Blood pressure screening in Mata Sector, a rural area of Rwanda

In rural sub-Saharan Africa, knowledge of non-communicable diseases such as high blood pressure (BP) is rather limited. This report provides information about a BP screening in Mata Sector, a rural region in Southern Province of Rwanda. Community-based, house-to-house screening was performed between February and July 2020 on more than 7000 inhabitants. The screening was conducted by a local team composed by 20 community health care workers, five community health care supervisors, and one nurse with hypertension surveillance training. BP and heart rate were recorded after 5 min of resting, using a validated automated oscillometric OMRON M6 IT-HEM-7322-E monitor with Intelli Wrap Cuff (HEM-FL31-E) technology. The mean of the second and third value was retained. BP was normal (<140/90 mm Hg) in 6340 (88%) and elevated in 863 (12%) participants with 95% of unawareness. Grade 1 (140-159/90-99 mm Hg) hypertensive BP readings were detected in 697 (81%), grade 2 (160-179/100-109 mm Hg) in 134 (16%), and grade 3 (≥180/≥110 mm Hg) in 32 (3.7%) individuals. The prevalence of hypertensive readings was significantly age-dependent. Additionally, a slightly greater proportion of participants with high BP (14% versus 11%) had a body mass index (BMI) ≥ 25.0 kg/m2. Also resting heart rate was higher in individuals with high BP (82 versus 77 beats/min). Although individuals identified with occasionally elevated BP values need further confirmatory measurements to establish the diagnosis of hypertension, these data suggest that high BP represents a noteworthy and preventable reason of concern within sub-Saharan Africa.

Secondary hypertension as a cause of treatment resistance

In secondary hypertension, elevated blood pressure is caused by a known and/or potentially treatable underlying disease.Although the prevalence of secondary hypertension depends on the patient population and the thoroughness of applied diagnostic approaches, arterial hypertension is classified in 90 to 95% as primary in nature. In young patients, individuals without a family history of hypertension, late onset of hypertension or worsening of a previous well-controlled hypertension as well as in patients who have a difficult to treat hypertension, the prevalence of secondary hypertension is significantly higher.Because the identification and the specific therapy of secondary hypertension may result in normalisation or improvement of elevated blood pressure in many cases, a targeted diagnostics is of great importance.

Effectiveness of low-dose iron treatment in non-anaemic iron-deficient women: a prospective open-label single-arm trial

BACKGROUND

Iron deficiency without anaemia is highly prevalent and is particularly associated with fatigue, cognitive impairment, or poor physical endurance. Standard oral iron therapy often results in intestinal irritation with associated side effects and premature discontinuation of therapy, therefore, optimal oral iron therapy with sufficient iron absorption and minimal side effects is desirable.

METHODS

Thirty-six iron-deficient non-anaemic premenopausal women (serum ferritin ≤30 ng/ml, haemoglobin ≥117 g/l) with normal body mass index (BMI) and no hypermenorrhea received 6 mg of elemental oral iron (corresponding to 18.6 mg ferrous sulphate) twice daily for 8 weeks.

RESULTS

Participants treated with low-dose iron had an average age of 28 years and a BMI of 21 kg/m2. Their serum ferritin and haemoglobin increased significantly from 18 ng/ml to 33 ng/ml (p <0.001) and from 135 g/l to 138 g/l (p = 0.014), respectively. Systolic blood pressure increased from 114 mmHg to 120 mmHg (p = 0.003). Self-reported health status improved after 8 weeks (p <0.001) and only one woman reported gastrointestinal side effects (3%).

CONCLUSION

This prospective open-label single-arm trial shows that oral iron treatment of 6 mg of elemental iron twice daily over 8 weeks is effective in iron-deficient non-anaemic women. Due to the negligible side effects, low-dose iron treatment is a valuable therapeutic option for iron-deficient non-anaemic women with normal BMI and menstruation. Further placebo-controlled studies with a larger number of participants are needed to confirm these results.

CLINICALTRIALS

gov NCT04636060.

Impact of Cardiovascular Risk Factors on Arterial Stiffness in a Countryside Area of Switzerland: Insights from the Swiss Longitudinal Cohort Study

INTRODUCTION

Cardiovascular disease is the leading cause of morbidity and mortality. Besides traditional cardiovascular risk factors, arterial stiffness is a recognized predictor of cardiovascular risk.

METHODS

We investigated the relationship between traditional cardiovascular risk factors, sex, and aortic pulse wave velocity in subjects living in a countryside area of Southern Switzerland. For this aim, we performed a cross-sectional analysis of data from adult participants of the Swiss Longitudinal Cohort Study, which, initiated in 2015, follows health status and disease risk factors in a Swiss countryside cohort at least 6 years of age.

RESULTS

A total of 387 people (205 women and 182 men) were included. Hyperlipidemia, overweight, and obesity were more common (p ≤ 0.001) and LDL-cholesterol, triglycerides, and hemoglobin A1c were higher (p < 0.03) in men than women. Systolic and diastolic brachial and aortic blood pressures were higher in men (p < 0.02), whereas aortic pulse wave velocity and aortic pulse pressure were higher in women (p < 0.05). The aortic pulse wave velocity was significantly higher in subjects with hypertension, hyperlipidemia, diabetes, and obesity, and significantly increased with age (p < 0.0001). Multiple linear regression analysis showed a significant correlation between pulse wave velocity and age, female sex, brachial systolic blood pressure, and heart rate (p < 0.005).

CONCLUSION

Also in a countryside area, the aortic pulse wave velocity is higher in subjects with hypertension, hyperlipidemia, diabetes and obesity, and significantly increases with age. Furthermore, with advancing age, aortic pulse wave velocity is higher in women than men.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02282748.

Dietary Patterns and Physical Activity Correlate With Total Cholesterol Independently of Lipid-Lowering Drugs and Antiretroviral Therapy in Aging People Living With Human Immunodeficiency Virus

Background

Hypercholesterolemia is a well established risk factor for coronary heart disease and is highly prevalent among human immunodeficiency virus (HIV)-positive persons. Antiretroviral therapy (ART) can both directly modify total cholesterol and have drug-drug interactions with statins. This makes investigating modifiable behavioral predictors of total cholesterol a pertinent task.

Methods

To explore the association between diet and physical activity with cross-sectionally measured total cholesterol, we administered a validated Food-Frequency-Questionnaire to participants of the Swiss HIV Cohort Study ≥45 years old. Linear mixed-effects models were applied to explore the associations between dietary patterns and physical activity with total cholesterol, after adjustment for clinical and demographic covariates.

Results

In total, 395 patients were included. Forty percent (158 of 395) had elevated total cholesterol (>5.2 mmol/L), and 41% (164 of 395) were not regularly physically active. In multivariable analysis, 2 factors were positively associated with total cholesterol; female sex (β = 0.562; 95% confidence interval [CI], 0.229–0.896) and the combined consumption of meat, refined/milled grains, carbonated beverages, and coffee (β = 0.243; 95% CI, 0.047–0.439). On the other hand, regular physical activity (β = −0.381; 95% CI, −0.626 to −0.136), lipid-lowering drugs (β = −0.443; 95% CI −0.691 to −0.196), ART containing tenofovir (β = −0.336; 95% CI −0.554 to −0.118), and black ethnicity (β = −0.967; 95% CI −1.524 to −0.410) exhibited a negative association.

Conclusions

We found independent associations between certain dietary patterns and physical activity with total cholesterol. Increasing physical activity might achieve cardiovascular and other health benefits in HIV-positive individuals. The clinical relevance of the identified dietary patterns requires further investigation in prospective cohort studies and randomized controlled trials.

Associations of sodium, potassium and protein intake with blood pressure and hypertension in Switzerland

BACKGROUND

Nutritional factors play an important role in the regulation of blood pressure and in the development of hypertension. In this analysis, we explored the associations of 24-hour urinary Na+, K+ and urea excretion with blood pressure levels and the risk of hypertension in the Swiss population, taking regional linguistic differences into account.

METHODS

The Swiss Survey on Salt is a population based cross-sectional study that included 1336 subjects from the three main linguistic regions (French, German and Italian) of Switzerland. Blood pressure was measured with a validated oscillometric Omron HEM 907 device. Hypertension was defined as current antihypertensive treatment or a mean systolic blood pressure >140 mm Hg and/or diastolic >90 mm Hg, based on eight blood pressure measurements performed at two visits. Na+, K+ and urea excretion were assessed in 24-hour urine collections. We use multiple logistic/linear regressions to explore the associations of urine Na+, K+ and urea with blood pressure / hypertension, taking into account potential confounders and effect modifiers.

RESULTS

The prevalence of hypertension was 30%, 26% and 17% in the German-, French- and Italian- speaking regions respectively, (p-value across regions <0.001). In the Swiss adult population, besides age, sex, and body mass index, urinary Na+ excretion was positively associated with systolic blood pressure and hypertension. Urinary K+ excretion tended to be negatively associated with blood pressure but this was not significant (p = 0.08). Hypertensive people had a higher 24-hour urinary Na+/K+ ratio than normotensive people (p = 0.003). Urinary urea excretion was associated with neither blood pressure nor hypertension. Participants from the German-speaking region had a higher likelihood of having a high systolic blood pressure.

CONCLUSIONS

We confirm a high prevalence of elevated blood pressure in Swiss adults, including regional differences. In Switzerland, urinary Na+ excretion is associated positively with blood pressure and hypertension, independently of urinary K+ and urea excretion. The observed differences in blood pressure levels across linguistic regions are independent of the urinary Na+, K+ and urea excretion.

Population-based reference values for the 1-min sit-to-stand test

OBJECTIVES

To determine reference values for the 1-min sit-to-stand (STS) test in an adult population.

METHODS

Cross-sectional study nested within a nationwide health promotion campaign in Switzerland. Adults performed the STS test and completed questions on demographics and health behavior.

RESULTS

6,926 out of 7,753 (89.3 %) adults were able to complete the STS test. The median number of repetitions ranged from 50/min (25-75th percentile 41-57/min) in young men and 47/min (39-55/min) in young women aged 20-24 years to 30/min (25-37/min) in older men and 27/min (22-30/min) in older women aged 75-79 years.

CONCLUSIONS

The reference values support the interpretation of 1-min STS test performance and identification of subjects with decreased lower body muscular strength and endurance.

Feasibility, limits and problems of clinical studies in Intensive Care Unit

In critical care medicine there is still a paucity of evidence on how to manage most of the clinical problems commonly encountered in critically ill patients. Randomized controlled trials (RCTs) are the most powerful instruments to evaluate the efficacy of a therapeutic intervention and to generate evidence for clinical practice. Unfortunately, the design and conduct of RCTs in our field are particularly complicated, because of some intrinsic and structural problems (e.g. lack of reliable nosography, concomitant use of different therapies, problems in the definition of end-points besides mortality) that will be discussed in this review. Further challenges are represented by the lack of tradition of large ICU networks, difficulties in linking or integrating physiologic and therapeutic objectives in designing clinical protocols, scarcity of independent or non-profit funds. A particularly stimulating opportunity of development is represented also by the relationship of critical care to EBM. Because of the above problems, metanalyses could be less informative than in other areas of medicine, as they are based on few trials which are often contradictory and of unsatisfactory quality. Few suggestions are formulated which could help looking forwards.

Is the pulmonary artery catheter misused? A European view

OBJECTIVES

To review the problems associated with pulmonary artery catheter use in the intensive care unit; to discuss the need for clinical trials to assess its benefits; and to present original data on the use of the pulmonary artery catheter in European countries.

DATA SOURCES

Selected relevant articles from the literature and data from a recent multicenter European study.

DATA EXTRACTION AND SYNTHESIS

It has recently been suggested that pulmonary artery catheter use increases mortality. As a result, some have recommended placing a moratorium on pulmonary catheter use or suggested conducting large multicenter trials to assess the positive and negative effects of pulmonary catheter use. Although there is limited evidence showing an improved outcome with pulmonary artery catheter use, many leaders in intensive care medicine feel that the pulmonary catheter is a useful tool, when used correctly. We believe that misuse of the pulmonary artery catheter is common. The incidence of complications is low and, with improved training of insertion techniques, the frequency of complication would decrease further. The pulmonary artery catheter is a monitoring tool and, as such, is only as good as the interpretation of the data it generates. Clinical trials on such an accepted technique are difficult to conduct and their cost/benefit ratio is debatable.

CONCLUSIONS

A moratorium on pulmonary artery catheter use is not necessary and clinical trials in heterogeneous ICU populations are not warranted. Improved training in the insertion, interpretation, and implementation of the pulmonary artery catheter and the data it generates is required. As an alternative to expensive clinical trials on the pulmonary artery catheter, we propose that our limited financial resources for clinical investigation be invested in the development of innovative techniques that may reduce the need for pulmonary artery catheter in the future.

Organization of intensive care units in Europe: lessons from the EPIC study

OBJECTIVE

To study differences related to intensive care unit (ICU) structure and patient demography between the various countries of Western Europe.

DESIGN

Application of data collected by the European Prevalence of Infection in Intensive Care (EPIC) study, a one-day prevalence study.

SETTING

Voluntary participation of all Western European ICUs. A total of 1417 ICUs responded.

PATIENTS

All patients, older than 10 years of age, occupying a bed in the participating ICUs over a 24-h period. 10,038 patient case reports were submitted.

RESULTS

The study revealed important differences. In particular, there seems to be a north/south divide with fewer ICU beds and more severely ill patients in the south. The United Kingdom seemed more similar to southern European countries than to the north.

CONCLUSION

While there are similarities between European countries, large differences still remain and are important to identify to enable us to work together to create a more uniform system of intensive care, which will in turn give more effective and efficient patient care.

Anticoagulation in patients treated by continuous venovenous hemofiltration: a retrospective study

The most adequate anticoagulation regimen during extracorporeal renal replacement therapy can be difficult to define. Two hundred fifty-five critically ill patients with a mean age (+/- SD) of 58.2 +/- 16.3 years were treated by continuous venovenous hemofiltration (CVVH) between 1986 and 1992 in our intensive care units. Blood was circulated through hemofilters, either polyacrylonitrile (AN 69; Hospal, Lyon, France) or polyamide (FH 66; Gambro, Lund, Sweden), using a roller pump and an air safety system. The patients were classified into three subgroups according to the amount of heparin needed to achieve an adequate anticoagulation (ie, prevention of extracorporeal circuit clotting without inducing a patient's bleeding tendency): group 1, 37 patients who received no heparin (14.5%); group 2, 189 patients who received 100 to 700 IU/hr of heparin (74.1%); and group 3: 29 patients who received more than 700 IU/hr of heparin (11.4%). We analyzed the filter survival, the routine coagulation parameters, and the evolution of the patients for each group. Median duration of treatment was 144 hours (range, 4 to 1,152 hours). There were no differences in requirement of heparin among the two types of membrane: AN 69 (mean +/- SD), 393 +/- 106 IU/hr v FH 66, 374 +/- 35.3 IU/hr (range, 0 to 2,000 IU/hr). There were no relationships between the amount of heparin the patients received and the mean survival of the filters (group 1, 22.1 +/- 14.8 hr; group 2, 24.7 +/- 13.2 hr; group 3, 23 +/- 9.6 hr).(ABSTRACT TRUNCATED AT 250 WORDS)

Enhancement of ethanol induced rectal mucosal hyper regeneration with age in F344 rats

Experimental studies in rats have shown an independent stimulation of rectal cell turnover by either chronic ethanol consumption or age. In this study the combined effect of these two factors on colorectal cell regeneration has been investigated. Ninety male F344 rats aged 2, 12, and 22 months were pair fed nutritionally adequate liquid diets containing 36% of total energy either as ethanol or isoenergetic carbohydrates. After four weeks of feeding, colorectal crypt cell production rates were measured using a stathmokinetic technique with vincristine. While age by itself did not affect colorectal cell renewal, chronic ethanol consumption stimulated rectal, but not colonic crypt cell production rate in an age dependent manner. While no significant effect of ethanol was noted in young animals, cell proliferation was significantly enhanced in middle aged animals by 81% (4.1 (2.7-5.5) v 7.4 (6.0-8.7) cells/crypt/hour, p < 0.001) and in old animals by 138% (4.5 (3.3-5.6) v 10.7 (8.9-12.4) cells/crypt/hour, p < 0.001) after ethanol ingestion. Because acetaldehyde, the first and most toxic metabolite of ethanol, has been detected in the colorectal mucosa and may lead to tissue injury influencing cell regeneration, acetaldehyde concentrations have been measured in the colons of 15 male F344 rats of various ages after an acute intraperitoneal dose of ethanol (2.5 g/kg bodyweight). There was a significant positive correlation between crypt cell production rate and acetaldehyde concentrations measured in the distal and proximal colon after an acute dose of ethanol (r = 0.5955, p < 0.005). These data clearly show that the ethanol mediated stimulation of cell regeneration in the rectum is age dependent. As reported earlier, there was found indirect evidence that acetaldehyde participates in the pathogenesis of rectal hyperregeneration after chronic alcohol consumption. This hyperregeneration of the rectal mucosa after alcohol drinking could by itself favour carcinogenesis, which is especially relevant in old age.

Imbalance between tumour necrosis factor-alpha and soluble TNF receptor concentrations in severe meningococcaemia. The J5 Study Group

The extracellular domain of tumour necrosis factor-alpha (TNF-alpha) receptors have inhibitory properties against TNF-alpha. The relative ratio between ligand and ligand inhibitors may influence the outcome of meningococcaemia. To test this hypothesis, levels of TNF-alpha and of each of the soluble inhibitory fragments originating from two distinct TNF-alpha receptors (sTNF-RI and sTNF-RII) were measured in sera of children with severe meningococcaemia. On admission to the hospital the levels of sTNF-RI, -RII and TNF-alpha were markedly increased and all three correlated with the outcome of the disease. A correlation was found between TNF-alpha and sTNF-RI (P less than 0.001 by Pearson rank correlation coefficient) or sTNF-RII (P = 0.012). For TNF-alpha concentrations below 500 pg/ml, the increase of TNF-alpha was proportional to that of sTNF-RI and RII; however, when TNF-alpha levels exceeded 500 pg/ml, sTNF-RI and RII concentrations did not increase proportionally. At admission, in patients with fatal outcome, the ratios TNF-alpha/sTNF-RI and -RII were higher than in survivors. During the first 6 hr, the kinetics of TNF-alpha, sTNF-RI and -RII were different. Naturally occurring TNF-alpha inhibitors may play an important role in modulating the biological activity of TNF-alpha in severe meningococcaemia.

[Liver transplantation for primary biliary cirrhosis]

Primary biliary cirrhosis (PBC) is regarded as one of the optimal indications for orthotopic liver transplantation (OLT) in adults. Between July 1987 and August 1991, 7 patients had PBC as the indication for OLT. 6 were transplanted and one patient is still on the waiting list. The patients' mean age was 47 years (range: 39 to 59) and the time from diagnosis to indication for OLT was 4, 7, 8, 10, 12, 15 and 17 years. Variceal hemorrhage episodes treated by sclerotherapy (plus porta-caval shunt in one patient) occurred in 3 patients before OLT. All suffered from jaundice (mean bilirubin 232 mumol/l, range 116 to 536), weakness, anorexia and pruritus. There were no deaths in this series during a mean follow-up time of 26 months (range 6 to 43). With the exception of osteopenia, all complications of chronic liver disease were reversed by OLT. Despite numerous postoperative problems (e.g. reoperations, intense rejection episodes, cytomegalovirus infections and lumbar column fractures), the quality of life is excellent for these 6 patients. Mean bilirubin at time of last follow-up was 18 mumol/l (range 8 to 26). No evidence of PBC recurrence was found. Based on international experience confirmed by this series, we support the notion that no patient suffering from advanced PBC should be denied OLT whenever possible.

Esophageal electrodes allow precise assessment of cardiac output by bioimpedance

OBJECTIVES

To analyze the impact of the position of the thoracic external electrodes on the values of cardiac output measured by electrical bioimpedance and to compare the results obtained by bioimpedance with those values determined by thermodilution in critically ill patients.

DESIGN

Open, prospective, comparative trial.

SETTING

ICU of a teaching hospital.

PATIENTS

Twenty healthy volunteers and ten critically ill patients.

INTERVENTIONS

Measurements of cardiac output by bioimpedance at rest and after physical activity in normal volunteers and after changing the neck or xiphoid electrodes. Comparisons of cardiac output obtained by thermodilution and bioimpedance with internal and external electrodes in patients.

MEASUREMENTS AND MAIN RESULTS

Mean +/- SD values are presented. Cardiac output values at rest and after exercise were 6.7 +/- 1.3 and 10.8 +/- 2.6 L/min at rest and after exercise, respectively (p less than .001). Displacement of the xiphoid electrodes 3 cm in the caudal direction was accompanied by a decrease of the mean cardiac output from 7.1 +/- 1.2 to 5.8 +/- 1.3 L/min (p less than .001) and displacement 3 and 6 cm cranially was accompanied by increases in cardiac output from 7.1 +/- 1.2 to 8.1 +/- 1.4 L/min (p less than .001) and 8.6 +/- 1.5 L/min (p less than .001), respectively. In the ten patients, cardiac output measurements were virtually identical when results obtained by thermodilution (6.7 +/- 3.1 L/min) were compared with those results obtained by bioimpedance using internal esophageal (6.6 +/- 3.1 L/min), but not external (4.7 +/- 1.6 L/min) electrodes.

CONCLUSIONS

a) The values of cardiac output derived from measurements obtained by bioimpedance using internal electrodes were comparable with those values derived from thermodilution. b) Values of cardiac output from bioimpedance studies with external electrodes were dependent on the position of the xiphoid electrodes.

Dental erosion in a population of Swiss adults

The purpose of this study was to determine the prevalence of dental erosion in an adult population in Switzerland. 391 randomly selected persons from two age groups (26-30 and 46-50 yr) were examined for frequency and severity of erosion on all tooth surfaces. Information was gathered by interview about lifestyle, dietary and oral health habits. For facial surfaces 7.7% of the younger age group and 13.2% of the older age group showed at least one tooth affected with erosion with involvement of dentin (grade 2). 3.5 teeth per person in the younger and 2.8 teeth per person in the older age group were affected. Occlusally, at least one severe erosion was observed in 29.9% of the younger and 42.6% of the older sample with 3.2 and 3.9 erosion-affected teeth per person, respectively. 3.6% of the younger age group and 6.1% of the older age group showed slight lingual erosion on the maxillary anterior teeth. Severe lingual erosions were scarce. Data from interviews and multiple regression analyses revealed that acids from beverages are significantly associated with presence of erosion.

[Posterior shoulder dislocation. An often overlooked injury]

Posterior dislocation of the shoulder is rare. Only 2% of dislocated shoulders are displaced posteriorly, and these are chiefly of the subacromial type. Over 60% of the cases are not diagnosed initially because the arm is held in the normal position of adduction and internal rotation. The most consistent findings on physical examination are: the fixed internal rotation of the arm and the characteristic movement of the scapula with abduction of the upper extremity. It is essential that appropriate radiographs are obtained to correctly diagnose the dislocation. While the routine anteroposterior shoulder film is often enough to diagnose various anterior dislocations, it is not sufficient to diagnose the subacromial type of posterior dislocation. We recommend an anteroposterior view and an axillary lateral or tangential scapula view.

[Intestinal angiodysplasia--a diagnostic and therapeutic challenge]

During an eight-year period we have treated 10 patients for intestinal angiodysplasia complicated by major hemorrhage. This condition represents a degenerative, acquired lesion mostly in elder people consisting of thin-walled vessels of venous origin. Angiodysplasias are usually multiple and predominantly localized in the right colon. Besides localizing the bleeding source the exclusion of concomitant lesions capable of bleeding but not responsible for hemorrhage represents the main diagnostic problem. Segmental colectomy for angiodysplasia is rarely followed by rebleeding when preoperatively the site of hemorrhage has reliably been identified, mainly by angiography. Today the colonoscopic electro- or lasercoagulation of vascular ectasia represents a valuable alternative therapeutic procedure. Subtotal colectomy should be used only as a last resort.

Necrotizing tracheobronchitis: a complication of high frequency jet ventilation

The tracheal and bronchial lesions observed are described in seven patients, presenting with respiratory distress syndrome and receiving both conventional and high frequency jet ventilation for various periods. The histological findings are related to the duration of the exposure as well as the number of pulsations administered to the tracheobronchial tree. Severe damage to the mucosa leading to acute tracheobronchitis, hyperplasia and hypersecretion of the mucosal glands may explain some of the clinical symptoms observed, especially the upper respiratory obstruction. Care should be taken to limit these changes which may lead to various degrees of stenosis in survivors receiving this mode of therapy.

Preoperative preparation of the bowel for urological surgery: a review

The risk of postoperative complications following opening of the intestine can be reduced by lowering the intraluminal bacterial count. The latter is achieved principally by decreasing the mass of the gut content and by antibiotic prophylaxis. Macroscopically satisfactory decontamination of the gut can be attained with laxatives, enemas, elementary diet or orthograde lavage. We prefer oral lavage with Golytely solution since it allows rapid preparation of the gut and is well tolerated. The value of antibiotic prophylaxis in association with operations on the colon or rectum is undisputed and a number of regimes have been shown to be effective. In view of its effectiveness and lack of side effects. 24-hour perioperative parenteral prophylaxis with metronidazole can be recommended.

Humoral and cellular immune responses in cattle and sheep inoculated with Sarcocystis

Cattle inoculated with Sarcocystis bovicanis (= Sarcocystis cruzi) and sheep inoculated with Sarcocystis ovicanis were monitored for the appearance of Sarcocystis-specific antibodies and lymphocytes in the peripheral circulation. Anti-Sarcocystis antibody was identified by enzyme-linked immunosorbent assay, whereas antigen-reactive lymphocytes were discerned by an in vitro lymphocyte blastogenic assay. The antigens used were the soluble fraction recovered from disrupted bradyzoites of mature sarcocysts. Cattle developed anti-Sarcocystis immunoglobulin (Ig)M responses, beginning 3 to 4 weeks after inoculation, and IgG1 antibody responses, beginning 5 to 6 weeks after inoculation. The increase in IgM antibody was relatively brief, returning to near preinfection levels in 2 to 3 months. In contrast, IgG1 antibody levels remained high for at least 5 to 6 months. Neither IgG2 nor IgA antibody responses were demonstrable in cattle. In sheep, the IgG antibody levels followed a time course similar to that seen in cattle, except that the increase was slightly delayed (6 to 8 weeks after inoculation was done). Measurable IgM antibody response was not seen in sheep. Cellular immunoresponsiveness as judged by in vitro lymphocyte blastogenesis in cattle was different from that in sheep. Sarcocystis-specific lymphocytes were demonstrable in the circulation of cattle within 15 days after they were inoculated, but the activity decreased rapidly. In sheep, reactive cells were not evident until 3 to 4 weeks after inoculation were done, but peripheral blood lymphocytes taken from these sheep as long as 5 to 6 weeks after the inoculations remained capable of mounting strong blastogenic responses. Neither the enzyme-linked immunosorbent assay nor the blastogenic assay showed species specificity. Animals immunized with a given species of Sarcocystis gave similar in vitro responses to antigens from the immunizing species and to other species of Sarcocystis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Influence of cimetidine on bacterial growth in gastric fluid (author's transl)]

Samples of gastric fluid were tested for pH and number of bacteria in 20 patients who received cimetidine 400 mg prior to selective gastric surgery. The results were compared with those obtained in a group of surgical patients who did not receive the drug. The cimetidine-treated patients had alkaline gastric fluid with pronounced bacterial growth (4.7 +/- 0.6 x 10(4) micro-organisms/ml), whereas 18/20 untreated patients has a sterile gastric fluid. Similar results were observed in 14 intensive care patients treated for 24 hours with cimetidine. The effect proved reversible: 12 hours after treatment was discontinued bacterial growth could only be demonstrated in 3/14 patients. Thus, short-term cimetidine treatment results in a rise of gastric pH with marked bacterial proliferation. This may have serious consequences in cimetidine-treated patients about to undergo gastric surgery or likely to develop aspiration pneumonia.

Nosocomial infections in intensive care wards: a multicenter prospective study

In a three-year prospective investigation, a total of 6,952 patients were investigated prospectively in nine intensive care wards and their rate of nosocomial infections was analysed. The frequency of the nosocomial infections varied between 3% and 27%. The most frequent nosocomial infections were urinary tract infections, sepsis, infections of the skin and of the subcutaneous tissue, pneumonia and wound infections. The most frequent causes of sepsis were ventilation pneumonia, venous catheters, wound infections and urinary tract infections. The pathogen spectrum was analysed. By specific control of infection with employment of an infection control nurse, the frequency of nosocomial infections on intensive care wards was lowered from 17.2% to 14.3% within one year in one of the hospitals.

Tracheal and subglottic lesions following long-standing intubation. A radiological and clinical study

A 3-year systematic study was made for subglottic and tracheal lesions of patients who had been intubated for more than 10 h (87 patients intubated for time periods ranging from 10 to 1,960 h). The radiological aspect of the lesions was studied and classified as tracheal stenosis, cartilage lesions and granulomas. The radiological analyses were performed by tracheography (14 cases), xerography, xerotomography (87 cases) and CT (2 cases). The incidence of lesions was 34% with 3.4% (3 cases) of severe stenosis; only 1 patient was symptomatic. The cuff, the tip of the endotracheal tube and the suction cannula were found to be responsible for the tracheal sequelae. A statistically significant correlation was found between the duration of the intubation and the severity of the tracheal lesions. The lesions, examined radiologically about a year after the intubation, were found to be stable.

[Physical training in high altitude]

Hemodynamic parameters and myocardial extraction of lactate and free fatty acids (FFA) have been studied at rest and during exercise (bicycle) in 9 mountain climbers who spent 4 weeks in the Himalayas at an altitude of 5500-7000 m. All investigations were performed before and immediately after the stay at high altitude. The combined effect of physical training and hypoxemia of high altitude did not alter the hemodynamic parameters, calculated VO2 max, production of lactate or decrease of FFA during the exercise test, but myocardial extraction of lactate and FFA changed. After returning from the expedition myocardial extraction (at rest and during exercise) of lactate increased and that of FFA decreased. The reasons for these alterations and their goals and implications are discussed.

The value of serum magnesium estimations in the diagnosis of acute perioperative myocardial infarction after coronary artery surgery

Serum magnesium levels fall significantly after acute myocardial infarction. Even greater decreases have been found in all patients undergoing aorto-coronary bypass surgery. This is probably related to the use of cardiopulmonary bypass. No significant difference in serum magnesium levels was found between those patients who had a well documented peri-operative infarct and those who had an uncomplicated course. Thus determination of serum magnesium levels if of no use in the diagnosis of peri-operative myocardial infarction.