Risk of malignant hyperthermia in patients carrying a variant in the skeletal muscle ryanodine receptor 1 gene

Malignant hyperthermia is a life-threatening disorder, which can be prevented by avoiding certain anesthetic agents. Pathogenic variants in the skeletal muscle ryanodine receptor 1-gene are linked to malignant hyperthermia. We retrospectively studied 15 patients who presented to our clinic with symptoms of muscle dysfunction (weakness, myalgia or cramps) and were later found to have a variant in the skeletal muscle ryanodine receptor 1-gene. Symptoms, creatine kinase levels, electromyography, muscle biopsy and in vitro contracture test results were reviewed. Six out of the eleven patients, with a variant of unknown significance in the skeletal muscle ryanodine receptor 1-gene, had a positive in vitro contracture test, indicating malignant hyperthermia susceptibility. In one patient, with two variants of unknown significance, both variants were required to express the malignant hyperthermia-susceptibility trait. Neurologists should consider screening the skeletal muscle ryanodine receptor 1-gene in patients with myalgia or cramps, even when few to no abnormalities on ancillary testing.

P-668 The LH endocrine profile in Gonadotropin-Releasing Hormone analogue cycles

Study question

What does the evolution of luteinizing hormone (LH) throughout the follicular phase look like in different treatment protocols for ovarian stimulation in IVF/ICSI?

Summary answer

Evolution of LH during the follicular phase of ovarian stimulation differs between Gonadotropin-Releasing Hormone (GnRH) analogues, with a significant decrease of LH in antagonist cycles.

What is known already

Physicians aim to tailor ovarian stimulation protocols to the patient, with protocols varying in type of GnRH analogue and gonadotropin. However, there is no clear consensus on the best treatment protocol and especially the role of LH is still not completely understood as earlier studies focused mainly on suppressing LH levels. Literature has since indicated that excessively suppressed LH levels could be detrimental for clinical outcomes. Research on LH is hampered by multiple measurements during the cycle, different treatment schedules and patients switching schedules over time.

Study design, size, duration

This was a non-interventional, retrospective, observational cohort study. 2200 ovarian stimulation cycles for assisted reproduction were analyzed, in 1303 individual patients. Patients were treated during the period of January 1st 2015 until September 30th 2020. Cycles were included if the patient was between 18 and 43 years of age, stimulated with human menopausal gonadotropin (hMG) or recombinant follicle stimulating hormone (rec-FSH, follitropin α or β) and using GnRH analogues.

Participants/materials, setting, methods

Data were extracted from two databases used at a tertiary infertility clinic. Cycles were divided into six treatment protocols: GnRH antagonist/hMG (13.8%), antagonist/rec-FSH (19.7%), long agonist/hMG (35.7%), long agonist/rec-FSH (4.8%), short agonist/hMG (22.5%) and short agonist/rec-FSH (3.5%). 59.5% of cycles were pretreated with an oral contraceptive pill (OCP). LH evolution was visualized by plotting LH levels against the days of the follicular phase and repeated daily LH measures were fitted with a linear mixed model.

Main results and the role of chance

Basal LH was significantly lower in antagonist/hMG cycles pretreated with OCP compared to no pretreatment (estimated difference -1.23 IU/L, p < 0.001). Mean LH value throughout the follicular phase was significantly lower with OCP pretreatment in antagonist/hMG (estimated difference -1.05 IU/L, p < 0.001) and antagonist/rec-FSH cycles (estimated difference -0.52 IU/L, p < 0.001). When LH evolution throughout the follicular phase was analyzed, no significantly different evolution between cycles with and without OCP was detected (all p > 0.1). Hence further analysis of the LH profiles was performed in the six protocol groups making no distinction between OCP use or not. LH evolution was significantly different between all six protocol groups (p < 0.001). In antagonist/hMG cycles, LH values showed a significant decrease of 0.17 IU/L per day (p < 0.001). In antagonist/rec-FSH cycles, the decrease per day was 0.26 IU/L (p < 0.001).The decrease in LH was significantly larger in rec-FSH cycles than hMG (estimated difference 0.09 IU/L per day, p < 0.001). Short agonist/hMG cycles showed a significant increase in LH of 0.04 IU/L per day (p = 0.002), while the increase of 0.01 IU/L per day in rec-FSH cycles was not significant (p = 1.00). In long agonist cycles, no significant in- or decrease in LH values during the follicular phase was found (p = 1.00).

Limitations, reasons for caution

Stimulation protocols were chosen by the treating physician which is a limitation of the retrospective design. The authors were able to partly respond to this limitation by adjusting for age and using different cycles per patient in all mixed models.

Wider implications of the findings

Using profiles to show LH evolution allowed the visualization of the decrease in the evolution of LH in antagonist cycles, even more pronounced in cycles stimulated with rec-FSH compared to hMG. This decrease in LH and the potential impact on estradiol levels and follicle growth needs further examination.

Trial registration number

not applicable

Review of the dental treatment backlog of people with disabilities in Europe

AIM

The present research aims at reviewing the oral health conditions and treatment needs of people with disabilities in Europe.

METHODS

A comprehensive literature search was conducted using Medline and Embase with a timeframe from January 2008 until December 2017. Subsequently, a citation tracking was undertaken. Articles in English, French and Dutch were included.

RESULTS

Forty-two articles were included. A variety of oral health problems and treatment needs was reported. More untreated carious lesions, less restorations, a higher number of extractions and less prosthetic rehabilitations were seen in people with disabilities compared with other individuals without disabilities. The oral hygiene level and the periodontal conditions were poor. Moreover, a higher risk of dental trauma, orthodontic problems and tooth wear were reported.

DISCUSSION

Different determinants contribute to the oral health condition and treatment needs of people with disabilities. These determinants can be inherent in persons with a disability (biological factors), their lifestyle, the environment or the organization of oral health care. A treatment backlog was a common finding in people with disabilities. However, results need to be interpreted with caution because of the variety of people with disabilities included in this literature review. Proposed solutions can be put at the level of daily oral care, through oral health promotion programs and the creation of a supportive environment, but also at the level of dental attendance, facilitating the access to oral health care services and focusing the training of dental students and dentists.

CONCLUSION

This comprehensive review clearly shows a dental treatment backlog in people with disabilities. Solutions require efforts from the caregivers and dental professionals.

[Oral health in older adults, a challenge? Determinants of oral health in older adults.]

Current data show many older adults to have poor oral health, deteriorating even more when they become frail or care dependent. In order to achieve a structural and sustained improvement of this situation, it is necessary to have a clear view of the factors determining oral health in older adults, such as (endogenous (biological, lifestyle), environmental determinants and determinants associated with the organisation of healthcare. The various determinants show oral health in older adults is the result of thecombined effects of very diverse factors and for that reason, a solution will have to be based on a multidisciplinary approach, also involving people outside of clinical care. To promote good oral health over the full course of life, it is important to invest in a good start in life, that helps accumulate oral health gains, and at the same time it is essential to adapt the healthcare system and prevention strategies to the individual's needs in order to make oral care effective for the full course of life.

[A view on collective oral care for frail older people: united we stand]

Oral health in frail older people is often poor. There are a number of reasons for this, such as increased morbity and decreased motivation for (self) care. Good oral health is, however, very important. Studies have revealed poor oral health to cause or aggravate several medical and psychological problems. Illness and medication can, in turn, damage oral health. Oral health among the elderly should therefore be carefully monitored and maintained. This requires multidisciplinary and interprofessional collaboration on the part of healthcare professionals and others involved. Such collaboration is now still very limited; hardly anything has been written about how such collaboration in the area of oral care for frail older people should or could be organised. This article provides an overview of the possibilities and the relevant factors in the area of oral care for the elderly in promoting collaboration among healthcare professionals and others involved. All of this is under the banner of 'united we stand'.

Associations between Measures of Structural Morphometry and Sensorimotor Performance in Individuals with Nonspecific Low Back Pain

BACKGROUND AND PURPOSE

To date, most structural brain imaging studies in individuals with nonspecific low back pain have evaluated volumetric changes. These alterations are particularly found in sensorimotor-related areas. Although it is suggested that specific measures, such as cortical surface area and cortical thickness, reflect different underlying neural architectures, the literature regarding these different measures in individuals with nonspecific low back pain is limited. Therefore, the current study was designed to investigate the association between the performance on a sensorimotor task, more specifically the sit-to-stand-to-sit task, and cortical surface area and cortical thickness in individuals with nonspecific low back pain and healthy controls.

MATERIALS AND METHODS

Seventeen individuals with nonspecific low back pain and 17 healthy controls were instructed to perform 5 consecutive sit-to-stand-to-sit movements as fast as possible. In addition, T1-weighted anatomic scans of the brain were acquired and analyzed with FreeSurfer.

RESULTS

Compared with healthy controls, individuals with nonspecific low back pain needed significantly more time to perform 5 sit-to-stand-to-sit movements (P < .05). Brain morphometric analyses revealed that cortical thickness of the ventrolateral prefrontal cortical regions was increased in patients with nonspecific low back pain compared with controls. Furthermore, decreased cortical thickness of the rostral anterior cingulate cortex was associated with lower sit-to-stand-to-sit performance on an unstable support surface in individuals with nonspecific low back pain and healthy controls (r = -0.47, P < .007). In addition, a positive correlation was found between perceived pain intensity and cortical thickness of the superior frontal gyrus (r = 0.70, P < .002) and the pars opercularis of the inferior ventrolateral prefrontal cortex (r = 0.67, P < .004). Hence, increased cortical thickness was associated with increased levels of pain intensity in individuals with nonspecific low back pain. No associations were found between cortical surface area and the pain characteristics in this group.

CONCLUSIONS

The current study suggests that cortical thickness may contribute to different aspects of sit-to-stand-to-sit performance and perceived pain intensity in individuals with nonspecific low back pain.

Continuous twin screw granulation of controlled release formulations with various HPMC grades

HPMC is a popular matrix former to formulate tablets with extended drug release. Tablets with HPMC are preferentially produced by direct compression. However, granulation is often required prior to tableting to overcome poor flowability of the formulation. While continuous twin screw granulation has been extensively evaluated for granulation of immediate release formulations, twin screw granulation of controlled release formulations including the dissolution behavior of the formulations received little attention. Therefore, the influence of the HPMC grade (viscosity and substitution degree) and the particle size of theophylline on critical quality attributes of granules (continuously produced via twin screw granulation) and tablets was investigated in the current study. Formulations with 20 or 40% HPMC, 20% theophylline and lactose were granulated with water at fixed process parameters via twin screw granulation. The torque was influenced by the viscosity and substitution degree of HPMC, but was not a limiting factor for the granulation process. An optimal L/S ratio was selected for each formulation based on the granule size distribution. The granule size distributions were influenced by the substitution degree and concentration of HPMC and the particle size of theophylline. Raman and UV spectroscopic analysis on 8 sieve fractions of granules indicated an inhomogeneous distribution of theophylline over the size fractions. However, this phenomenon was not correlated with the hydration rate or viscosity of HPMC. Controlled release of theophylline could be obtained over 24h with release profiles close to zero-order. The release of theophylline could be tailored via selection of the substitution degree and viscosity of HPMC.

Influence of shoes and foot orthoses on lower extremity muscle activation onset times in healthy subjects during the transition from double-leg stance to single-leg stance

AIM

The aim of this study was to evaluate the influence of shoes and foot orthoses on lower extremity muscle activation patterns in healthy subjects during the transition from double-leg stance to single-leg stance.

METHODS

Eight male and seven female young asymptomatic adults who wear foot orthoses were recruited. Muscle activation onset times of 9 lower extremity muscles were recorded using surface electromyography during the transition from double-leg stance to single-leg stance, performed with eyes open and with eyes closed. This was tested in 4 experimental conditions: 1) barefoot (BF); 2) shoes only (SO); 3) shoes with standardized FO (SSFO); and 4) shoes with customized FO (SCFO).

RESULTS

Based on a four-way (condition-region-leg-vision) linear model for repeated measures, we found a significant condition effect (P=0.025). Differences between conditions did not depend on the leg and/or the vision condition, but on the region (ankle-knee-hip). Based on a two-way (condition-muscle) linear model within each region, only significant differences between conditions for peroneus longus (P=0.003) were found. The onset times of peroneus longus were significantly earlier in SO (P=0.029) and SCFO (P=0.001) compared to BF.

CONCLUSION

These results indicate that SO and SCFO can accelerate peroneus longus muscle activation onset times during the transition from double-leg stance to single-leg stance. Further research is required to determine how these adaptations may develop over time.

A clinical measurement to quantify spasticity in children with cerebral palsy by integration of multidimensional signals

Most clinical tools for measuring spasticity, such as the Modified Ashworth Scale (MAS) and the Modified Tardieu Scale (MTS), are not sufficiently accurate or reliable. This study investigated the clinimetric properties of an instrumented spasticity assessment. Twenty-eight children with spastic cerebral palsy (CP) and 10 typically developing (TD) children were included. Six of the children with CP were retested to evaluate reliability. To quantify spasticity in the gastrocnemius (GAS) and medial hamstrings (MEH), three synchronized signals were collected and integrated: surface electromyography (sEMG); joint-angle characteristics; and torque. Muscles were manually stretched at low velocity (LV) and high velocity (HV). Spasticity parameters were extracted from the change in sEMG and in torque between LV and HV. Reliability was determined with intraclass-correlation coefficients and the standard error of measurement; validity by assessing group differences and correlating spasticity parameters with the MAS and MTS. Reliability was moderately high for both muscles. Spasticity parameters in both muscles were higher in children with CP than in TD children, showed moderate correlation with the MAS for both muscles and good correlation to the MTS for the MEH. Spasticity assessment based on multidimensional signals therefore provides reliable and clinically relevant measures of spasticity. Moreover, the moderate correlations of the MAS and MTS with the objective parameters further stress the added value of the instrumented measurements to detect and investigate spasticity, especially for the GAS.

Incontinent Women Have Altered Pelvic Floor Muscle Contraction Patterns

PURPOSE

Pelvic floor exercises are invaluable for regaining continence but mechanisms are not fully understood. To contribute to the understanding of these mechanisms we investigated the contraction sequence of superficial vs deep pelvic floor muscles in 6 positions in continent and incontinent women.

MATERIALS AND METHODS

The onset of contraction of the superficial and deep pelvic floor muscles was recorded by perineal and intravaginal surface electromyography in 32 continent and 50 incontinent women. The agreement between perineal and intravaginal recordings was calculated with the kappa statistic and the percent of agreement. Differences in onset between superficial and deep pelvic floor muscle contractions are reported as the median and IQR.

RESULTS

Perineal and intravaginal electromyography recordings used to define the onset of muscle activity showed a high level of agreement. In the continent group the superficial muscles almost always contracted before the deep muscles in all 6 positions. In the incontinent group the reverse sequence was observed in 3 of 6 positions. Higher and less consistent time differences in the onset of contraction of the 2 muscle layers were found in incontinent vs continent women.

CONCLUSIONS

Contractions of the superficial and deep pelvic floor muscles can be recorded by intravaginal or perineal electrodes. A consistent contraction sequence can be found in continent women but it is lacking in incontinent women. This might be a possible explanation for incontinence. Including differentiated muscle contraction exercises in pelvic floor muscle exercise programs may further optimize treatment outcomes.

An infected hip prosthesis in a dog diagnosed with a 99mTc-ciprofloxacin (infecton) scan

This case report describes the use of the 99mTc-labeled radiopharmaceutical ciprofloxacin (Infecton) in a case of hip prosthesis loosening in a dog. Serial planar radiographs were not conclusive, and culture of the synovial fluid was negative. Antibiotic treatment did not result in improvement of the lameness. Scintigraphy was performed with 99-Tc-Infecton, a tracer claimed to be specific for infection. Antibiotic treatment was interrupted 6 weeks prior to the examination. Planar and tomographic images at 3 h and at 24 h postinjection showed increased activity along the acetabulum and the proximal femoral bone surrounding the femoral prosthesis, indicating focal infection. Bacteriology performed after removal of the implant revealed Pseudomonas aeruginosa.

The effect of a home physiotherapy program for persons with Parkinson's disease

The purpose of this study was to evaluate the effect of a home physiotherapy program for persons with Parkinson's disease. Thirty-three patients took part in the study using a within-subject controlled design. Functional activities including walking and carrying out transfers were measured at home and in the hospital before and after a 6-week baseline period, after 6 weeks home physiotherapy and after 3 months follow-up. Spatiotemporal and plantar force variables of gait were determined with video and pododynography. Treatment provided by community physiotherapists consisted of teaching cueing and conscious movement control 3 times a week. The study revealed that patients had significantly higher scores on a functional activity scale after treatment in the home setting and to a lesser degree in hospital, a result, which was partly sustained at follow-up. However, duration of the transfer movements, spatiotemporal and plantar force variables were not significantly improved except for stride length. The results support application and development of the treatment concept and highlight that physiotherapy aimed at improving function in Parkinson's disease is best provided in the home situation.

Rapid screening for dominant negative mutations in the beet necrotic yellow vein virus triple gene block proteins P13 and P15 using a viral replicon

Point mutations were introduced into the genes encoding the triple gene bock movement proteins P13 and P15 of beet necrotic yellow vein virus (BNYVV). Mutations which disabled viral cell-to-cell movement in Chenopodium quinoa were then tested for their ability to act as dominant negative inhibiters of movement of wild-type BNYVV when expressed from a co-inoculated BNYVV RNA 3-based replicon. For P13, three types of mutation inhibited the movement function: non-synomynous mutations in the N- and C-terminal hydrophobic domains, a mutation at the boundary between the N-terminal hydrophobic domain and the central hydrophilic domain (mutant P13-A12), and mutations in the conserved sequence motif in the central hydrophilic domain. However, only the 'boundary' mutant P13-A12 strongly inhibited movement of wild-type virus when expressed from the co-inoculated replicon. Similar experiments with P15 detected four movement-defective mutants which strongly inhibited cell-to-cell movement of wild-type BNYVV when the mutants were expressed from a co-inoculated replicon. Beta vulgaris transformed with two of these P15 mutants were highly resistant to fungus-mediated infection with BNYVV.

Unstable angina due to spontaneous dissection of a LIMA graft

We report a case of a spontaneous dissection of a left internal mammary artery grafted on the diagonal branch and the left anterior descendens. The clinical and diagnostic features of this condition are discussed. Despite an extensive literature search, no such case could be found. This case report must be regarded as the first. We speculate that extensive kinking of the left internal mammary artery contributed in the pathogenesis of this syndrome.

[Primary hyperparathyroidism: etiology, diagnosis and treatment]

Primary hyperparathyroidism is a not so infrequent disease that is often overlooked by physicians. Its incidence is estimated to be about 28 in 100.000 subjects, mainly women over seventy years old. Three to four percents of women over seventy are affected. Hyperparathyroidism can be isolated or be a component of a more complex syndrome like multiple endocrine neoplasms (MEN). Patients can be asymptomatic or present with symptoms like asthenia, hypertension or nephrolithiasis. The biological investigation requires the combined measurements of plasmatic ionized calcium and parathormone. In some cases, more specific explorations like calcium loading tests have to be performed in order to confirm the diagnosis.

Reliability of torque measurements during passive isokinetic knee movements in healthy subjects

In the literature, few data are available about the reliability of torque measured during passive isokinetic knee movements. This study investigated the consistency of torque measurements during passive knee movements at 60, 180 and 300 degrees/second in 30 healthy subjects. Intraclass correlation values ranged between 0.78 and 0.92 when the results of two consecutive tests were compared. When retests were performed after repositioning the subjects, intraclass correlation values ranged between 0.43 and 0.87. These findings indicate the necessity for meticulous standardization of the test situation. Series of 10 consecutive movements, specifically repetitions of knee flexion at 180 and 300 degrees/second, indicated that torque measurements during the first two movements were less stable than those following. A concurrent change in electromyographic activity in the rectus femoris muscle suggested that these torque variations resulted from habituation of the stretch reflex.

[Pharma-clinics. How I treat ... abnormalities of serum calcium]

Treatment of both hypercalcemia and hypocalcemia depends on the underlying disorder; the magnitude of the calcium abnormalities and the severity of symptoms. In the case of hypercalcemia, there is a broad selection of effective medications, especially the biphosphonates. Treatment of hypocalcemia relies on the calcium intake and often vitamin D supplementation. For both abnormalities, the underlying cause must be treated, if possible, to definitively restore normocalcemia.

[How I explore ... abnormalities in serum calcium concentration]

Mechanisms for calcium homeostasis are complex but their understanding is important before investigating the calcium disorders. Hypercalcaemia is often due to hyperparathyroidism or cancers. The diagnosis must thus be rapid and a treatment decided in a global approach. Hypocalcaemia, more frequently noted, is often due to a general disorder with hypoalbuminemia or chronic renal failure.

Thrombotic thrombocytopenic purpura: a rare but potential life-threatening complication following ticlopidine administration

Thrombotic thrombocytopenic purpura (TTP) is a known, although rare, complication of ticlopidine treatment. It typically appears within the first days or weeks after initiation of therapy. We describe a case of TTP in a 75-year-old patient, due to ticlopidine, occurring three weeks after coronary stent implantation. The patient responded favourably to fresh frozen plasma exchanges. We are reporting this case to emphasize that prognosis depends on prompt diagnosis and early treatment, implying careful biochemical monitoring.

A randomized clinical trial of two single-dose treatments for paucibacillary leprosy

We compared 2 single-dose regimens for the treatment of paucibacillary leprosy in a randomized clinical trial in Zaïre. The regimens were: C2 (rifampicin 40 mg/kg and 1200 mg clofazimine once) and C4 (rifampicin 40 mg/kg, clofazimine 100 mg, DDS 100 mg and ethionamide 500 mg once). An analysis of the results of patients enrolled between May 1987 and December 1988, with a maximum follow-up of 4 years, is presented. A total of 622 patients were enrolled and 14 paucibacillary and 1 multibacillary relapses occurred. The overall paucibacillary relapse rate was 2.4 per 100 person years. This relapse rate was higher for older patients as well as for patients with 3 or more lesions. The probability of cure at 3 years is 0.816 for C2 and 0.823 for C4, the difference not being statistically significant. The probability of cure at 3 years with either regimen is higher for patients with 1 or 2 lesions (0.872) than for patients with 3 or more lesions (0.787), and it is higher for patients with a bacterial index of 0 (0.831) than for patients with a bacterial index of 1 (0.699). These results are compared to other studies. We also discuss the potential of single-dose treatment regimens for paucibacillary leprosy.

Short-term effects of early intravenous treatment with a beta-adrenergic blocking agent or a specific bradycardiac agent in patients with acute myocardial infarction receiving thrombolytic therapy

OBJECTIVES

This study was conducted to explore mechanisms that could explain the possible clinical benefit of early administration of a beta 1-selective adrenoreceptor blocking agent or a bradycardiac drug as adjunct to thrombolysis in acute myocardial infarction.

BACKGROUND

The effects of beta-blockers given concomitantly with thrombolytic therapy in patients with acute myocardial infarction have not been fully examined. The potential role of specific bradycardiac agents lacking negative inotropism as an alternative to beta-blockers in this setting has never been studied in humans.

METHODS

In a double-blind study, we examined the effects of early intravenous and continued oral administration of a beta-blocker (atenolol), a specific bradycardiac agent (alinidine) or placebo on left ventricular function, late coronary artery patency, infarct size, exercise capacity and incidence of arrhythmias.

RESULTS

A total of 292 patients with acute myocardial infarction of < or = 5 h duration and without contraindications to thrombolytic or beta-blocker therapy were studied. Of these, 100 were allocated to treatment with atenolol (5 to 10 mg intravenously followed by 25 to 50 mg orally every 12 h), 98 to alinidine (20 to 40 mg intravenously followed by 20 to 40 mg orally every 8 h) and 94 to placebo. All patients received 100 mg of alteplase over 3 h and full intravenous heparinization. No significant differences in coronary artery patency, global ejection fraction or regional wall motion were observed at 10 to 14 days among the three groups. Likewise, enzymatic and scintigraphic infarct size were also very similar. Neither atenolol nor alinidine was associated with a significant reduction in the incidence of arrhythmias during the 1st 24 h. No significant differences in clinical events were observed, with the exception of a greater incidence of nonfatal pulmonary edema in the atenolol group (6% vs. 1% in the alinidine group and 0% in the placebo group, p = 0.021).

CONCLUSIONS

In the absence of contraindications, the administration of a beta-blocker or a specific bradycardiac agent together with thrombolytic therapy was safe. In this limited number of patients, these agents did not appear to enhance myocardial salvage or preservation of left ventricular function or to reduce the incidence of major arrhythmias in the early phase of infarction.

Treatment of multibacillary leprosy with a regimen of 13 weeks duration

In a prospective study 559 multibacillary patients in Zaire were treated for 13 weeks with twice weekly rifampicin (600 mg) and daily ethionamide (500 mg) and dapsone (100 mg), 13-RED, or clofazimine (100 mg), 13-REC. The patients were followed for a total of 1418 person years, mean 3.2 years. The incidence of hepatitis was 3.3%. The incidence of relapses was 0.28 per 100 person years. Relapses were due to drug-sensitive organisms. In patients who received the same drug regimens but with a reduced dosage of ethionamide to 5 mg/k bodyweight, the incidence of hepatitis was significantly lower but the relapse rate was 7.8 per 100 person years of follow-up in the RED group, no relapses were diagnosed in the REC group. It is concluded that by the use of potent antileprosy drugs in suitable combinations and dosages, it will be possible to shorten the duration of antibacterial treatment in multibacillary leprosy to 3 months.

Crosstalk with external bipolar DVI pacing: a case report

An increase of the basic atrial pacing rate from a preset value of 70 beats/min up to 91 beats/min was recorded in a patient with an external bipolar dual chamber pacing system. This observation could be explained by the occurrence of crosstalk; this specific manifestation of crosstalk was the result of the use of an uncommitted DVI pacing mode.

A controlled therapeutic trial in paucibacillary leprosy comparing a single dose of rifampicin with a single dose of rifampicin followed by one year of daily dapsone. The Collaborative Study Group for the Treatment of Leprosy in Zaire

The cure rates of two treatment regimens in PB leprosy were compared in a prospective randomized trial: treatment U consisting of a single dose of rifampicin 40 mg/K bodyweight, and treatment A of rifampicin 1500 mg in a single dose, followed by one year of daily dapsone 100 mg. In patients with a BI = 0, the cure rates evaluated on the basis of histopathology of skin biopsies, were identical for the two regimens but in patients with a BI = 1, cure and relapse rates were unacceptable. For this reason and particularly the need to separate patients on the basis of the BI in skin biopsies, the single dose regimen does not appear to be suited for wide-scale application.

Occurrence of lymphoproliferative disorders in heart transplant recipients

Lymphoproliferative diseases may occur as a complication of severe immunosuppression. In our own center two out of 46 heart transplant recipients, receiving a cyclosporin A containing immunosuppressive regimen, presented with this complication and are reported here. Hepatic involvement and an occult small bowel localisation, which only became evident after a chemotherapy-induced small bowel perforation, illustrate the predilection of posttransplant lymphoproliferations for extranodal sites. Both cases represent the extremes of a spectrum of post-transplant lymphoproliferations ranging from polyclonal benign lesions to monoclonal malignant lymphomas. Their B-cell origin was pathologically established, but in none of the two reported cases the previously postulated role of Epstein-Barr virus in the pathogenesis could be confirmed by serological tests. Severe immunosuppression played a major role in the pathogenesis of these disorders, as suggested by concomitant opportunistic infections occurring in both cases. The lymphoproliferation diagnosed in the polyclonal stage was reversible after reduction of the immunosuppressive therapy, without subsequent graft rejection. This observation underscores the importance of early recognition of lympho-proliferative disorders in organ transplant patients, allowing a prompt and successful reduction of the immunosuppressive therapy. Overwhelming opportunistic infections, occurring in the patient treated with cytotoxic drugs, illustrate the inherent risks of such an approach in an already severely immunosuppressed population.

Extracorporeal shock wave lithotripsy and cardiac arrhythmias

Holter monitoring was performed in 400 patients undergoing extracorporeal shock wave lithotripsy (ESWL). The highest heart rate occurred before and after ESWL. During respiratory-triggered ESWL, 30% of the patients had one or more ventricular premature beats (VES), and 7% had couplets of VES. The number of ventricular and supraventricular premature contractions was significantly lower during ECG-triggered ESWL. Ventricular tachycardia occurred in seven patients during respiratory-triggered ESWL, and in one patient during nontriggered ESWL. All ventricular tachycardias were nonsustained, asymptomatic, and slow. Supraventricular tachycardia was seen in nine patients. The preference of the urologist for respiratory-triggered ESWL, conflicts with its higher incidence of ventricular arrhythmias.

Combined regimens of one year duration in the treatment of multibacillary leprosy--II. Combined regimens with rifampicin administered during 6 months

From 1981 to 1983 all multibacillary patients presenting at the collaborating centres in Zaire and Rwanda were treated with one of the following regimens: 6 months supervised daily RMP 600 mg, ETH 500 mg and DDS 100 mg or CLO 100 mg followed by 6 months unsupervised daily DDS 100 mg or CLO 100 mg with ETH 500 mg added or not. These regimens gave rise to hepatotoxicity, reversal and erythema nodosum leprosum reactions as described previously. Bactericidal activity was excellent. Among the 289 patients in the trial, with a mean follow-up period of 3.88 years, no relapses were observed, with an upper 95% confidence limit of 0.35 per 100 person years. Because of the hepatotoxicity, alternative short-course therapies need to be tested.

The incubation time of relapses after treatment of multibacillary leprosy with rifampicin containing regimens

In order to determine the duration of follow-up needed to evaluate the efficacy of short-course bactericidal regimens for multibacillary leprosy, information is needed on the incubation time of relapses after stopping treatment. Several groups of patients, who had been on rifampicin-containing regimens, were followed up for periods ranging from 4 to 10 years. Two groups of relapses were observed: early relapses occurring within 3.5 years after stopping treatment, with a median incubation time of 1 year and 10 months (upper limit of 95% confidence interval: 2 years); and late relapses occurring more than 3.5 years after stopping treatment, with a median incubation of 5 years. Early relapses are probably due to insufficient treatment, and late relapses to persisting bacilli or to reinfection. It is concluded that the efficacy of short-course RMP-containing therapeutic regimens can be evaluated by observing the occurrence of early relapses, 50% of which occur before 2 years after the end of therapy.

Paraneoplastic Sjögren's syndrome

A patient with primary Sjögren's syndrome preceding an oat cell carcinoma of the lung, is presented. Arguments to support a possible relationship between these two disorders are discussed.

[Histological progression of paucibacillary leprosy during treatment with various therapeutic regimens]

Histopathological examination of skin biopsies from PB patients during the first 12-18 months of treatment did not reveal any significant difference in the time necessary for disappearance of the lesions. The regimens studied were: DDS 100 mg 7/7, RMP 600 mg 1/30 6x, RMP 600 mg 6/6 6x, RMP 900 mg 1/7 8x and 12x, RMP 1500 mg 1x and 1 year of DDS, RMP 4 mg/K 1x.

[Inadequate treatment in multibacillary leprosy and incubation times for relapses]

Among a population of over 500 PB patients treated with different regimens, 6 multibacillary relapses were detected: 5 in patients erroneously classified as PB but in reality MB with a low bacterial load, one patient was PB at the start. Treatment regimens had been: 10 weekly doses of RMP either 600 mg (1 case) or 900 mg (1 case) two successive doses of RMP 1500 mg (1 case) a single dose of RMP 40 mg/K (3 cases). Four MB patients with proven DDS-R relapsed after a single dose of RMP either 20 mg/K (1 case) or 40 mg/K (3 cases). The two strains isolated were RMP sensitive. Seven of the 10 relapses appeared within 24 months after start of treatment.

[Growth of lignocellulolytic microorganisms on activated sludge: potential application]

A culture medium containing activated sludge and sawdust supports the growth of numerous lignocellulolytic microorganisms. One of them, Phanerochaete chrysosporium could be used in a composite feed for ruminants.

Prospective study on the relationship between intensive bactericidal therapy and leprosy reactions

A systematic study was performed on the reactions occurring during several short-course therapy regimens for the treatment of paucibacillary and multibacillary patients. Most type 1 upgrading reactions in paucibacillary (PB) leprosy were mild to moderate and of short duration, while the time of onset was extremely variable. Their incidence was higher in the regimen rifampin (RMP) 900 mg once weekly for ten weeks than when a single dose of RMP 40 mg/kg body weight was given or 1500 mg in one dose followed by one year of dapsone (DDS) 100 mg daily. In multibacillary (MB) leprosy, three regimens were compared: MB-WHO regimen; regimen C, consisting of daily RMP 600 mg, ethionamide (ETH) 500 mg, and DDS or clofazimine (CLO) 100 mg for six months, followed by six months of daily DDS or CLO; and regimen D, identical to regimen C but comprising daily DDS or CLO plus ETH 500 mg during the second semester. Type 1 upgrading reactions occurred more frequently in MB patients and were more severe than in PB patients. They occurred more frequently and were more severe in regimens C and D than in the MB-WHO regimen. CLO 100 mg daily prevented type 1 reactions in MB patients and rendered them less severe. ENL was also more frequent in regimens C and D and was not prevented by CLO in the dosage used. Although there is some correlation between type 1 reactions and the total amount of RMP administered, other aspects of RMP administration.(ABSTRACT TRUNCATED AT 250 WORDS)

The Primary Health Care Project in Belgium: a survey on the utilization of health services

The article consists of two major parts. In the Introduction a general overview is given of the Primary Health Care Project, carried out in Belgium from 1975 to 1978 in the broader framework of a large National Project in the Social Sciences. An explanation is given of the scope of the study, its method and sampling. Since the very broad study design, it was decided to make a selection of interesting results. An overview is given of the most relevant data with respect to the utilization of health care services and of medicines. After a short clarification of the concept of utilization behaviour, some data are presented in order to describe the use of medical services and the consumption of medicines. Secondly an attempt is made to explain utilization behaviour. For the explanatory model used in this project, the WHO-model functioned as an important source of inspiration. In this way it surmounted the limitations of much previous research. This model included variables on the level of the individual-perceived morbidity, predisposing factors and enabling factors-as well as system variables--such as degree of urbanization, proximity and the way of functioning of the medical supply. The research results have successfully shown that: there is a strong relationship between perceived presence and perceived seriousness of morbidity on the one hand, utilization behaviour on the other hand; the health perspective (including medical knowledge, values and attitudes) seems to have a differential influence on utilization behaviour, depending on age and social background of the respondent; the inclusion of socio-structural variables is an innovation in the Belgian health care research. The hypothetical character of the relationships found here is largely supported by the research simultaneously conducted in the French-speaking region of Belgium; accessibility and socialization are factors having a clear influence on the use of general practice services. The importance of the presence and the organization of the supply in the explanation of utilization behaviour is partly confirmed.