[The relationship of mental health providers with health insurers; an exploration]

BACKGROUND

In 2020, Zorgverzekeraars Nederland (ZN), the umbrella organization of nine health insurers in The Netherlands. presented a vision of the future of mental health care in the Netherlands in ‘De GGZ in 2025. Vergezicht op de geestelijke gezondheidszorg’ (‘Outlook on mental health care’). This document can be seen as marking the fact that key stakeholders share a common vision on the future of the GGZ in the Netherlands. Contracting care is often difficult. The tension between providing quality and sufficient care and available funding leads to friction. Congruence in vision, goals and practices are important conditions for adequate relationship building. Does the vision document contribute to this?

AIM

To discuss the experiences of mental health care administrators and health insurers in contracting and collaboration.

METHOD

Conducting interviews with both directors of mental health institutions and the strategic (policy) advisors of health insurers. In the approach we used the salience model.

RESULTS

The relationship between mental health care administrators and health insurers is perceived to be distrustful and complex, and has deteriorated slightly in 2021 compared to 2019. Perceived power, legitimacy and urgency affect the relationship. Almost all health insurers are characterized as dominant stakeholders based on the salience model. Both parties are open to improving the relationship, which requires more transparency and mutual understanding.

CONCLUSION

With the supported content of the vision document, there is to some extent shared governance. The change steps (shared innovation) considered desirable will be promoted by partly granting the intended benefits to each other (shared savings).

[Rheumatoid arthritis: more than a joint disease]

Rheumatoid arthritis (RA), one of the most common autoimmune disorders, mostly manifests itself as polyarthritis. However, extra-articular organ manifestations can also occur, even though their incidence has decreased substantially due to effective treatment with disease-modifying anti-rheumatic drugs. In this article we describe three patient cases of extra-articular manifestations in RA in the absence of prominent arthritis. The diversity of symptoms in RA can be of interest to different medical specialties who will occasionally encounter them in daily practice.

Recoil-Induced Asymmetry of Nondipole Molecular Frame Photoelectron Angular Distributions in the Hard X-ray Regime

We investigate angular emission distributions of the 1s photoelectrons of N_{2} ionized by linearly polarized synchrotron radiation at hν=40  keV. As expected, nondipole contributions cause a very strong forward-backward asymmetry in the measured emission distributions. In addition, we observe an unexpected asymmetry with respect to the polarization direction, which depends on the direction of the molecular fragmentation. In particular, photoelectrons are predominantly emitted in the direction of the forward nitrogen atom. This observation cannot be explained via asymmetries introduced by the initial bound and final continuum electronic states of the oriented molecule. The present simulations assign this asymmetry to a novel nontrivial effect of the recoil imposed to the nuclei by the fast photoelectrons and high-energy photons, which results in a propensity for the ions to break up along the axis of the recoil momentum. The results are of particular importance for the interpretation of future experiments at x-ray free electron lasers operating in the few tens of keV regime, where such nondipole and recoil effects will be essential.

Photon-Momentum-Induced Molecular Dynamics in Photoionization of N_{2} at hν=40 keV

We investigate K-shell ionization of N_{2} at 40 keV photon energy. Using a cold target recoil ion momentum spectroscopy reaction microscope, we determine the vector momenta of the photoelectron, the Auger electron, and both N^{+} fragments. These fully differential data show that the dissociation process of the N_{2}^{2+} ion is significantly modified not only by the recoil momentum of the photoelectron but also by the photon momentum and the momentum of the emitted Auger electron. We find that the recoil energy introduced by the photon and the photoelectron momentum is partitioned with a ratio of approximately 30∶70 between the Auger electron and fragment ion kinetic energies, respectively. We also observe that the photon momentum induces an additional rotation of the molecular ion.

[Two sisters with lung emphysema]

BACKGROUND

α1-antitrypsin is an antiprotease that is mainly produced in the liver; it plays a crucial role in the protection of lung parenchyma against the destructive effects of proteases. Mutations in the α1-antitrypsin gene can cause α1-antitrypsin deficiency. Individuals homozygous for the Z-genotype have drastically lowered serum α1-antitrypsine concentrations and often develop lung emphysema at an early age.

CASE DESCRIPTION

A 38-year-old woman and her 43-year-old sister both developed lung emphysema at an early age; this could be attributed to severe α1-antitrypsin deficiency. The only treatment for this condition is α1-antitrypsin supplement therapy, but this therapy is not reimbursed by health insurance companies in the Netherlands.

CONCLUSION

α1-antitrypsin deficiency is a relatively rare cause of lung emphysema and can be seen as an orphan phenotype of chronic obstructive pulmonary disease (COPD). We appeal for reconsideration of coverage of α1-antitrypsine supplement therapy by basic health insurance in the Netherlands, on the basis of a recent randomised placebo-controlled study in which the protective effect of this therapy on progressive emphysema was demonstrated by CT lung densitometry.

Single nucleotide polymorphisms in immune response genes in acute Q fever cases with differences in self-reported symptoms

Genes involved in human immune response are well recognized to influence the clinical course of infection. The association of host genetics with susceptibility to and severity of clinical symptoms in acute Q fever was investigated. Single nucleotide polymorphisms (SNPs) in the IFNG (rs2430561/rs1861493), STAT1 (rs1914408), and VDR (rs2228570) genes were determined in 85 patients from the 2007 Dutch acute Q fever outbreak, and a symptom score was calculated. IFNG rs1861493 showed a significant association with the symptom score; IFNG rs2430561 showed a similar trend. These SNPs were then used to reproduce results in a 2009 outbreak population (n = 123). The median symptom score differed significantly in both populations: 2 versus 7. The significant association of IFNG rs1861493 with symptom score in the first population was not reproduced in the second population. We hypothesize that individuals in the second outbreak were exposed to a higher Coxiella burnetii dose compared to the first, which overruled the protection conferred by the A-allele of IFNG rs1861493 in the first population.

Vitamin D-binding protein haplotype is associated with hospitalization for RSV bronchiolitis

BACKGROUND

Between 75 000 and 125 000 U.S. infants are hospitalized for respiratory syncytial virus (RSV) bronchiolitis every year. Up to half will be diagnosed with asthma in later childhood. Vitamin D deficiency has been associated with susceptibility to asthma and respiratory infections. Measured vitamin D is largely bound to vitamin D-binding protein (VDBP); VDBP levels are influenced by its gene (GC) haplotype.

OBJECTIVE

We assessed the relationship between polymorphisms rs7041 and rs4588, which define haplotypes GC1s, GC1f, and GC2, and RSV bronchiolitis susceptibility and subsequent asthma.

METHODS

We retrospectively recruited 198 otherwise healthy children (93% White) hospitalized for severe RSV bronchiolitis in Boston and 333 parents into a follow-up study to assess asthma diagnosis. Data were analysed using family-based genetic association tests. We independently validated our results in 465 White children hospitalized with RSV bronchiolitis and 930 White population controls from the Netherlands.

RESULTS

The rs7041_C allele (denoting haplotype GC1s) was overtransmitted (P = 0.02, additive model) in the entire Boston cohort, in Whites (P = 0.03), and especially in children subsequently diagnosed with asthma (P = 0.006). The GC1f haplotype was undertransmitted in the asthma subgroups (all races and White, both P < 0.05). The rs7041_C allele was also more frequent in the RSV bronchiolitis group compared with controls (OR 1.12, 95% CI 1.02, 1.4, P = 0.03) in the Netherlands, especially in mechanically ventilated patients (P = 0.009).

CONCLUSION AND CLINICAL RELEVANCE

GC1s haplotype carriage may increase the risk of RSV bronchiolitis in infancy and subsequent asthma development. The GC1s haplotype is associated with higher VDBP levels, resulting in less freely available vitamin D.

KEY MESSAGES

Vitamin D-binding protein (VDBP) haplotypes influence free vitamin D levels. We report an association between a VDBP haplotype and hospitalization for RSV bronchiolitis in infancy in two independent cohorts.

Reaction-Diffusion Dissipative Systems—Detailed Stability Analysis-Pattern of Growth and Effect of Inhomogenity

A detailed stability analysis of the one dimensional steady state solutions for the Brusselator model under the conditions of diffusion of initial (non-autocatalytic) components has been performed both for zero flux as well as fixed boundary conditions. In addition to subcritical as well as supercritical bifurcations, situations have been observed where all solution branches at a bifurcation point are unstable. A case of degenerate steady state bifurcation (2 solutions emanating from the same bifurcation point) has also been noticed. A transient simulation of the system in growth reveals the importance of growth rate on the pattern selection process and suggests that the selection of branches at a bifurcation point may be influenced by perturbations/ fluctuations. It also indicates that a stability analysis of the bifurcation diagram alone cannot decide the state of the system in a transient process, and under certain situations complex behavior may be observed at limit points.

Numerical calculations on coupled cells indicate that a heterogenity in the system can introduce multiple (two) time scales in the system. As the ratio of time scales increases, aperiodic or irregular oscillations are observed for the 'fast' variable. A combination of cells with one cell in a steady-state mode and the other in a periodic motion results in a combined motion of the entire system. For a distributed parameter system, a heterogenity can cause development of sharp local concentration gradients, alter the stability properties of steady state as well as periodic solutions and can cause partitioning of the system.

Imperfect Bifurcations and Spatial Structures in Dissipative Systems

One-dimensional reaction-diffusion equations associated with the trimolecular model of Prigogine and Lefever ("Brusselator") are analyzed. A physical description of possibilities of keeping con-centrations of initial components constant is discussed. It is shown that the problem considering diffusion of initial components gives rise to an imperfect bifurcation problem. The diffusion equa-tions have been solved numerically by a continuation procedure for the fixed and zero flux boundary conditions. The analysis indicates that the models including diffusion of all reacting components do not admit an occurence of trivial solutions. These models, as a result, also exclude the pos-sibility of primary bifurcations. The models which consider diffusion of the initial components suppress the number of possible solutions of governing equations. These models may also predict both symmetric and asymmetric states. Apparently this type of models is more suitable for predic-tion of patterns of spatial organization in growth. Since the number of possible profiles is strongly reduced this principle may lead to a more deterministic way of an evolution process. Symmetric profiles occuring on an isola cannot be reached by an evolution process unless a large perturbation is imposed on the system.

Technical strategies to improve tissue engineering of cartilage-carrier-constructs

Technical aspects play an important role in tissue engineering. Especially an improved design of bioreactors is crucial for cultivation of artificial three-dimensional tissues in vitro. Here formation of cartilage-carrier-constructs is used to demonstrate that the quality of the tissue can be significantly improved by using optimized culture conditions (oxygen concentration, growth factor combination) as well as special bioreactor techniques to induce fluid-dynamic, hydrostatic or mechanical load during generation of cartilage.

Interactive spatial tools for the design of regional adaptation strategies

Regional adaptation strategies are plans that consist of feasible measures to shift a region towards a system that is flexible and robust for future climate changes. They apply to regional impacts of climate change and are imbedded in broader planning. Multiple adaptation frameworks and guidelines exist that describe the development stages of regional adaptation strategies. Spatial information plays a key role in the design of adaptation measures as both the effects of climate change as well as many adaptation measures have spatial impacts. Interactive spatial support tools such as drawing, simulation and evaluation tools can assist the development process. This paper presents how to connect tasks derived from the actual development stages to spatial support tools in an interactive multi-stakeholder context. This link helps to decide what spatial tools are suited to support which stages in the development process of regional adaptation strategies. The practical implication of the link is illustrated for three case study workshops in the Netherlands. The regional planning workshops combine expertise from both scientists and stakeholders with an interactive mapping device. This approach triggered participants to share their expertise and stimulated integration of knowledge.

Psychometric evaluation of a Dutch version of the Mini PAS-ADD for assessing psychiatric disorders in adults with different levels of intellectual disability

BACKGROUND

People with intellectual disabilities (ID) have an increased vulnerability to develop psychiatric problems. Moreover, the early recognition and the accurate diagnosis of psychiatric disorders in the population of persons with ID are challenging.

METHOD

A Dutch version of the Mini PAS-ADD, which is a screening instrument for identification of mental health problems in people with ID, was evaluated in terms of internal consistency, interinformant reliability, item grouping and criterion validity based on a large-scale random sample (n = 377) and a clinical sample (n = 99) of adults with ID.

RESULTS

The Dutch version of the Mini PAS-ADD showed moderate internal consistency, and moderate concordance among informants. Both aspects of the reliability were comparable for different levels of ID. A factor analysis largely confirmed the scale structure. Concurrent validity with the Reiss Screen for Maladaptive Behavior was high for the Depression, Psychosis and Autism scale. The outcome of the criterion-validity analysis indicated high specificity. The sensitivity for specific psychiatric disorders by the corresponding scales was moderate, but the general sensitivity for the presence of psychopathology on the basis of any of the scales was satisfying.

CONCLUSIONS

The present research reconfirmed the use of the Mini PAS-ADD as a primary screening device for the identification of mental health problems among people with ID.

Confirmation of an association between single nucleotide polymorphisms in the VDR gene with respiratory syncytial virus related disease in South African children

Respiratory syncytial virus is a leading cause of lower respiratory tract infection in infants. Disease severity has been linked to host immune responses and polymorphisms in genes associated with innate immunity. A large-scale genetics study of single nucleotide polymorphisms (SNPs) in children in the Netherlands identified SNPs in the vitamin D receptor (VDR) and JUN genes which have a strong association with an increased risk of developing bronchiolitis following the first respiratory syncytial virus (RSV) infection. The Toll-like receptor 4 (TLR4) gene has two SNPs which have been associated previously with RSV disease severity in various populations. The aim of this study was to determine if these SNPs may be associated with RSV disease in African children in South Africa. RSV patient (n = 296) and control (n = 113) groups were established (median ages: 3 and 3.5 months) and DNA extracted from the collected specimens. Real-time polymerase chain reaction using hydrolysis probes was used to screen for SNPs in the VDR (Thr1Meth; rs10735810), TLR4 (Asp299Gly; rs4986790 and Thr399Ile; rs4986791) and JUN (c.750G/A; rs11688) genes. Carriers of the VDR (Thr1Meth) SNP minor T allele were more prone to RSV disease than individuals in the control group. The TLR4 (Asp299Gly), TLR4 (Thr399Ile), and JUN (c.750G/A) SNPs showed no significant association with RSV disease. It is concluded that children carrying the minor T allele of the VDR (Thr1Meth) SNP may be predisposed to RSV disease, as this SNP was identified as a risk factor for severe RSV disease in South African children, confirming the findings in the Netherlands.

Volumetric analysis of osteoclastic bioresorption of calcium phosphate ceramics with different solubilities

Commonly, to determine osteoclastic resorption of biomaterials only the resorbed area is measured. The depth of the resorption pit, however, may also be important for the performance of a material. To generate such data we used two calcium phosphate ceramics (Ca(10) and Ca(2)). The solubility of the materials was determined according to DIN EN ISO 10993-14. They were scanned three-dimensionally using infinite focus microscopy and subsequently cultivated for 4 weeks in simulated body fluid without (control) or with human osteoclasts. After this cultivation period osteoclasts number was determined and surface changes were evaluated two- and three-dimensionally. Ca(10) and Ca(2) showed solubilities of 11.0+/-0.5 and 23.0+/-2.2 mgg(-1), respectively. Both materials induced a significant increase in osteoclast number. While Ca(10) did not show osteoclastic resorption, Ca(2) showed an increased pit area and pit volume due to osteoclastic action. This was caused by an increased average pit depth and an increased number of pits, while the average area of single pits did not change significantly. The deduced volumetric osteoclastic resorption rate (vORR) of Ca(2) (0.01-0.02 microm(3)microm(-2)day(-1)) was lower than the remodelling speed observed in vivo (0.08 microm(3)microm(-2)day(-1)), which is in line with the observation that implanted resorbable materials remain in the body longer than originally expected. Determination of volumetric indices of osteoclastic resorption might be valuable in obtaining additional information about cellular resorption of bone substitute materials. This may help facilitate the development of novel materials for bone substitution.

Hand-assisted laparoscopic splenectomy for a splenic hamartoma: two case reports

We present two patients, each with a hamartoma of the spleen. These cases were thought to be well indicated for a hand-assisted laparoscopic approach and subsequent treatment was successful. Focal lesions of the spleen should be removed intact to allow a complete histological examination and to avoid peritoneal dissemination in case of malignancy. In these patients, the hand-assisted laparoscopic approach makes it possible to remove an unmorcellated organ and has the advantages of the laparoscopic technique. It can be considered as one of the suitable methods of surgical treatment.

Treatment with anti-TNF? does not induce reactivation of latent Salmonella enterica serovar Typhimurium infection in C3H/HeN mice

Therapy with tumour necrosis factor-alpha (TNFalpha)-blocking agents is successful in treating inflammatory disorders, but carries an increased risk of manifest and reactivating infection with intracellular bacteria. In a mouse model of latent Salmonella typhimurium infection, neutralization of TNFalpha did not result in reactivation of infection, suggesting only a minor role for TNFalpha during latency of persistent Salmonella infection.

[Effect of genetic polymorphisms on the susceptibility to and course of infectious diseases]

The highly variable susceptibility to and course of infectious diseases are caused by variable environmental factors and by genetic differences in both the pathogens and the host. The genetic variability of the host is determined mainly by polymorphisms in genes that play a role in processes such as adhesion, specific and non-specific immunity, antigen presentation, and inflammation. These variations are important, for example, in infections with HIV or respiratory syncytial virus. It is important to combine genetic knowledge with knowledge about the functional properties of variant genes. Applications of knowledge about genetic variability can be found in the development of vaccines and therapeutic agents, prognostics, and the treatment of individual patients.

No association between interleukin-18 gene polymorphisms and haplotypes in Dutch sarcoidosis patients

Previously, an association between susceptibility to sarcoidosis and a polymorphism in the interleukin (IL-18) gene (IL-18 -607A/C) has been reported in Japanese. The aim of the present study was to validate this association in a clinically well-characterized population of Dutch Caucasians. Three other polymorphisms at positions -656, -137, and 1248 were included in order to extend the mapping of the IL-18 gene and to enable the construction of haplotypes. Polymorphisms were determined using sequence-specific primers (SSPs) and polymerase chain reaction (PCR). A total of 236 individuals was studied (133 patients and 103 controls). No significant differences were observed in the distribution of the -607 and the other polymorphisms between Dutch sarcoidosis patients and controls. However, significant differences in IL-18 -607 genotype and allele frequency distributions were found between the Dutch and the Japanese. From the investigated IL-18-promoter polymorphisms, we were able to deduce four haplotypes. No differences were observed in haplotype frequencies between Dutch sarcoidosis patients and controls. In conclusion, IL-18 polymorphisms do not appear to influence the susceptibility to sarcoidosis in Dutch Caucasians. Important differences in allele frequencies were observed between Japanese and Dutch sarcoidosis patients and controls.

Pneumonia caused by Mycobacterium kansasii in a series of patients without recognised immune defect

The clinical and epidemiological characteristics of 17 patients diagnosed with Mycobacterium kansasii pneumonia within a limited geographical region over a period of 10 years are described. An in-depth evaluation of the innate and adaptive immune systems was performed for five available patients. A comparison was made of the genetic fingerprint patterns of the isolates obtained by restriction fragment length polymorphism (RFLP) analysis, with the major polymorphic tandem repeat (MPTR) as a probe. Predisposing factors consisted of smoking, airway abnormalities, substance abuse, diabetes or poor general condition, but in two patients no risk factor was identified. In the five patients tested, no abnormalities or deficiencies were detected in the innate or adaptive type-1 immunity. All M. kansasii isolates had identical MPTR RFLP patterns, although no epidemiological connection could be established, and these were identical to those of clinical isolates from Australian patients. These data do not support the theory that defects in the innate or adaptive type-1 immunity have a role in the pathogenesis of invasive M. kansasii infections. The identical fingerprint patterns of the isolates suggested the existence of a virulent strain of M. kansasii.

Linkage of myostatin pathway genes with knee strength in humans

This study was the first to explore the potential role of the myostatin (GDF8) pathway in relation to muscle strength and estimated muscle cross-sectional area in humans using linkage analysis with a candidate gene approach. In young male sibs (n = 329) 11 polymorphic markers in or near 10 candidate genes from the myostatin pathway were genotyped. Muscle mass was estimated by anthropometric measurements, and maximal knee strength was evaluated using isokinetic dynamometers (Cybex NORM). Single-point nonparametric variance components and linear quantitative trait locus regression linkage analysis methods were used. Linkage patterns were observed between knee extension and flexion peak torque with markers D2S118 (GDF8), D6S1051 (CDKN1A), and D11S4138 (MYOD1), and a maximum LOD score of 2.63 (P = 0.0002) was observed with D2S118. The ratios of peak torque over muscle and bone area of the midthigh of the lower contraction velocity (60 degrees/s) showed more frequently significant LOD scores than the torques at high velocity (240 degrees/s). Although myostatin is physiologically more related to muscle mass through possible effects of hyperplasia and hypertrophy than it is to strength, only two estimated muscle cross-sectional areas were marginally linked (LOD 1.06 and 1.07, P = 0.01) with marker D2S118 near GDF8 (2q32.2). The present results gave suggestive evidence that the myostatin pathway might be important for strength phenotypes, and GDF8, CDKN1A, and MYOD1 are potential candidate regions for a further and denser mapping with respect to these phenotypes.

Metal versus plastic spacers: an in vitro and in vivo comparison

This study compared the metal Nebuchamber with the polycarbonate Volumatic spacer in vivo as well as in vitro. Seventeen asthmatic patients were evaluated in a crossover placebo-controlled double-blind study. Bronchodilation, heart rate and serum potassium levels were measured at baseline and 15 min after administration of salbutamol. Cumulative dose-response curves (200, 400, 800 and 1600 microg) were constructed. The Andersen Cascade Impactor was used to compare the aerodynamic particle size distribution. The FEV(1) measurements showed highly significant differences between placebo and the two active preparations (P<0.001), but not between the two active preparations (P=0.433). The serum potassium levels also showed highly significant differences between placebo and the two active preparations (P=0.009), but not between the two active preparations (P=0.532). Only 1600 microg salbutamol dose raised the heart rate significantly, but the difference between the two active preparations was not significant. The in vitro deposition study revealed no significant differences in the delivered dose or in the fine particle dose (P>0.05). In conclusion, there are no significant differences between the Volumatic and Nebuchamber either in vivo or in vitro.

Mismatched wear couple zirconium oxide and aluminum oxide in total hip arthroplasty

A patient complained about a squeaking noise in his total hip arthroplasty. Clinical evaluation revealed good function, and there were no signs of loosening on the radiograph. Physiotherapy did not alter this phenomenon, and ultimately a revision was performed 42 months after the first surgery. The analysis of the retrievals revealed that a zirconium oxide ceramic head had been paired with a monolithic alumina ceramic cup. The cup showed large deviations from an ideal sphere but minor wear signs. The head exhibited heavy local damage in the articulation zone. This damage might have been caused by the observed unsatisfactory fit between cup and ball, resulting in high stress concentrations and increased wear of the zirconium head. The characteristics of the zirconium and aluminum ceramics pairing might have worsened the process. The combination of implants used in this retrieved wear couple was never approved. To prevent such problems, components of different manufacturers should never be mixed and matched unless explicitly stated.

Novel Salmonella enterica serovar Typhimurium protein that is indispensable for virulence and intracellular replication

Upon contact with host cells, the intracellular pathogen Salmonella enterica serovar Typhimurium promotes its uptake, targeting, and survival in intracellular niches. In this process, the bacterium evades the microbicidal effector mechanisms of the macrophage, including oxygen intermediates. This study reports the phenotypic and genotypic characterization of an S. enterica serovar Typhimurium mutant that is hypersusceptible to superoxide. The susceptible phenotype is due to a MudJ insertion-inactivation of a previously undescribed Salmonella gene designated sspJ that is located between 54.4 and 64 min of the Salmonella chromosome and encodes a 392-amino-acid protein. In vivo, upon intraperitoneal injection of 10(4) to 10(7) bacteria in C3H/HeN and 10(1) to 10(4) bacteria in BALB/c mice, the mutant strain was less virulent than the wild type. Consistent with this finding, during the first hour after ingestion by macrophage-like J774 and RAW264.7 cells in vitro, the intracellular killing of the strain carrying sspJ::MudJ is enhanced fivefold over that of wild-type microorganisms. Wild-type salmonellae displayed significant intracellular replication during the first 24 h after uptake, but sspJ::MudJ mutants failed to do so. This phenotype could be restored to that of the wild type by sspJ complementation. The SspJ protein is found in the cytoplasmic membrane and periplasmic space. Amino acid sequence homology analysis did reveal a leader sequence and putative pyrroloquinoline quinone-binding domains, but no putative protein function. We excluded the possibility that SspJ is a scavenger of superoxide or has superoxide dismutase activity.

[Long iliac artery occlusions: Feasibility, short- and mid-term outcome]

PURPOSE

It was the aim of the following study to determine the feasibility of the recanalization of long occlusions in iliac arteries and to establish its patency rate.

MATERIAL AND METHODS

We retrospectively evaluated the data of 23 patients (15 male and 8 female) with occlusions of the iliac arteries with a mean length of 12 cm (range: 9-15 cm). The occlusions were situated either in the common iliac artery (CIA) (n = 3), in the external iliac artery (EIA) (n = 12) or in both CIA and EIA (n = 7). In one patient three vessels, the common femoral artery included, were involved. The recanalization procedure was performed with wire and catheter from retrograde and, in case of a failure, from antegrade in a cross-over technique.

RESULTS

Recanalization succeeded in all patients. Technical success defined as residual stenosis < 30 % was seen in 20 of 23 patients. Early reocclusions were seen in four patients, in three of whom, the stent dilatation had been incomplete. Late reocclusions were observed in three patients, one of whom had already had early reocclusion. The reason was stent breakage in one, stent dehiscence in the second and restenosis in the third patient. All of the patients with reocclusion either early or late, had received covered stents. In four patients restenosis developed within 30 months: It was successfully treated by ballon dilatation or stent. Embolism during the recanalization procedure was observed in six patients. Embolism was observed on the ipsilateral side in five, and on the contralateral side in one patient. In each patient who had experienced embolism, balloon dilatation had been performed before stent implantation.

CONCLUSION

1) There is some evidence that the recanalization of long iliac artery occlusions is feasible. 2) The main reason for early and late reocclusions is either rest stenosis or restenosis. 3) Covered stents should only be used in selected cases. 4) Primary stenting is the treatment of choice in order to prevent embolism.

Recombinant Lactobacillus plantarum inhibits house dust mite-specific T-cell responses

Recent evidence suggests that chronic exposure to lactobacilli, which are part of the normal intestinal flora, inhibits the development of allergic disorders. Allergy is mediated by Th2 cells, which produce high levels of IL4 and IL5, and suppressive effects of lactic acid bacteria on the development of allergy have been attributed to their Th1-inducing properties. On the other hand, lactic acid bacteria have also been shown to suppress autoimmune disorders which are mediated by Th1 cells producing high levels of IFNgamma. To study this apparent discrepancy, the immunomodulatory potential of lactobacilli was evaluated using recombinants that express an immunodominant T-cell epitope of Der p 1 of house dust mites. Mucosal immunization of C57BL/6 J mice with such recombinants resulted in the induction of T cells which produced low amounts of IFNgamma. Immunization with the house dust mite peptide followed by treatment with recombinant Lactobacillus plantarum resulted in the inhibition of both IFNgamma and IL5 production. The effect on IFNgamma production was shown to be a non-specific effect of L. plantarum. The effect on IL5 production, however, was only observed when the recombinant expressing the Der p 1 peptide, but not the control recombinant, was used for treatment. Neither of the recombinants had an effect on the antibody response. Taken together, these data suggest that recombinant L. plantarum may be a suitable candidate for the treatment of allergic disorders.

Multifocal osteomyelitis caused by nontuberculous mycobacteria in patients with a genetic defect of the interferon-gamma receptor

We describe three patients with multifocal osteomyelitis caused by Mycobacterium avium and a family history of one or more first degree family members diagnosed with various clinical presentations of infections with nontuberculous mycobacteria. There was a significant delay in the diagnosis and they had a protracted course of their illness, which responded only slowly to prolonged multi-drug treatment. In one patient, additional treatment with interferon-gamma (IFN-gamma) was necessary. Macrophages of these patients had decreased in vitro responsiveness to IFN-gamma. Genomic sequencing revealed that these patients and their affected family members were heterozygous for a previously described dominant negative mutation in the gene encoding the IFN-gamma binding receptor-1 chain. The clinical presentations of the infections with nontuberculous mycobacteria in these families, with spread limited to skin, bone and lymph nodes, is discussed in the light of the immune mechanisms that are responsible for the clearance of otherwise poorly pathogenic environmental mycobacteria.

Estimated risk of HIV transmission by blood transfusion in Kenya

BACKGROUND

During the past decade, developing countries have received limited support for blood safety programmes. The Kenya Ministry of Health did a collaborative multicentre assessment to establish the risk of HIV transmission by transfusion in Kenya, to promote awareness of blood safety issues in this country with a mature HIV epidemic, and to identify methods to reduce the risk of HIV transmission by blood transfusion in Kenya.

METHODS

For 12 weeks, from April to July 1994, we collected information and blood samples from all blood donors, and pretransfusion samples were collected from all recipients in six government hospitals in Kenya. Blood donations were collected and screened for HIV according to standard practice in the hospital laboratories. Test results at a reference laboratory were compared with those of the hospital laboratories and risk of transfusion-associated HIV transmission was calculated.

FINDINGS

The prevalence of HIV among blood donors was 6.4% (120 of 1877) and varied by hospital (range 2-20%). HIV test results were available for 1290 donor-recipient pairs. Of these, 26 HIV-positive donations were given to HIV-negative patients. We estimate that 2.0% of transfusions transmitted HIV. Problems in the hospitals that contributed to transfusion risk included inconsistent refrigeration, data entry errors, equipment failure, and lack of a quality-assurance programme.

INTERPRETATION

A high proportion of blood transfusions transmitted HIV in this high-prevalence area of Africa, primarily because of erroneous laboratory practices. On the basis of these results, the Kenya Ministry of Health introduced a number of practical and inexpensive interventions to improve national blood safety.