Novel ambulatory glucose-sensing technology improves hypoglycemia detection and patient monitoring adherence in children and adolescents with type 1 diabetes.

PURPOSE: Glucose monitoring [GM] is a mainstay of diabetes control and management. Improving glycemic control is essential to prevent microvascular complications. However, adherence to GM can be a challenge in children and adolescents. Detecting hypoglycemia is essential for its prevention and treatment. We aim to study the impact of the flash ambulatory glucose monitoring in detecting hypoglycemia and enhancing adherence in children and adolescents with type 1 diabetes. METHODS: The study is prospective involving 3 hospital visits. Children and adolescents with diabetes were enrolled in the study which involved a period on conventional glucose self-monitoring [glucometers] followed by a similar period of monitoring using the flash glucose monitoring device (FreeStyle Libre). Frequency of GM, duration and frequency of hypoglycemia were compared on conventional and the flash monitoring. RESULTS: 75 subjects were studied. Age mean (range) was 11.9 years (2-19). Significant difference was seen in hypoglycemia detection between both testing devices. 68 (94%) and 65 (90%) patients detected nocturnal and diurnal hypoglycemia respectively on Flash monitoring compared to 12 (16.6%) and 30 (41%) on glucometer testing (p < 0.00). Mean (range) duration of hypoglycemia was 95 min (15-330). Statistically-significant difference was found between the frequency of GM on glucometer testing compared with Flash monitoring (2.87 and 11.6/day) (p < 0.001). CONCLUSIONS: Flash monitoring is a useful tool to improve adherence to GM and detecting hypoglycemia [diurnal and nocturnal] in children and adolescents with type 1 diabetes.

Long-Term Effects of Repeated Prefrontal Cortex Transcranial Direct Current Stimulation (tDCS) on Food Craving in Normal and Overweight Young Adults.

BACKGROUND: The dorsolateral prefrontal cortex (DLPFC) plays an important role in the regulation of food intake. Several previous studies demonstrated that a single session of transcranial direct current stimulation (tDCS) of the DLPFC reduces food craving and caloric intake. OBJECTIVES: We hypothesized that repeated tDCS of the right DLPFC cortex may exert long-term changes in food craving in young, healthy adults and that these changes may differ between normal and overweight subjects. METHODS: Thirty healthy individuals who reported frequent food cravings without a prior history of eating disorders were initially recruited. Subjects were randomized into an ACTIVE group who received 5 days of real tDCS (20 minutes, anode right-cathode left montage, 2 mA with current density kept at 0.06 mA/cm2, 1 min ramp-up/ramp-down), and a SHAM group, who received one day of real tDCS, on the first day (same parameters), followed by 4 days of sham tDCS. Food craving intensity was examined by Food Craving Questionnaires State and Trait and Food Craving Inventory before, during, (5-days) and one month (30-days) after tDCS. RESULTS: Single session of tDCS significantly reduced the intensity of current food craving (FCQ-S). Five days of active tDCS significantly reduced habitual experiences of food craving (FCQ-T), when compared to baseline pre-stimulation levels. Furthermore, both current (FCQ-S) and habitual craving (FCQ-T) were significantly reduced 30 days after active tDCS, while sham tDCS, i.e. a single tDCS session did not have significant effects. Also, active tDCS significantly decreased craving for fast food and sweets, and to a lesser degree for fat, while it did not have significant effects on craving for carbohydrates (FCI). There were no significant differences between individual FCQ-T subscales (craving dimensions) after 5 or 30 days of either sham or active tDCS. Changes in craving were not significantly associated with the initial weight, or with weight changes 30 days after the stimulation in the subjects. CONCLUSIONS: The results confirm earlier findings that single session of tDCS has immediate effects in reducing food craving. They also show that repeated tDCS over the right DLPFC may increase the duration of its effects, which may be present 30 days after the stimulation. These results support further investigation of the use of tDCS in obesity.

Nutrient intake of infants and toddlers in the United Arab Emirates: the Feeding Infants and Toddlers Study.

This descriptive study evaluated the nutrient adequacy of the diet of infants (aged 6-11.9 months) and toddlers (aged 12-24 months) in the United Arab Emirates. A random sample of 1000 infants and toddlers was recruited from 2 cities (Al Ain and Dubai) from March 2011 to February 2012 and their usual nutrient intake was determined using 24-hour recall. In all, 54.2% of infants and 25.2% of toddlers were breastfeeding. Mean energy intake of infant girls in Al Ain and Dubai was 747 (SD 189) kcal and 773 (SD 215) kcal respectively and 810.5 (SD 232.2) kcal and 821.9 (SD 262) kcal for boys. In toddlers, mean energy intake for girls in Al Ain and Dubai was 1032.8 (SD 252) kcal and 1013 (SD 339.1) kcal respectively and 1057.2 (SD 201.8) kcal and 1030.3 (SD 341.7) kcal for boys. Iron intake was low in both groups. Mean body mass index and body weight and height were similar to World Health Organization figures but significant numbers of infants and toddlers of both sexes were over- or underweight. Although mean energy and macronutrient intakes were comparable to the RDA, significant numbers were over- or underfed.

Pregnancy outcomes in Benghazi, Libya, before and during the armed conflict in 2011.

Stressful life events experienced by pregnant women may lead to adverse obstetric outcomes. This study in Benghazi compared the rates of preterm, low-birth-weight and caesarean-section births at Al-Jamhouria hospital in the months before and during the armed conflict in Libya in 2011. Data were collected on all women admitted to the delivery ward during February to May 2011 (the months of the most active fighting in the city) (n = 7096), and October to December 2010 (the months immediately before the war) (n = 5935). Compared with the preceding months there was a significant rise during the conflict in the rate of deliveries involving preterm (3.6% versus 2.5%) and low-birth-weight (10.1% versus 8.5%) infants and caesarean sections (26.9% versus 25.3%). Psychosocial stress may have been a factor (among others) in an increase in negative pregnancy outcomes, and obstetric hospitals should be aware of these issues in times of war.

A tool to assess knowledge, attitude and behavior of Indonesian health care workers regarding infection control.

AIM: to investigate knowledge, attitude and behaviour toward infection control in two teaching hospitals on the island of Java by means of a questionnaire and to evaluate the use of the questionnaire as a tool. METHODS: we investigated knowledge, attitude and behaviour toward infection control in two teaching hospitals on the island of Java by means of a questionnaire to identify problem areas, barriers and facilitators. The target was to include at least 50% of all health care workers (physicians, nurses, assistant nurses and infection control nurses) in each hospital, department and profession. Differences between demographic variables and scores for individual questions and groups of questions were compared using the chi-square statistic and analysis of variance and Spearman's rho was used to test for correlations between knowledge, attitude, self-reported behaviour and perceived obstacles. RESULTS: more than half of the health care workers of the participating departments completed the questionnaire. Of the 1036 respondents (44% nurses, 37% physicians and 19% assistant nurses), 34% were vaccinated against hepatitis B, 77% had experienced needle stick accidents and 93% had been instructed about infection control. The mean of the correct answers to the knowledge questions was 44%; of the answers to the attitude questions 67% were in agreement with the correct attitude; obstacles to compliance with infection control guidelines were perceived in 30% of the questions and the mean self-reported compliance was 63%. Safe handling of sharps, hand hygiene and the use of personal protective equipment were identified as the most important aspects for interventions. Significant positive correlations were found between knowledge, attitude, self-reported behaviour and perceived obstacles. CONCLUSION: the questionnaire in conjunction with site visits and interviews was a valuable strategy to identify trouble spots in the hospitals and to determine barriers to facilitators of change that should be taken into account when planning interventions. Successful interventions should cover hospital management, the infection control team, as well as the health care workers on the wards.

Clinical semiology and neuroradiologic correlates of acute hypernatremic osmotic challenge in adults: a literature review.

The complex interplay between hypernatremic osmotic disturbances and cerebral lesions is yet to be clarified. In this review, we discuss, on the basis of the reported data of hypernatremic CNS challenge in the adult population, the clinical and radiologic features of the condition. Our search captured 20 case studies and 1 case series with 30 patients in total who acquired acute hypernatremia due to different etiologies and developed CNS lesions. We explored the associations between premorbid conditions, clinical presentation, hypernatremic state, correction rate, and radiologic appearance, including the localization of brain lesions and the outcomes. The results revealed that altered mental status was the most commonly reported symptom and osmotic demyelination syndrome in the form of extrapontine myelinolysis was the prevailing radiologic pattern. Finally, we contrasted, when appropriate, clinical and experimental data related to hypernatremic and hyponatremic osmotic insults to aid the understanding of the pathophysiology of CNS osmotic brain injury.

The prevalence and potential determinants of obesity among school children and adolescents in Abu Dhabi, United Arab Emirates.

OBJECTIVES: To estimate the prevalence and determinants of obesity in childhood and adolescence and their association with blood pressure (BP) in Abu Dhabi, United Arab Emirates (UAE). DESIGN: A cross-sectional population-representative study. SUBJECTS: A total of 1541 students (grades 1-12; aged 6-19 years) were randomly selected from 246 schools (50% male). Anthropometric and demographic variables were measured, and CDC criteria were used to classify children's weights. RESULTS: A total of 1440 (93%) students provided complete results. Crude prevalences were: 7.6% underweight, 14.7% overweight and 18.9% obesity. Further analyses were restricted to UAE nationals (n=1035), of whom these figures were: 8.3% underweight (females 6.5%, males 10.1%; P=0.06), 14.2% overweight (females 16.7%, males 11.6%; P<0.01), 19.8% obesity (females 18.1%, males 21.4%; P=0.09). Obesity significantly (P<0.001) increased with age. The majority (61.3%) of students had body mass index (BMI) percentiles above the 50th CDC percentile. Stepwise linear regression of BMI percentile on age, sex, dairy consumption, exercise and family income showed a significant (P<0.01) positive association with age and lack of dairy consumption, but not exercise and income. BP significantly (P<0.01) increased with BMI percentile. CONCLUSIONS: The prevalence of childhood obesity is high across the age spectrum in the UAE. Older age, male sex, lack of dairy intake and higher parental BMI, are independent determinants of childhood obesity in this population. Higher BMI percentile is associated with a higher BP. Prevention strategies should focus on younger children, particularly children of obese parents. Longitudinal studies are needed to investigate trends and the impact of childhood obesity on the risk of non-communicable diseases.

Rectal taurocholate increases L cell and insulin secretion, and decreases blood glucose and food intake in obese type 2 diabetic volunteers.

AIMS/HYPOTHESIS: Glucagon-like peptide-1 (GLP-1) and peptide YY (PYY) are secreted from enteroendocrine L cells in response to numerous stimuli, including bile salts. Both have multiple effects that are potentially useful in treating diabetes and obesity. L cell number and hormone content in the intestine are highest in the rectum in humans. We investigated the effects of intrarectal sodium taurocholate on plasma GLP-1, PYY, insulin and glucose concentrations, and on food intake of a subsequent meal. METHODS: Ten obese type 2 diabetic volunteers were each studied on five separate occasions after an overnight fast and oral administration of 100 mg sitagliptin 10 h before the study. They then received an intrarectal infusion of either one of four doses of taurocholate (0.66, 2, 6.66 or 20 mmol, each in 20 ml of vehicle) or vehicle alone (1% carboxymethyl cellulose) single-blind over 1 min. Hormone and glucose measurements were made prior to, and for 1 h following, the infusion. The consumption of a previously selected favourite meal eaten to satiety was measured 75 min after the infusion. RESULTS: Taurocholate dose-dependently increased GLP-1, PYY and insulin, with 20 mmol doses resulting in peak concentrations 7.2-, 4.2- and 2.6-fold higher, respectively, than those achieved with placebo (p < 0.0001 for each). Plasma glucose decreased by up to 3.8 mmol/l (p < 0.001). Energy intake was decreased dose-dependently by up to 47% (p < 0.0001). The ED(50) values for effects on integrated GLP-1, insulin, PYY, food intake and glucose-lowering responses were 8.1, 10.5, 18.5, 24.2 and 25.1 mmol, respectively. CONCLUSIONS/INTERPRETATION: Therapies that increase bile salts (or their mimics) in the distal bowel may be valuable in the treatment of type 2 diabetes and obesity.

Human papillomavirus vaccination uptake and factors related to uptake in a traditional desert city in the United Arab Emirates.

It is important to assess uptake of a new vaccine. The present survey estimated the uptake of the recently introduced human papillomavirus vaccine (HPVV) in the emirate of Abu Dhabi and also explored barriers to uptake. A questionnaire survey was conducted in secondary schools, enrolling 334 girls. The uptake percentage was estimated and factors associated with uptake were assessed with multilevel logistic regression. Crude vaccination uptake was 53%. Factors positively associated with uptake were, among others, having knowledge on human papillomavirus (vaccine) and having United Arab Emirates (UAE) nationality. The HPVV uptake of just over 50% could probably be improved by educating the target group and their parents before offering the HPVV and by making it free of costs for everyone.

Association between history of tuberculosis and vegetarianism from a nationally representative survey in India.

A vegetarian diet has been implicated as a risk factor for tuberculosis (TB) among South Asians in the United Kingdom. To explore whether this is also the case in India, we analysed data from the nationally representative National Family Health Survey-3 (2006) which collected information on TB and diet, and tested for human immunodeficiency virus (HIV) 1. TB was reported by heads of households. Using logistic regression, we found that vegetarianism was not a risk factor for TB among HIV-1 negative married men and women aged 15-49 (women) or 15-54 (men) years (OR 0.66, 95%CI 0.49-0.89), while poverty and a history of blood transfusions were.

Prevalence of depression and suicidal behaviors among male migrant workers in United Arab Emirates.

Migrant workers comprise 80% of the population of the United Arab Emirates, but there is little research on their mental health. To determine the prevalence and correlates of depression among workers living in labor camps, we conducted a cross-sectional survey in labor camps in Al Ain city. The Depression Anxiety and Stress Scale (DASS-42) was used to assess depression and suicidal ideation among the study participants. Off the 319 contacted workers agreed to participate, however 239 fully completed the DASS-42. The prevalence of a score >=10 ("depression") was 25.1% (60/239). Depression was correlated with physical illness (97/301), (adjusted odds ratio-AOR = 2.9; 95% CI 2.26-5.18), working in construction industry (prevalence 124/304), AOR = 2.2; 95%CI 1.56-3.83), earning less than 1,000 UAE Dirham per month (prevalence 203/314), (AOR = 1.8; 95%CI 1.33-3.16), and working more than 8 h a day (prevalence 213/315), (AOR = 2.7; 95%CI 1.19-6.27). 20/261 (6.3%) of the study participants reported thoughts of suicide and 8/265 (2.5%) had attempted suicide. People with suicidal ideation were more likely to have a physical illness (AOR = 8.1, 95%CI 2.49-26.67), earn less than 1,000 UAE Dirham per month (AOR = 5.98, 95%CI 1.26-28.45), and work for more than 8 h a day (AOR = 8.35, 95%CI 1.03-67.23). The study identified self reported indicators of a substantial burden of depression, and thoughts of self-harm among laborers surveyed. Policy level intervention and implementation, is needed to improve working conditions, including minimum wages and regulation of working hours is recommended.

Evaluation of syndromic surveillance in the Netherlands: its added value and recommendations for implementation.

In the last decade, syndromic surveillance has increasingly been used worldwide for detecting increases or outbreaks of infectious diseases that might be missed by surveillance based on laboratory diagnoses and notifications by clinicians alone. There is, however, an ongoing debate about the feasibility of syndromic surveillance and its potential added value. Here we present our perspective on syndromic surveillance, based on the results of a retrospective analysis of syndromic data from six Dutch healthcare registries, covering 1999­2009 or part of this period. These registries had been designed for other purposes, but were evaluated for their potential use in signalling infectious disease dynamics and outbreaks. Our results show that syndromic surveillance clearly has added value in revealing the blind spots of traditional surveillance, in particular by detecting unusual, local outbreaks independently of diagnoses of specific pathogens, and by monitoring disease burden and virulence shifts of common pathogens. Therefore we recommend the use of syndromic surveillance for these applications.

On some novel aspects of consanguineous marriages.

Consanguineous marriages, often viewed as incestuous and objectionable, are more widespread than commonly perceived. They integrate multiple facets of human adaptation: economic, cultural and genetic. The widely touted explanation for the origin and persistence of consanguinity is that it provides many socioeconomic benefits; however, this view may be too simplistic. The bias against consanguinity may preclude an objective understanding of this sociobiological puzzle. Inbreeding increases the speed of selection of beneficial recessive and co-dominant alleles, e.g. those that protect against diseases. In populations endemic with malaria, the prevalence of consanguineous marriages and the frequency of alleles protective against malaria are both very high. Thus, consanguinity could theoretically increase the relative fitness of a population under specific ecological conditions; sometimes, the overall genetic benefits may exceed genetic costs of inbreeding. We discuss some recent evidence from studies on inbreeding along with the reasons responsible for the mating strategy found in some human populations. We contend that a better appreciation of our inherent biases and potential genetic benefits of inbreeding in specific ecological conditions would help us to appreciate the wider picture of consanguinity.

In search of hidden Q-fever outbreaks: linking syndromic hospital clusters to infected goat farms.

Large Q-fever outbreaks were reported in The Netherlands from May 2007 to 2009, with dairy-goat farms as the putative source. Since Q-fever outbreaks at such farms were first reported in 2005, we explored whether there was evidence of human outbreaks before May 2007. Space-time scan statistics were used to look for clusters of lower-respiratory infections (LRIs), hepatitis, and/or endocarditis in hospitalizations, 2005-2007. We assessed whether these were plausibly caused by Q fever, using patients' age, discharge diagnoses, indications for other causes, and overlap with reported Q fever in goats/humans. For seven detected LRI clusters and one hepatitis cluster, we considered Q fever a plausible cause. One of these clusters reflected the recognized May 2007 outbreak. Real-time syndromic surveillance would have detected four of the other clusters in 2007, one in 2006 and two in 2005, which might have resulted in detection of Q-fever outbreaks up to 2 years earlier.

The effects of neuropeptide Y on skeletal muscle contractile properties in streptozotocin diabetic rats.

Diabetes induces changes in the structural, biochemical, electrical, and contractile properties of skeletal muscles. Neuropeptide Y (NPY) administered locally can induce angiogenesis in a rat ischemic limb model and restore the contractile function of the ischemic muscle. The effects of NPY on the contractile characteristics of limb skeletal muscles were examined in streptozotocin-induced diabetic rats. Rats were treated with sham pellets (control groups) or NPY-containing pellets (1 mg of NPY/pellet, 14 days releasing time) administered locally to the rat hind limb 2 months after induction of diabetes. Contractile properties and fatigability of the slow-twitch soleus and fast-twitch gastrocnemius medials muscle were compared in control (sham), control NPY, diabetic (sham), and diabetic NPY groups. In order to induce fatigue trains of repetitive tetanic stimulation were used (600 ms/1 s simulation-rest cycle per train, 112 trains at an 85-Hz fusion frequency). Two months of untreated diabetes significantly prolonged soleus contraction and slowed its relaxation, but had minimal effects on soleus tension. NPY ameliorated the diabetic effects on soleus speed-related contractile properties, restoring its contraction and relaxation times. Diabetes significantly reduced gastrocnemius medials tetanic tension, leaving its contractile characteristics mostly unaffected. NPY partially restored gastrocnemius tetanic tension production capacity. Diabetes significantly increased fatigability of both muscles, which was partially restored by NPY, as evidenced by restored endurance of soleus muscle. The results suggest that NPY administered locally tends to normalize muscle performance and improve fatigue resistance of skeletal muscles in streptozotocin diabetes. Further examination is needed to establish the mechanisms of local NPY action on muscle contractile properties in streptozotocin-induced diabetes.

Geographical heterogeneity of dengue transmission in two villages in southern Vietnam.

This study was performed to test the hypothesis that there are 'hotspots', i.e. geographical heterogeneity, of dengue transmission. Data from two repeat serosurveys in two villages in Vietnam were used to identify incident infections and to relate these to prevalence at baseline and thus assess geographical heterogeneity, i.e. clustering, in dengue transmission. A total of 400 households were surveyed; serological data from 521 children at baseline and from 119 children at follow-up were included in a spatial analysis. Geographical heterogeneity of dengue transmission was explored using a permutation null distribution test. This showed for the first time evidence of clustering of dengue virus transmission at the household level in asymptomatic children. Risk areas could be identified by seroprevalence surveys combined with mapping. Control of dengue virus transmission could be supported by identification and control of hotspots.

Evaluation of a multi-antigen test based on B-cell epitope peptides for the serodiagnosis of pulmonary tuberculosis.

SETTING: Two sample panels: 1) 20 pulmonary tuberculosis (PTB) patients and 10 healthy subjects from a country with a low incidence of TB (Italy); and 2) 47 PTB patients and 26 healthy subjects from a country with a high incidence of TB (Morocco). OBJECTIVE: To identify a combination of Mycobacterium tuberculosis peptides useful for the serodiagnosis of active PTB. METHODS: Fifty-seven B-cell epitope peptides of M. tuberculosis were evaluated by immunoenzymatic assay and the data were analysed using logistic regression analysis and the random forest method. RESULTS: The best discriminating peptide between PTB patients and healthy subjects from the sample of the low TB incidence country was the 23 amino acid peptide of the Rv3878 protein. The sensitivity and specificity were respectively 65% and 100%. The same peptide had a sensitivity and specificity of respectively 47% and 100% for the sample from the high TB incidence country. The best combination of peptides was a pool of nine peptides which had a sensitivity of 70.2% and a specificity of 100% in the high TB incidence country. CONCLUSIONS: The 9-peptide pool can be useful in identifying patients with active PTB.

Multiple small bowel ligation compared to conventional primary repair after abdominal gunshot wound with haemorrhagic shock.

AIMS: The aim of this study was to evaluate the effects of early rapid control of multiple bowel perforations on cardiovascular function in combined abdominal missile trauma and haemorrhagic shock compared with conventional surgery. METHODS: Eighteen anesthetised pigs were injured with a standardised abdominal missile trauma. The animals were bled to a mean arterial pressure of 50 mm Hg for 30 minutes, after which they were resuscitated and had laparotomy. They were divided into conventional surgery group (n=9) with primary resection and anastomosis of bowel -injuries and early rapid multiple bowel ligation group (n?=?9). Repeated measurement analysis of variance was used for analysis. RESULTS: There was profound hypotension, reduced cardiac output, increased vascular resistance and lactic acidaemia in both groups. Lactic acidaemia persisted longer in the early rapid multiple bowel ligation group. There were no significant differences in mean arterial pressure, cardiac output , stroke volume or systemic vascular resistance between the groups. The mean operation time was significantly shorter in the early rapid multiple bowel ligation group (13.3 (1.5) (SEM) minutes, compared with 116.4 (1.74) (SEM) minutes in the conventional surgery group, p =0.001). CONCLUSIONS: Damage control principles have shortened the operating time in our model but did not improve the cardiovascular function and caused more lactic acidaemia than conventional repair.

Audit of antibiotic prescribing in two governmental teaching hospitals in Indonesia.

This article estimates the magnitude and quality of antibiotic prescribing in Indonesian hospitals and aims to identify demographic, socio-economic, disease-related and healthcare-related determinants of use. An audit on antibiotic use of patients hospitalized for 5 days or more was conducted in two teaching hospitals (A and B) in Java. Data were collected by review of records on the day of discharge. The method was validated through concurrent data collection in Hospital A. Multivariate logistic regression analysis was performed to determine variables to explain antibiotic prescribing. Prescriptions were assessed by three reviewers using standardized criteria. A high proportion (84%) of 999 patients (499 in Hospital A and 500 in Hospital B) received an antibiotic. Prescriptions could be categorized as therapeutic (53%) or prophylactic (15%), but for 32% the indication was unclear. Aminopenicillins accounted for 54%, and cephalosporins (mostly third generation) for 17%. The average level of antibiotic use amounted to 39 DDD/100 patient-days. Validation revealed that 30% of the volume could be underestimated due to incompleteness of the records. Predictors of antibiotic use were diagnosis of infection, stay in surgical or paediatric departments, low-cost nursing care, and urban residence. Only 21% of prescriptions were considered to be definitely appropriate; 15% were inappropriate regarding choice, dosage or duration, and 42% of prescriptions, many for surgical prophylaxis and fever without diagnosis of infection, were deemed to be unnecessary. Agreement among assessors was low (kappa coefficients 0.13-0.14). Despite methodological limitations, recommendations could be made to address the need for improving diagnosis, treatment and drug delivery processes in this setting.

Effect of intrathecal pralidoxime administration upon survival of rats exposed to the organophosphate paraoxon.

The therapeutic results of systemic administration of pralidoxime (2-PAM) in the treatment of poisoning with organophosphate-type cholinesterase inhibitors are disappointing. It has been hypothesized that this is due to poor entry of 2-PAM into the brain. To test if survival rates can be improved by direct administration of 2-PAM into the cerebrospinal fluid (CSF), the effect of intrathecal 2-PAM injections upon mortality after paraoxon intoxication was examined. Eight groups of rats (n=30 each) were examined, all of which received paraoxon (1 micromol=272 microg, 3 micromol=816 microg, or 5 micromol=1.36 mg) intraperitoneally (i.p.). One group received no further treatment; the other groups were given 50 micromol (=8.63 mg) 2-PAM i.p., 5 micromol (=863 microg) 2-PAM intrathecally and pentobarbital/lidocaine in various combinations. Results were compared with the no treatment group and the control groups that did not receive any paraoxon injections, but were given intrathecal injections of saline or 2-PAM. The relative risk of death was estimated by Cox survival analysis. Mortality was lowest after treatment with a combination of both i.p. and intrathecal 2-PAM plus pentobarbital, and with 2-PAM i.p. alone plus pentobarbital. Both treatments were significantly better than 2-PAM i.p. alone (p