Unacceptably high mortality related to measles epidemics in Niger, Nigeria, and Chad

BACKGROUND

Despite the comprehensive World Health Organization (WHO)/United Nations Children's Fund (UNICEF) measles mortality-reduction strategy and the Measles Initiative, a partnership of international organizations supporting measles mortality reduction in Africa, certain high-burden countries continue to face recurrent epidemics. To our knowledge, few recent studies have documented measles mortality in sub-Saharan Africa. The objective of our study was to investigate measles mortality in three recent epidemics in Niamey (Niger), N'Djamena (Chad), and Adamawa State (Nigeria).

METHODS AND FINDINGS

We conducted three exhaustive household retrospective mortality surveys in one neighbourhood of each of the three affected areas: Boukoki, Niamey, Niger (April 2004, n = 26,795); Moursal, N'Djamena, Chad (June 2005, n = 21,812); and Dong District, Adamawa State, Nigeria (April 2005, n = 16,249), where n is the total surveyed population in each of the respective areas. Study populations included all persons resident for at least 2 wk prior to the study, a duration encompassing the measles incubation period. Heads of households provided information on measles cases, clinical outcomes up to 30 d after rash onset, and health-seeking behaviour during the epidemic. Measles cases and deaths were ascertained using standard WHO surveillance-case definitions. Our main outcome measures were measles attack rates (ARs) and case fatality ratios (CFRs) by age group, and descriptions of measles complications and health-seeking behaviour. Measles ARs were the highest in children under 5 y old (under 5 y): 17.1% in Boukoki, 17.2% in Moursal, and 24.3% in Dong District. CFRs in under 5-y-olds were 4.6%, 4.0%, and 10.8% in Boukoki, Moursal, and Dong District, respectively. In all sites, more than half of measles cases in children aged under 5 y experienced acute respiratory infection and/or diarrhoea in the 30 d following rash onset. Of measles cases, it was reported that 85.7% (979/1,142) of patients visited a health-care facility within 30 d after rash onset in Boukoki, 73.5% (519/706) in Moursal, and 52.8% (603/1,142) in Dong District.

CONCLUSIONS

Children in these countries still face unacceptably high mortality from a completely preventable disease. While the successes of measles mortality-reduction strategies and progress observed in measles control in other countries of the region are laudable and evident, they should not overshadow the need for intensive efforts in countries that have just begun implementation of the WHO/UNICEF comprehensive strategy.

Methodological considerations and impact of school-based interventions on objectively measured physical activity in adolescents: a systematic review and meta-analysis

OBJECTIVE

The aims of this systematic review and meta-analysis are (i) to determine the impact of school-based interventions on objectively measured physical activity among adolescents and (ii) to examine accelerometer methods and decision rule reporting in previous interventions.

METHODS

A systematic search was performed to identify randomized controlled trials targeting adolescents (age: ≥10 years), conducted in the school setting, and reporting objectively measured physical activity. Random effects meta-analyses were conducted to determine the pooled effects of previous interventions on total and moderate-to-vigorous physical activity. Potential moderators of intervention effects were also explored.

RESULTS

Thirteen articles met the inclusion criteria, and twelve were included in the meta-analysis. The pooled effects were small and non-significant for both total physical activity (standardized mean difference = 0.02 [95% confidence interval = -0.13 to 0.18]) and moderate-to-vigorous physical activity (standardized mean difference = 0.24 [95% confidence interval = -0.08 to 0.56]). Sample age and accelerometer compliance were significant moderators for total physical activity, with a younger sample and higher compliance associated with larger effects.

CONCLUSION

Previous school-based physical activity interventions targeting adolescents have been largely unsuccessful, particularly for older adolescents. There is a need for more high-quality research using objective monitoring in this population. Future interventions should comply with best-practice recommendations regarding physical activity monitoring protocols.

Ceftriaxone as effective as long-acting chloramphenicol in short-course treatment of meningococcal meningitis during epidemics: a randomised non-inferiority study

BACKGROUND

In sub-Saharan Africa in the 1990s, more than 600,000 people had epidemic meningococcal meningitis, of whom 10% died. The current recommended treatment by WHO is short-course long-acting oily chloramphenicol. Continuation of the production of this drug is uncertain, so simple alternatives need to be found. We assessed whether the efficacy of single-dose treatment of ceftriaxone was non-inferior to that of oily chloramphenicol for epidemic meningococcal meningitis.

METHODS

In 2003, we undertook a randomised, open-label, non-inferiority trial in nine health-care facilities in Niger. Participants with suspected disease who were older than 2 months were randomly assigned to receive either chloramphenicol or ceftriaxone. Primary outcome was treatment failure (defined as death or clinical failure) at 72 h, measured with intention-to-treat and per-protocol analyses.

FINDINGS

Of 510 individuals with suspected disease, 247 received ceftriaxone, 256 received chloramphenicol, and seven were lost to follow-up. The treatment failure rate at 72 h for the intention-to-treat analysis was 9% (22 patients) for both drug groups (risk difference 0.3%, 90% CI -3.8 to 4.5). Case fatality rates and clinical failure rates were equivalent in both treatment groups (14 [6%] ceftriaxone vs 12 [5%] chloramphenicol). Results were also similar for both treatment groups in individuals with confirmed meningitis caused by Neisseria meningitidis. No adverse side-effects were reported.

INTERPRETATION

Single-dose ceftriaxone provides an alternative treatment for epidemic meningococcal meningitis--its efficacy, ease of use, and low cost favour its use. National and international health partners should consider ceftriaxone as an alternative first-line treatment to chloramphenicol for epidemic meningococcal meningitis.

Influence of propofol concentrations on multipulse transcranial motor evoked potentials

BACKGROUND

Motor evoked potentials can be affected by propofol anaesthesia. We studied how increasing target concentrations of propofol altered transcranial motor evoked potentials (tcMEP) during scoliosis surgery.

METHODS

Fifteen patients undergoing surgery for scoliosis were anaesthetized with remifentanil and propofol without nitrous oxide or neuromuscular blocking agents (BIS<60). tcMEP were elicited by transcranial electric multipulse stimulation of the motor cortex and recording of compound action potentials from the anterior tibialis muscle. tcMEP were obtained before surgery with propofol target values set from 4 to 8 mg litre(-1), and then during surgery. Arterial propofol concentrations were measured for each tcMEP recording.

RESULTS

Before surgery, increasing propofol reduced tcMEP amplitude in a dose-dependent manner, with no effect on latency. During surgery, at equivalent propofol concentrations, tcMEP were not statistically different from those obtained before surgery. In all except one patient, tcMEP signals were present during the entire procedure. In this patient the loss of tcMEP was unfortunately related to an anterior spinal cord lesion, which was confirmed by a wake-up test.

CONCLUSION

We found that, although propofol had a dose-dependent effect on tcMEP amplitude, anaesthesia could be maintained with remifentanil and propofol to allow recording and interpretation of tcMEP signals.

Thrombelastogram reveals hypercoagulability after administration of gelatin solution

We have compared the effects of gelatin, low molecular weight hydroxyethyl starch (HES) or albumin on tests of haemostasis and on the thrombelastogram in 42 ASA I patients undergoing total hip or knee replacement. Patients were allocated randomly to receive one of the three blood substitutes to obtain moderate intraoperative haemodilution. Blood loss and packed red cell infusion was the same in each group. A greater amount of gelatin was given (1.5 times the measured blood loss) because of its shorter half-life. There was a statistically significant but clinically negligible decrease in platelets count, prothrombin time and fibrinogen, and an increase in bleeding time in all groups. Platelets were slightly but significantly lower after HES. Haemodilution was comparable between groups. TEG showed a state of hypercoagulability in the gelatin group with a significant decrease in r, r + k and an increase in alpha angle.

Comparison of sevoflurane and propofol for ambulatory anaesthesia in gynaecological surgery

PURPOSE

To analyse the cost-efficiency ratio of sevoflurane compared with propofol for gynaecological ambulatory anaesthesia.

METHODS

In a prospective randomised study 52 ASA I patients scheduled for ambulatory pregnancy termination were premedicated with lorazepam and received alfentanil prior to anaesthesia induction with propofol (group P, n = 26) or with sevoflurane 8% (group S, n = 26) using the single breath vital capacity technique. Anaesthesia was maintained with N2O in both groups supplemented with sevoflurane (group S) or propofol boluses (group P).

RESULTS

The quality of induction and maintenance of anaesthesia was similar between groups except for the incidence of movement during anaesthesia (14/26 patients in group P and 4/26 in group S, P < 0.05). The incidence of post-operative emesis was increased in the sevoflurane group (P < 0.05) but the patients felt able to perform normal activity after a similar delay (18.4 +/- 2.9 hr vs 20.6 +/- 2.8 hr, P > 0.05). The direct cost of anaesthesia was lower in the sevoflurane group (679 FF, n = 24 vs 1153 FF, n = 2-5 in propofol group) but the weight of uterine aspiration products was higher (293 +/- 66 g, median = 230 g, Range 110-800 g, n = 13 vs 108 +/- 8 g, median = 110 g, Range 60-160 g, n = 12, group S vs group P respectively, P = 0.004). Four patients needed reoperation and ambulatory anaesthesia failed in six patients because of uterine haemorrhage.

CONCLUSION

Ambulatory anaesthesia with sevoflurane offers a good alternative to propofol but further investigation concerning blood loss with sevoflurane needs to be performed in gynaecological practice.

Effects of a 'school-based' physical activity intervention on adiposity in adolescents from economically disadvantaged communities: secondary outcomes of the 'Physical Activity 4 Everyone' RCT

BACKGROUND/OBJECTIVES:

Obesity prevention during adolescence is a health priority. The ‘Physical Activity 4 Everyone' (PA4E1) study tested a multi-component physical activity intervention in 10 secondary schools from socio-economically disadvantaged communities. This paper aimed to report the secondary outcomes of the study; to determine whether the intervention impacted on adiposity outcomes (weight, body mass index (BMI), BMI z-score), and whether any effect was moderated by sex, baseline BMI and baseline physical activity level, at 12 and 24 months.

SUBJECTS/METHODS:

A cluster randomised controlled trial was conducted in New South Wales, Australia. The school-based intervention included seven physical activity strategies targeting the following: curriculum (strategies to maximise physical activity in physical education, student physical activity plans, an enhanced school sport programme); school environment (physical activity during school breaks, modification of school policy); and parents and the community (parent engagement, links with community physical activity providers). Students' weight (kg), BMI and BMI z-score, were collected at baseline (Grade 7), 12 and 24 months. Linear Mixed Models were used to assess between-group mean difference from baseline to 12 and 24 months. Exploratory sub-analyses were undertaken according to three moderators of energy balance.

RESULTS:

A total of 1150 students (mean age=12 years) provided outcome data at baseline, 1051 (91%) at 12 months and 985 (86%) at 24 months. At 12 months, there were group-by-time effects for weight (mean difference=–0.90 kg (95% confidence interval (CI)=–1.50, −0.30), P<0.01) and BMI (−0.28 kg m⁻² (−0.50, −0.06), P=0.01) in favour of the intervention group, but not for BMI z-score (−0.05 (−0.11; 0.01), P=0.13). These findings were consistent for weight (−0.62 kg (−1.21, 0.03), P=0.01) and BMI (−0.28 kg m⁻² (−0.49, −0.06), P=0.01) at 24 months, with group-by-time effects also found for BMI z-score (−0.08 (−0.14; −0.02), P=0.02) favouring the intervention group.

CONCLUSION:

The PA4E1 school-based intervention achieved moderate reductions in adiposity among adolescents from socio-economically disadvantaged communities. Multi-component interventions that increase adolescents' engagement in moderate-to-vigorous physical activity (MVPA) may assist in preventing unhealthy weight gain.

Continuous epidural infusion of ropivacaine for postoperative analgesia after major abdominal surgery: comparative study with i.v. PCA morphine

We have compared the quality of three regimens of postoperative analgesia (continuous epidural administration of ropivacaine (Ropi. group), epidural ropivacaine and patient-controlled analgesia (PCA) with i.v. morphine (Ropi. + PCA group) and PCA morphine alone (PCA group)) during the first postoperative 24 h in a multicentre, randomized, prospective study. Postoperative analgesia was studied in 130 patients after major abdominal surgery performed under general anaesthesia. The ropivacaine groups received 20 ml of epidural bolus ropivacaine 2 mg ml-1 via the epidural route at the end of surgery, followed by continuous infusion of 10 ml h-1 for 24 h. The Ropi. + PCA group also had access to i.v. PCA morphine 1 mg, with a 5-min lockout. The PCA group received morphine as the sole postoperative pain treatment. The two ropivacaine groups had lower pain scores (P < 0.01) than the PCA group. Morphine consumption was higher in the PCA group (P < 0.05) than in the two ropivacaine groups. The quality of pain relief was rated as good or excellent in 79-85% of patients in the three groups. The percentage of patients without motor block increased between 4 and 24 h from 61% to 89% in the Ropi. group, and from 51% to 71% in the Ropi. + PCA group.

Platelet function during pregnancy: an evaluation using the PFA-100 analyser

In clinical practice, the only tests of platelet function are bleeding time and platelet number. Bleeding time lacks sensitivity and specificity but the PFA-100, an in vitro analyser of platelet function may be of value. This study aimed to evaluate any correlation between platelet number and function using the PFA-100 in pregnant women. During a 21-month period, platelet function was evaluated in whole blood as part of the pre-anaesthetic coagulation testing screen with the PFA-100 using collagen and epinephrine (PFA-EPI) or ADP (PFA-ADP) as platelet agonists. Thrombocytopenia was defined as a platelet number less than 150 G litre(-1). The patients were divided into four groups: Group I (n=110) normal pregnancy; Group II (n=38) thrombocytopenia of pregnancy; Group III (n=13) women with pre-eclampsia without thrombocytopenia; Group IV (n=19) women with pre-eclampsia and thrombocytopenia. Results are expressed as mean (SD). Platelet count was not statistically different between Groups II and IV (111.1 (23.1) vs 99.5 (28.0) G litre(-1)). PFA-EPI was statistically increased in Group II (124.0 (26.3) s), Group III (128.3 (17.9) s), and Group IV (143.6 (47.7) s) compared with normal pregnant patients (114.6 (27.3) s, P<0.05, Mann-Whitney U-test). PFA-ADP was statistically increased only in Group II compared with normal pregnant patients (90.5 (18.9) vs 80.2 (11.2) s, P<0.05). PFA values were increased above normal laboratory values in (four of 38) Group II patients and (six of 19) Group IV patients but in no patients in Group III. PFA-ADP results were correlated with platelet count only in Group IV (r=-0.74, P=0.0003). The increased PFA values and the correlation between PFA-ADP and platelet number in hypertensive thrombocytopenic women confirms that platelet function may be decreased in such patients. In patients with pregnancy-induced thrombocytopenia, platelet function may be preserved when the platelet count is as low as 60 G litre(-1).

Timely detection of meningococcal meningitis epidemics in Africa

BACKGROUND

Epidemics of meningococcal disease in Africa are commonly detected too late to prevent many cases. We assessed weekly meningitis incidence as a tool to detect epidemics in time to implement mass vaccination.

METHODS

Meningitis incidence for 41 subdistricts in Mali was determined from cases recorded in health centres (1989-98) and from surveillance data (1996-98). For incidence thresholds of 5 to 20 cases per 100000 inhabitants per week, we calculated sensitivity and specificity for detecting epidemics, and determined the time lapse between threshold and epidemic peak.

FINDINGS

We recorded 9084 meningitis cases. Clinic-based weekly incidence of 5 and 10 cases per 100000 inhabitants detected all meningitis epidemics (sensitivity 100%, 95% CI 93-100), with median threshold-to-peak time of 5 and 3 weeks. Under-reporting reduced sensitivity: only surveillance thresholds of 5 or 7 cases per 100000 inhabitants per week detected all epidemics. Crossing the lower threshold before the 10th calendar week doubled epidemic risk relative to crossing it later (relative risk 2.1, 95% CI 1.4-3.2). At 10 cases per 100000 inhabitants per week, specificity for outbreak prediction was 88%, 95% CI 83-91). For populations under 30000, 3 to 5 cases in one or two weeks predicted epidemics with 85% to 97% specificity.

INTERPRETATION

Low meningitis thresholds improve timely detection of epidemics. Ten cases per 100000 inhabitants per week in one area confirm epidemic activity in a region, with few false alarms. An alert threshold of 5 cases per 100000 inhabitants per week allows time to investigate, prepare for an epidemic, and initiate mass vaccination where appropriate. For populations under 30000, the alert threshold is two cases in a week. High quality surveillance is essential.

PAF-acether and acetylhydrolase in stool of patients with Crohn's disease

PAF-acether (PAF) is a phospholipid mediator with potent biological effects on the digestive tract. We report the presence of PAF in stool of patients with active Crohn's disease (39.1 +/- 13.5 ng/g of stool, mean +/- SEM, N = 19) and its absence in patients with irritable bowel syndrome with diarrhea and diarrhea with malabsorption. Fecal PAF acetylhydrolase activity was higher (P less than 0.04) in patients with Crohn's disease as compared to patients with irritable bowel syndrome with diarrhea and diarrhea with malabsorption. We also report a solid-phase extraction of fecal PAF using silica minicolumns, which yielded results highly correlated with those obtained with a high-performance liquid chromatography method (r = 0.86, P less than 0.001, N = 16). These findings may allow us to implicate PAF in the onset and perpetuation of digestive tract inflammatory symptoms observed during Crohn's disease. They would warrant to investigate the influence of various therapeutic agents, including PAF antagonists, on fecal PAF levels during inflammatory digestive ailments.

Can oral vitamin K before elective surgery substitute for preoperative heparin bridging in patients on vitamin K antagonists?

BACKGROUND

After a vitamin K antagonist (VKA) overdose, 1-2 mg of oral vitamin K can lower the International Normalized Ratio (INR) to the therapeutic range.

OBJECTIVE

To establish whether oral vitamin K can substitute for heparin bridging and decrease the INR to < or = 1.5 before elective surgery.

METHODS

Patients on long-term VKAs were randomized either to heparin bridging after the last VKA dose on day -5 before surgery (group H) or to VKA treatment until day -2, followed by 1 mg of oral vitamin K on the day before surgery (group K). Blood clotting variables were assessed on days -5/-2, 1 and 0, and postoperatively. If the target INR was not achieved 2 h before incision, surgery was deferred or performed after injection of prothrombin complex concentrate (PCC).

RESULTS

In 30 of 94 included patients, baseline INR was outside the chosen range (18, INR < 2; 12, INR > 3.5), leaving 34 eligible patients in group H and 30 in group K. The groups were balanced in terms of body mass index, VKA treatment duration and indication, scheduled surgery, preoperative and postoperative hemoglobin, and blood loss. The INR was significantly higher in group K on days -1 and 0 than in group H. An INR < or = 1.5 was not achieved in 20 group K patients (66%). Surgery was postponed or performed after PCC injection in 12 of these 20 patients.

CONCLUSIONS

Oral vitamin K (1 mg) cannot substitute for heparin bridging before surgery. In addition, one-third of patients on VKAs were exposed to a risk of bleeding (overdose) or thrombosis (underdose), thus highlighting the need for new oral anticoagulants.

Transjugular liver biopsy--an Australian experience

During the four year period 1983-87 transjugular liver biopsy was performed on 67 patients (M43, F24) aged 17-79 yr (mean 45.6 yr). Standard percutaneous biopsy was contraindicated by coagulation disorders (95%) often with ascites (17%). Biopsies were taken using a specially modified Ross trans-septal needle passed into hepatic veins under fluoroscopic guidance. Hepatic tissue samples were obtained from the initial biopsy in 62 (93%) patients. In 30 consecutive transjugular biopsies a mean area of 38.2 mm2 per section (0.9-100 mm2) was available for histology compared with an area of 15.9 mm2 (9.3-48.8 mm2) in 50 consecutive percutaneous biopsies. Improved techniques of sample washing, sieving and fixation optimised separation of hepatic tissue from blood clot and fibrin. Four patients experienced significant complications but no deaths occurred. Individual diagnoses were changed in 17 patients as a result of biopsy findings. This study confirms the efficacy and relative safety of the transjugular approach in obtaining liver biopsies from patients with contraindications to standard percutaneous techniques.

Shortage of vaccines during a yellow fever outbreak in Guinea

A yellow fever epidemic erupted in Guinea in September, 2000. From Sept 4, 2000, to Jan 7, 2001, 688 instances of the disease and 225 deaths were reported. The diagnosis was laboratory confirmed by IgM detection in more than 40 patients. A mass vaccination campaign was limited by insufficient international stocks. After the epidemic in Guinea, the International Coordinating Group on Vaccine Provision for Epidemic Meningitis Control decided that 2 million doses of 17D yellow fever vaccine, being stored as part of a UNICEF stockpile, should be used only in response to outbreaks.

Plasma interleukin-4, interleukin-10, and interleukin-13 concentrations and complications after coronary artery bypass graft surgery

OBJECTIVES

To determine whether plasma interleukin (IL)-4, IL-10, and IL-13 concentrations are associated with complications after coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB).

STUDY DESIGN

Prospective descriptive study.

SETTING

University teaching hospital.

PARTICIPANTS

Thirty-two patients during and 24 hours after CABG surgery.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic measurements and blood samples were obtained from 32 patients during and after surgery. Coagulation, pulmonary, and cardiovascular functions were specifically assessed during the first 24 hours postoperatively. Plasma IL-4 and IL-13 levels remained unchanged during CABG surgery. In contrast, plasma IL-10 concentrations increased by 117-fold in the immediate postoperative period and returned to pre-CPB values by 24 hours postoperatively. Plasma IL-10 levels were not different in patients with or without cardiovascular impairment, coagulation disorders, and lung injury. Plasma IL-10 levels did not correlate with the leukocyte count, the amount of catecholamines infused, or the duration of CPB.

CONCLUSION

The present results suggest that the development of post-CABG surgery complications might be linked to an insufficient production of anti-inflammatory cytokines, such as IL-4, IL-10, or IL-13, which are unable to counteract the overproduction of inflammatory cytokines.

Induction with propofol target-concentration infusion vs. 8% sevoflurane inhalation and alfentanil in hypertensive patients

Haemodynamic parameters during an inhalation induction with 8% sevoflurane were compared with those obtained with a target-controlled infusion of propofol in 50 hypertensive patients in a prospective randomised study. Heart rate and arterial pressure were recorded continuously. End-tidal sevoflurane and nitrous oxide concentration, SpO2 and bispectral index (BIS) were also collected from the beginning of anaesthesia until 8 min after tracheal intubation. Patients either received 4 mg.l-1 target-concentration propofol or performed a vital capacity inhalation of 8% sevoflurane in a high flow of oxygen (8 l.min-1) supplemented with 50% nitrous oxide at loss of consciousness. As soon as BIS was < 60, 20 microg.kg-1 alfentanil and 0.6 mg.kg-1 rocuronium were injected and orotracheal intubation was then performed 1 min later. Thereafter, the end-tidal concentration of sevoflurane was reduced to 1.3 minimum alveolar concentration (MAC). Hypotension was defined as a 30% decrease in arterial pressure and was treated with repeated 3-mg boluses of ephedrine. When 12 mg ephedrine was unable to correct hypotension, the concentration of propofol was reduced by 1 mg.l-1 and that of sevoflurane by 0.5%. Hypotension occurred in 22 patients in the sevoflurane group and 21 in the propofol group, and hypertension occurred in two and three patients in each group, respectively. The maximal reduction in mean (SD) arterial pressure was similar in the sevoflurane (45 (4) mmHg) and propofol (41.3 (2.6) mmHg) groups, as were the ephedrine requirements (9.6 (1.1) vs. 9.1 (1.1) mg, sevoflurane vs. propofol, p > 0.05), the duration of hypotension (276 (37) vs. 292 (38) s, sevoflurane vs. propofol, p > 0.05), and the number of hypotensive episodes or anaesthetic changes and depth of anaesthesia. Nevertheless, heart rate was lower during the 8 min following tracheal intubation in the sevoflurane group. In both groups, the duration of hypotension was easily controlled either by ephedrine or by adjusting the anaesthetic concentrations. Overall, haemodynamic tolerance appears to be similar in the two techniques. Because hypotension occurred after alfentanil in most patients, this study questioned which is the best opioid dose, if any, to associate with propofol or sevoflurane for the induction in hypertensive patients.

[PhysioFlex: a target-controlled self-regulating closed-circuit inhalation anesthesia regulator]

Physi Flex is the first commercially available apparatus capable for quantitative, or self-regulating target controlled inhalational anaesthesia, with a totally closed circuit, in adults and children. The fresh gas supply to the circuit is intermittent, automatically regulated by continuous monitoring of the volume and composition of the gas mixture in the breathing circuit. The circle system includes, instead of the two conventional one way valves, a blower creating a continuous unidirectional flow at 70 L.min-1. In addition to the CO2-absorber it contains an absorber with carbon, absorbing the anaesthetic vapour when switched into the circuit. The ventilator consists of four ventilating chambers, each one with a membrane separating the patient and the motor compartments. The displacement of the membranes generates and measures the tidal volume. Automatic ventilation is achieved by electric valves and motor gas, and manual ventilation using a bag. Spontaneous ventilation is also possible. The machine is operated via a computer with selects the number of ventilating chambers (one, two or four), and the tidal volume between 50 and 2,000 mL, depending on age, gender and weight of the patient. The computer maintains the gas volume and the gas and vapour concentrations at their preset values. The O2-flow and consumption, the N2O flow and uptake, FICO2 and FETCO2, FI and FET of the volatile anaesthetic, all other important data are displayed in a numerical and graphical form on a color screen and registered for a delayed analysis. The end tidal concentration of the volatile anaesthetic drives a stepmotor with a syringe containing the selected volatile anaesthetic agent with is directly injected into the breathing circuit where it is vaporized. Therefore the concentration of the anaesthetic vapour can be instantaneously increased with this injector at induction and lowered at end of anaesthesia with the carbon absorber, and the fresh gas consumption is significantly decreased.

High sensitivity and specificity of the Pastorex® latex agglutination test for Neisseria meningitidis serogroup A during a clinical trial in Niger

There is a great need for a rapid diagnostic test to guide vaccine choice during outbreaks of meningococcal meningitis in resource-poor countries. During a randomised clinical trial conducted during an epidemic of Neisseria meningitidis serogroup A in Niger in 2003, the sensitivity and specificity of the Pastorex latex agglutination test for this serogroup under optimal field conditions were assessed, using culture and/or PCR as the gold standard. Results from 484 samples showed a sensitivity of 88% (95% CI 85-91%) and a specificity of 93% (95% CI 90-95%). Pastorex could be a good alternative to current methods, as it can be performed in a local laboratory with rapid results and is highly specific. Sensitivity can be improved with prior microscopy where feasible. A study specifically to evaluate the Pastorex test under epidemic conditions, using laboratories with limited resources, is recommended.

The efficacy of chloroquine for the treatment of acute, uncomplicated, Plasmodium falciparum malaria in Laos

To assess the local efficacy of chloroquine for the treatment of acute, uncomplicated, Plasmodium falciparum malaria, children and adults from Sekong province (an area of Laos with a low intensity of transmission) were tested in a 28-day, in-vivo study. Complete data were collected from 88 of the 102 subjects enrolled between October 1999 and September 2000. After genotypic analysis to distinguish recrudescing infections from re-infections, 35 (39.7%, with a 95% confidence interval of 29.5%-50.7%) of these 88 patients were considered treatment failures. These results seriously question the use of chloroquine as the first-line treatment for P. falciparum malaria in the study area.

Plasma leukaemia inhibitory factor, interleukin 6 and soluble interleukin 6 receptor levels during cardiopulmonary bypass with extracorporeal circulation

In this study the authors assessed plasma leukaemia inhibitory factor (LIF), interleukin 6 (IL-6) and soluble IL-6 receptor (sIL-6R) concentrations in 28 patients undergoing coronary artery bypass graft (CABG) with extracorporeal circulation (ECC). Plasma IL-6 levels increased during ECC, reaching a 33-fold increase 6 h after surgery as compared to pre-operative values. In contrast, plasma sIL-6R and LIF concentrations did not vary significantly during cardiac surgery. Thus, LIF is not implicated in the haematological changes and in the inflammatory syndrome observed after CABG. Despite the fact that LIF and IL-6 exhibit several common biological activities, the production of these two cytokines is differently regulated during cardiac surgery with ECC. Plasma IL-6 levels increased during cardiac surgery while sIL-6R levels did not changed. These data contrast with the decreased sIL-6R concentrations with concomitantly high IL-6 levels in patients with sepsis syndrome suggesting that inflammatory reactions in sepsis and after cardiopulmonary bypass are triggered by different mechanisms.

Semimembranosus tenosynovitis: operative results

Semimembranosus tenosynovitis is a common knee problem in the over-50 age-group, occurring mainly in women. It affects the reflected portion of the tendon of the semimembranosus muscle as well as the bursa below it. The tendon becomes inflamed as a result of friction at the entrance to the bony canal (semimembranosus groove), especially if osteophytes are present on the edges of the groove. Conservative treatment includes anti-inflammatory drugs, ultrasound, and friction massage. If necessary, nonresponders may be given local injection of 40-80 mg methylprednisolone acetate with 1% Xylocaine. Between 1979 and 1983 we operated on 16 patients who had not obtained relief even after three or four injections. The approach in each case was through a posterior medial oblique incision. The semimembranosus osteofibrotic tunnel was revealed and the fibrous sheath surrounding the tendon was excised. Good results were obtained in eight patients in whom the inflammatory process had been localized to only the semimembranosus insertion area: eight patients in whom the knee joint or the pes anserinus insertion was also involved achieved fair or poor results. The operation is not advised for young athletes because of the important function of the reflected head of the semimembranosus muscle.