and without clinical pertussis, respectively (P < 0.0001, chi-square 41.1). The attack rate of laboratory-confirmed pertussis was 42% (41/98). This rate was 5% (1/19), 20% (1/5), and 53% (39/74) in vaccinated personnel, nonvaccinated personnel, and nonvaccinated residents, respectively (not significant). Among residents aged between 55-74 years and 75-94 years, the attack rates were 47% (17/36) and 58% (22/38), respectively (relative risk=0.8; 95% confidence interval 0.5-1.3). Four of 75 residents (5%) died from intracranial bleeding, while they were symptomatic for pertussis. It is concluded that the attack rate of pertussis was high among nonvaccinated elderly and that pertussis tended to increase with age. There may be a considerable risk of mortality from pertussis in this population. Physicians should be alert to the diagnosis of pertussis in the elderly with nocturnal and prolonged periods of coughing.

[The global eradication of polio by the year 2000]

The World Health Organization wants to attain global eradication of poliomyelitis in the year 2000. In all countries commissions are installed to document polio-free certification. Four activities are considered vital by the WHO to achieve this goal: (a) strict surveillance of all suspected cases of poliomyelitis, (b) close clinical and virological examination of all children younger than 15 years with acute flaccid paralysis (AFP), (c) laboratory surveillance of poliovirus isolates and (d) surveillance of sewage. The Netherlands has been selected as example country for the certification process. However, the AFP surveillance is not yet optimal, therefore all physicians are asked to join in the effort.

Ileal apparent protein and amino acid digestibilities and endogenous nitrogen losses in pigs fed soybean and rapeseed products

We investigated the effects of various protein sources on the apparent ileal digestibilities (AID) of CP and amino acids (AA) and on the recoveries of ileal endogenous nitrogen (N) in pigs. Ileal endogenous N losses (ENL) were measured using the 15N-isotope dilution method. Thirteen pigs (BW of 13 to 20 kg) were fitted with a post-valve-T-cecal cannula and two indwelling blood catheters. They were fed twice daily at a level of 2.6 times ME for maintenance. Cornstarch-based diets contained a soy concentrate (SC; 180.5 g/kg), soybean meal (SBM; 295 g/kg), or a mixture of toasted and untoasted soybean meal (mSBM; 330.4 g/kg) in Trial I or three rapeseed cakes, dehulled-toasted (RC1; 395 g/kg), non-dehulled-toasted (RC2; 458 g/kg), and dehulled-untoasted (RC3; 390 g/kg) in Trial II. The protein sources provided diets with similar levels of apparent ileal digestible CP (108 g/kg as-fed diet) and Lys, Met+Cys, Thr, and Trp. The AID of CP was greater (P < .05) for the SC (86.8%) and SBM (82.8%) than for the SBM (68.1%) diet. In Trial II, the AID of CP was greater (P < .05) for RC1 (76.2%) and RC3 (75.8%) than for the RC2 (69.5%) diet. For all diets, the differences in the AID for most of the AA corresponded to the differences in the AID of CP. The ENL (g/kg DMI) were greater (P < .05) for the mSBM diet (3.75) than for the SC (2.53) and SBM (2.53) diets in Trial I but were similar (P > .05; 2.24, 3.03, and 2.89 for RC1, RC2, and RC3, respectively) among diets in Trial II. We concluded that AID of CP of the soybean diets were associated with endogenous and dietary N losses. For these diets, increased ENL and dietary N losses were associated with a higher dietary trypsin inhibitor activity. For the rapeseed diets, dehulling increased AID of CP and AA, due to reduced ENL (P = .08) and dietary N losses (P < .05). Toasting of dehulled rapeseed cake did not affect the AID of CP and AA (P > .05) while reducing the true ileal CP digestibility (P < .05).

Nitrogen utilization in pigs fed diets with soybean and rapeseed products leading to different ileal endogenous nitrogen losses

Nitrogen (N) balance was determined in 36 pigs (BW 24 to 30 kg) fed diets inducing different ileal endogenous N losses (ENL). We tested the hypothesis that enhanced ENL may be indicative of a higher recycling of endogenous proteins that will induce a greater urinary N loss and a lower efficiency of the dietary N utilization for retention. The cornstarch-based diets contained either soy concentrate (SC), soybean meal (SBM), a mixture of toasted and untoasted soybean meal (mSBM), dehulled-toasted rapeseed cake (RC1), non-dehulled-toasted rapeseed cake (RC2), or dehulled-untoasted rapeseed cake (RC3). The diets were balanced for their content of apparent ileal digestible (ID) CP (108 g/kg feed) and apparent ID of Lys, Thr, Met+Cys, Trp, and Ile. Feeding level was 2.7 times ME for maintenance per kilogram BWx75 and restricted to 88% of the requirements for ID Lys as the first-limiting amino acid. During a 5-d period, urine and feces were collected daily in metabolism cages. Compared with the SC diet (low ENL), the diets with SBM (medium ENL) and mSBM (high ENL) resulted in a greater (P < .05) urinary N excretion. Nitrogen retention tended to be less (P = .08) in pigs fed diets that caused greater ENL. The utilization of ID N for retention in pigs fed the mSBM diet was lower (P < .05) than for those fed the SC diet. There were no differences in urinary N excretion, N retention, and the utilization of ID N for retention in pigs fed the rapeseed diets of different fiber contents (hulls as the NDF source). We concluded that, at similar intakes of the first-limiting ID amino acid, N retention in pigs fed soybeans tended to be reduced by greater ENL as induced by antinutritional factors (e.g., trypsin inhibitors). Rapeseed hulls, as the predominant fiber source, do not affect N retention and the utilization of ID N for retention.

Personality development of adolescents with hypogonadotropic hypogonadism

Hypogonadotropic hypogonadism is a disorder of puberty characterized by absence of spontaneous sexual maturation. 8 male adolescents with this disorder, who were treated with pulsatile GnRH administration, were examined psychologically by means of standardized interviews. Problems were found in the development of independence (specifically relating to own body image and social functioning) and in identity development (particularly on personal characteristics).

The use of 15N-labeled dietary proteins for determining true ileal amino acid digestibilities is limited by their rapid recycling in the endogenous secretions of pigs

We assessed the use of 15N-labeled dietary proteins as a possible tool for the determination of the true ileal amino acid (AA) digestibility in pigs. The first experiment was designed to study the dietary N excretion pattern at the ileum subsequent to the ingestion of a single 15N-labeled meal. In a second experiment, we compared ileal endogenous AA outputs and true AA digestibility estimates obtained in pigs ingesting 15N-labeled dietary proteins in a single meal vs. intravenous infusion of [15N]leucine for 10 d during the ingestion of a pea-based diet and a protein-free starch diet. The proportion of endogenous N found in the ileal digesta differed when the label was delivered orally (50%) vs. intravenously (72%) and changed with time. As a consequence, the true ileal AA digestibilities measured with labeled diets were lower. A third experiment demonstrated that this was due to the rapid recycling of labeled dietary N in endogenous moieties, because 15N was found in blood within 10 min of consuming the labeled meal, within 50 min of consumption in pancreatic enzymes, 90 min in bile and 4 h in ileal mucins. We conclude that the use of 15N-labeled meals for determination of true ileal AA digestibilities is limited by the fast recycling of dietary N in endogenous secretions following a single 15N-labeled meal. The accuracy of results will depend on meaningful estimates of AA flow during a limited period and accurate estimates of 15N in AA.

Information processing in patients with early and continuously-treated phenylketonuria

A total of 33 patients with early and continuously-treated phenylketonuria (PKU) between 7 and 16 years of age and 33 matched controls participated in a study examining perceptual, central, and response-related mechanisms of information processing. The specific mechanisms studied were: perceptual filtering, memory search, response selection, response execution, and motor presetting. In addition, groups were compared on mean intelligence level and task oriented behaviour. The performance of the PKU patients practically matched that of the controls on all three tasks, suggesting that PKU patients who are continuously maintained on a well-controlled phenylalanine-restricted diet are not impaired in the elementary mechanisms of information processing. Furthermore, groups did not differ in mean IQ or task-oriented behaviour.

CONCLUSION

These results underline the importance of continued, well-controlled dietary treatment. Further studies are recommended to obtain a more complete evaluation of the potential of PKU patients under these stricter dietary treatment conditions.

The nutritional significance of endogenous N-losses along the gastro-intestinal tract of farm animals

In animal production, endogenous protein losses associated with the digestion process are important losses, but difficult to measure. Measuring methods include feeding N-free diets, regression techniques based on amino acid profiles, and separating feed protein and endogenous protein by markers like homoarginine, hydrolysed casein or stable isotopes like 15N. Endogenous losses arise from saliva, digestive enzymes, bile, shedded epithelial cells and mucins and may be extra stimulated by the presence in feeds of antinutritional factors (ANF) such as lectins, trypsin inhibitors (TI), tannins and fibre. The impact of such factors may differ between non-ruminants and ruminants. The magnitude of the effect of the different factors is quantified and some of the consequences for protein deposition and nitrogen losses to the environment are discussed.

Effects of hulls of faba beans (Vicia faba L.) with a low or high content of condensed tannins on the apparent ileal and fecal digestibility of nutrients and the excretion of endogenous protein in ileal digesta and feces of pigs

In three experiments (Exp. 1, 2, and 3) with young pigs (BW 10 to 26 kg), the effects of dietary inclusion of hulls of faba beans (Vicia faba L.) (200 g/kg) with a low (< .1% catechin equivalents; LT) or high tannin content (3.3% catechin equivalents; HT) on the apparent ileal (Exp. 1 and 2) and fecal (Exp. 3) digestibility of nutrients were determined. In addition, the true digestibility of protein of the diets and the excretion of endogenous protein (N x 6.25) in ileal digesta and feces of pigs were measured, using the 15N isotope dilution technique (Exp. 3). Diets contained either casein and faba bean cotyledons as highly soluble (HS) protein sources (Exp. 1 to 3) or potato protein, soy concentrate, sunflower meal, meat meal, and fish meal as protein sources with a low solubility (LS) (Exp. 1). Control diets contained cellulose as a fiber source (64 to 73 g/kg). Inclusion of either type of hulls decreased the apparent ileal digestibility for DM, organic matter (OM), and nonprotein organic matter (NPOM) (P < .05). Inclusion of LT hulls instead of cellulose only reduced the apparent ileal digestibility of crude protein (N x 6.25; CP) in Exp. 3 (P < .05). Inclusion of HT instead of LT hulls reduced the apparent ileal digestibility of CP (by 7 to 10 units) and amino acids (by 4 to 29 units) (P < .05). The LT hulls decreased apparent and true ileal digestibility of CP from 88 to 83 and from 97 to 94, respectively (P < .05). Inclusion of HT instead of LT hulls decreased apparent and true ileal CP digestibility from 83 to 74 and 94 to 90 (P < .05) and increased the excretion of endogenous CP from 22 to 32 and from 13 to 23 g/kg of DM intake at the ileal and fecal level, respectively (P < .05). It is concluded that condensed tannins in faba beans interact with both dietary and endogenous proteins in the digestive tract of pigs. This reduces the true digestibility of dietary protein and increases the excretion of endogenously secreted proteins. Tannins from faba beans show some preference to interact with proteins with a high content of proline and histidine.

Social behaviour and task orientation in early-treated PKU

In the context of the Dutch Collaborative Study on the Psychological Development of Children, early treated for Phenylketonuria (PKU), data were obtained on children's behaviour as perceived by parents (n = 53) and teachers (n = 57), using standardized behavioural questionnaires. Results are compared with a group representative of Dutch school-aged children (n = 1381) with a matched control group (n = 38), and with a group, to be considered as "Attention Deficit Hyperactivity Disorder" (ADHD, n = 38). Especially the clusters "negative task orientation" and "extraversion" distinguish between PKU children and controls. In parents' descriptions as well as in teachers' descriptions PKU children score higher in both clusters. Intriguing differences are found between PKU and ADHD. In parents' but not in teachers' descriptions PKU children show signs of negative task orientation almost to a similar degree as children with ADHD, but not of the signs of "negative social behaviour", characteristic for ADHD children. Data are discussed in terms of the effectiveness of early treatment and guidance.

Information processing deficits in children with early and continuously treated phenylketonuria?

Thirty-three patients with early and continuously treated classical phenylketonuria (PKU) and 33 controls matched for age, gender, and educational level of both parents, participated in a chronometric study exploring elementary mechanisms of information processing. Subjects performed speeded performance tasks designed to systematically vary the load on perceptual, central, and output-related mechanisms of information processing. A preliminary analysis of the data indicated that the overall performance of patients with early and continuously treated PKU practically matched that of the controls on all three tasks. Although this finding must be interpreted with caution as it is based on only a preliminary analysis of the data, it suggests that PKU patients who are continuously maintained on a well-controlled phenylalanine-restricted diet are not deficient in the elementary mechanisms of processing. Given the more recent findings indicating that young children with early-treated classical PKU have specific cognitive deficits in the executive function skills, despite relatively strict dietary control, the authors suggest that future studies should focus on these higher-order cognitive processes.

Phenylketonuria and some aspects of emotional development

Early dietary treatment of phenylketonuria (PKU) prevents intellectual retardation and gross neurological impairment although not all neuropsychological problems. This study investigates to what extent the illness and its treatment imposes a burden on emotional development of early-treated PKU patients and on rearing practices of their parents. It is concluded that in early-treated PKU it is particularly difficult to find constructive ways to adapt to the situation for children as well as for parents. As coping with PKU and its treatment is so complicated, paediatric control should be combined with psychocounselling.

Effect of level of dietary neutral detergent fiber on ileal apparent digestibility and ileal nitrogen losses in pigs

A study was conducted with 20 barrows (average BW 25 kg) to determine the effect of various levels of neutral detergent fiber (NDF) in the diet on the apparent ileal nutrient digestibility and ileal diaminopimelic acid (DAPA) content, and consequently on the amount of ileal endogenous nitrogen. The pigs were fitted with a post-valvular T-cecal cannula. They were fed .8 kg/d of a corn starch-based semisynthetic diet formulated to contain equal amounts of protein and starch and 0, 60, 120, or 180 g of purified NDF/kg of diet, included at the expense of glucose. The purified NDF (pNDF) was isolated from wheat bran using an incubation procedure with pancreatin. Ileal digestibility of NDF was approximately 17% and was independent of the pNDF level in the diet. By increasing the amount of pNDF in the diets, apparent ileal digestibilities of dry matter (DM), nitrogen (N), neutral detergent insoluble N (NDF-N), and ash decreased linearly (P < .05). The DAPA content of the ileal digesta (g/d) was not affected by the percentage of pNDF in the diets. Calculation of the ileal bacterial N excretion indicated that more than 50% of the ileal N was of bacterial origin. With increased percentage of dietary pNDF, both endogenous and exogenous N in ileal chyme were linearly increased (P < .05). Thus, an increase in the dietary fiber content leads to a decreased apparent ileal protein digestibility due to increased ileal losses of both endogenous and exogenous protein.