Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract infection: 3.5-year follow-up of a cluster randomized trial.

PURPOSE: The purpose of the study was to assess the long-term effect of family physicians' use of C-reactive protein (CRP) point-of-care testing and/or physician training in enhanced communication skills on office visit rates and antibiotic prescriptions for patients with respiratory tract infections. METHODS: We conducted a 3.5-year follow-up of a pragmatic, factorial, cluster-randomized controlled trial; 379 patients (20 family practices in the Netherlands) who visited their family physician for acute cough were enrolled in the trial and had follow-up data available (88% of original trial cohort). Main outcome measures were the average number of episodes of respiratory tract infections for which patients visited their family physician per patient per year (PPPY), and the percentage of the episodes for which patients were treated with antibiotics during follow-up. RESULTS: The mean number of episodes of respiratory tract infections during follow-up was 0.40 PPPY in the CRP test group and 0.56 PPPY in the no CRP test group (P = .12). In the communication skills training group, there was a mean of 0.36 PPPY episodes of respiratory tract infections, and in the no training group the mean was 0.57 PPPY (P = .09). During follow-up 30.7% of all episodes of respiratory tract infection were treated with antibiotics in the CRP test group compared with 35.7% in the no test group (P = .36). Family physicians trained in communication skills treated 26.3% of all episodes of respiratory tract infection with antibiotics compared with 39.1% treated by family physicians without training in communication skills (P = .02) CONCLUSIONS: Family physicians' use of CRP point-of-care testing and/or training in enhanced communication skills did not significantly affect office visit rates related to respiratory tract infections. Patients who saw a family physician trained in enhanced communication skills were prescribed significantly fewer antibiotics during episodes of respiratory tract infection in the subsequent 3.5 years.

Long-term protection against malaria after experimental sporozoite inoculation: an open-label follow-up study.

BACKGROUND: We have shown that immunity to infection with Plasmodium falciparum can be induced experimentally in malaria-naive volunteers through immunisation by bites of infected mosquitoes while simultaneously preventing disease with chloroquine prophylaxis. This immunity was associated with parasite-specific production of interferon γ and interleukin 2 by pluripotent effector memory cells in vitro. We aim to explore the persistence of protection and immune responses in the same volunteers. METHODS: In an open-label study at the Radboud University Nijmegen Medical Centre (Nijmegen, Netherlands), from November to December, 2009, we rechallenged previously immune volunteers (28 months after immunisation) with the bites of five mosquitoes infected with P falciparum. Newly recruited malaria-naive volunteers served as infection controls. Our primary outcome was the detection of blood-stage parasitaemia by microscopy. We assessed the kinetics of parasitaemia with real-time quantitative PCR (rtPCR) and recorded clinical signs and symptoms. In-vitro production of interferon γ and interleukin 2 by effector memory T cells was studied after stimulation with sporozoites and red blood cells infected with P falciparum. Differences in cellular immune responses between the study groups were assessed with the Mann-Whitney test. This study is registered with ClinicalTrials.gov, number NCT00757887. FINDINGS: Four of six immune volunteers were microscopically negative after rechallenge. rtPCR-based detection of blood-stage parasites in these individuals was negative throughout follow-up. Patent parasitaemia was delayed in the remaining two immunised volunteers. In-vitro assays showed the long-term persistence of parasite-specific pluripotent effector memory T-cell responses in protected volunteers. The four protected volunteers reported several mild to moderate adverse events, of which the most commonly reported symptom was headache (one to three episodes per volunteer). The two patients with delayed patency had adverse events similar to those in the control group. INTERPRETATION: Artificially induced immunity lasts longer than generally recorded after natural exposure; providing a new avenue of research into the mechanisms of malaria immunity. FUNDING: Dioraphte Foundation.

Inter-laboratory comparison of three different real-time PCR assays for the detection of Pneumocystis jiroveci in bronchoalveolar lavage fluid samples.

Pneumocystis jiroveci pneumonia (PCP) is an opportunistic infection affecting immunocompromised patients. While conventional diagnosis of PCP by microscopy is cumbersome, the use of PCR to diagnose PCP has great potential. Nevertheless, inter-laboratory validation and standardization of PCR assays is lacking. The aim of this study was to evaluate the inter-laboratory agreement of three independently developed real-time PCR assays for the detection of P. jiroveci in bronchoalveolar lavage fluid samples. Therefore, 124 samples were collected in three tertiary care laboratories (Leiden University Medical Center, Maastricht Infection Center and Radboud University Nijmegen Medical Centre) and were tested by both microscopy and real-time PCR. Of 41 samples positive for P. jiroveci by microscopy, 40 were positive in all three PCR assays. The remaining sample was positive in a single assay only. Out of 83 microscopy-negative samples, 69 were negative in all three PCR assays. The other 14 samples were found positive, either in all three assays (n=5), in two (n=2) or in one of the assays (n=7). The data demonstrate high inter-laboratory agreement among real-time PCR assays for the detection of P. jiroveci.

How safe is the meat inspection based on artificial digestion of pooled samples for Trichinella in pork? A scenario from wildlife to a human patient in a non-endemic region of Europe.

The occurrence of trichinellosis in a resident of the Netherlands prompted us to examine the likelihood of this originating from infected rats in spite of prevailing biosecurity and testing procedures. In so doing, we sought to calculate the possible risks for trichinellosis in countries deemed non-endemic. The infection risk was determined by simulating a scenario from a reservoir of minimally contaminated wildlife to pigs to humans. Results indicate that humans might become infected even in the event that artificial digestion had been performed on individually tested pig carcasses. Our conclusions justify reconsidering Trichinella control strategies based on the current testing protocol, and emphasize the importance of proper cooking as further insurance against human infection.

[Neuroschistosomiasis; an unexpected finding in a Dutch woman]. / Neuroschistosomiasis. Een onverwachte bevinding bij een Nederlandse vrouw.

A 67-year-old Dutch woman presented with neurological symptoms of several months duration. MRI scans of the brain showed intracerebral lesions. Brain biopsy revealed granulomatous inflammation and remnants of worm eggs. Eggs of Schistosoma mansoni were found in the stools and serological tests were positive for Schistosoma. From additional history taking it became clear that the patient contracted schistosomiasis when visiting Brazil several years before. She was treated with praziquantel and corticosteroids. Neuroschistosomiasis is a rare but severe complication of Schistosoma infection. This diagnosis should be considered in patients that travelled to or originate from endemic schistosomiasis areas.

Analysis of variation in tandem repeats in the intron of the major surface glycoprotein expression site of the human form of Pneumocystis carinii.

Variation in the tandem repeats in the expression site of the human-derived Pneumocystis carinii major surface glycoprotein gene was characterized by denaturing gel electrophoresis. The number of repeats in 147 isolates ranged from 2 to 6, with 2, 3, and 4 repeats being the most common. Sequence analysis identified 3 types of repeat units that differed by 1 nucleotide, which suggests a hierarchy of evolution of human-derived P. carinii. Examination of sequential samples obtained from 6 patients at an interval of 10-90 days showed an identical repeat pattern in each patient. However, in 2 of 4 patients with 2-3 different samples obtained within 4 days, different repeat patterns were observed among the samples. Quantifying the number of repeats by denaturing gel electrophoresis is a simple and rapid-typing method that can be used alone or in combination with other methods to study the epidemiology of P. carinii.