[Economic study of dialysis using the cost-per-procedure method according to clinical protocols]. / Estudio económico de la diálisis por el método de coste por procedimiento ajustado a protocolo clínico.

Studies analyzing the economic cost of dialysis therapy have raised a considerable interest in the nephrologic community, both inside and outside our country. The objective of the present study was to approach this question from a different point of view, by applying the cost-per-procedure method, according to clinical protocol, to all the routine clinical procedures in our dialysis unit (both Hemodialysis and Peritoneal Dialysis). We analyzed 68 routine protocols (42 for Hemodialysis and 26 for peritoneal Dialysis), carrying out a pormenorized study of all the components of the economic cost of each procedure (personnel, laboratory, surgical and sanitary material, drugs and other concepts). We calculated the final cost of all these procedures after individualizing the different components of the economic spends, with the informatic support of the management department of our center, and in coordination with the data bases of the Pharmacy and General Supplies units. Although the initial implementation of this method is tedious, it subsequently allows to analyze the global cost of therapy in the Unit, as also the cost of certain subsets, or even particular patients, in a simple and flexible way. Moreover, the system is easy to update, as clinical protocols undergo changes or the economic cost of individual components vary. Finally, this method is a useful tool at the time of comparing the cost of clinical procedures in different centres, according to their varying clinical protocols, economic spends and clinical results.

Free ceramides of Echinococcus multilocularis metacestodes.

Free ceramides were isolated and purified from the metacestodes of Echinococcus multilocularis. Two different fractions were obtained by preparative thin-layer chromatography. Their structure was determined by gas chromatography and electron impact mass spectrometry of trimethylsilylated derivatives. The ceramide with the higher thin-layer chromatographic migration rate contained exclusively erythro-sphinganine associated with saturated C16, C18 and very-long-chain fatty acids (up to C30) and unsaturated C24 fatty acid. The second ceramide contained 90.3% sphingosine and 9.7% sphinganine associated with saturated C16 and C24 and unsaturated C18 and C24 fatty acids. These findings were discussed with regard to the structure and metabolic pathway of neutral and acid glycosphingolipids found in the metacestodes.

Gangliosides of Echinococcus multilocularis metacestodes.

Gangliosides, glycosphingolipids with sialic acid, were found in metacestodes of Echinococcus multilocularis in low quantities. All gangliosides were resolved after preparative high-performance thin layer chromatography into four fractions. Cholera toxin was specifically bound to the major ganglioside, allowing the identification of it as a GM1. Precise structure of the four fractions was determined by sequential degradation by exoglycosidases, gas chromatography, electron impact mass spectrometry and liquid secondary ion-mass spectrometry. Beside GM1, the other fractions were GM3, GD1a and, at a lesser percentage, GM2, all belonging to the same a-ganglio-series. The ceramide part of these parasite gangliosides contained sphingosine associated to unsaturated n24, saturated n24 and n16 fatty acids.

Prevalence of intestinal protozoans in French patients infected with HIV.

To assess the prevalence of intestinal protozoans in French HIV-infected patients, stool samples, duodenojejunal biopsies, and/or colorectal biopsies from 81 patients were studied for parasites, viruses, and bacteria. Pathogens were found in 70.6% of AIDS patients with diarrhea or malabsorption. The respective prevalence of protozoa in AIDS patients with diarrhea was Cryptosporidium sp.: 37.3%, Blastocystis hominis: 13.7%, Giardia intestinalis: 5.8%, Isospora belli: 2%, Enterocytozoon bieneusi: 2%. Microsporidia were noted in one patient with severe malabsorption but no diarrhea. Other pathogens included cytomegalovirus in 27.4% and Mycobacterium avium in 5.8%. Patients with identified pathogens were more immunosuppressed and more severely malnourished than those with unexplained diarrhea. Multiple pathogens were found in 13 of 81 patients (16%). Twenty-six of 66 identified pathogens (40%) were diagnosed only on biopsy specimens. Chronic diarrhea in HIV patients could be explained in the vast majority by appropriate gastrointestinal investigations. Cryptosporidia played a major role, while microsporidia appeared to be less common.

Analysis of the monohexosylceramide fraction of Echinococcus multilocularis metacestodes.

Monohexosylceramides of Echinococcus multilocularis metacestodes have been isolated and analyzed by thin-layer chromatography, gas-liquid chromatography and mass spectrometry. 90.9% of the parasite fraction was galactosylceramide; glucosylceramide was present at only 9.1%. The most important fatty acids were normal C16:0 and C26:0 fatty acids. The hydroxylated fatty acids of the ceramide part constituted 20.1% of the total, their major constituents were C18:0 and C26:0. The sphinganine accounted for 70.4% of long-chain bases, phytosphingosine and sphingosine were also detected. The importance of the long chain fatty acids and the presence of sphinganine in the monohexosylceramide fraction were discussed.

Glycosphingolipids of Echinococcus multilocularis metacestodes.

Neutral and acid glycosphingolipids of Echinococcus multilocularis metacestodes that were obtained after intraperitoneal infection of Meriones unguiculatus have been analyzed by thin layer chromatography. Neutral and acid glycosphingolipids accounted for 95% and 5% of total glycosphingolipids, respectively. 12 different fractions were observed in the neutral glycosphingolipids extracts of the parasite. The most important was a monohexosylceramide fraction accounting for 56.4% of neutral glycosphingolipids. 9 different fractions were detected in gangliosides (acid glycosphingolipids). The fact that these glycosphingolipids were specific to the parasite was established by the analysis of different cell populations of the host. Glycosphingolipids were purified from control and parasite-infected gerbil blood cells as well as from peritoneal exudate cells of healthy gerbils after a non-specific immunostimulation. The chromatograms obtained with these extracts were totally different from the parasite. In addition, parasitosis was found to have no effect on the host blood cell glycosphingolipids.

Enzyme-linked immunosorbent assay compared with indirect immunofluorescence test for detection of Pneumocystis carinii specific immunoglobulins G, M, and A.

An ELISA to measure Pneumocystis carinii-specific IgG, IgM, and IgA has been developed. The antigen was prepared from purified cysts by sonication and ultracentrifugation. Antigen particles with sedimentation coefficients less than 165 S were used. The technique has been compared with indirect immunofluorescence, using whole cysts as antigen. Ninety human sera were assayed. The results were significantly correlated. The ELISA-technique was more sensitive, and owing to the soluble antigen the daily variation was less than 1 per cent. The technique is useful for quick and reliable detection of Pneumocystis carinii antibodies in a routine laboratory.

Type I reactions directed against Pneumocystis carinii in AIDS patients.

Type I allergy directed against Pneumocystis carinii (PC) has been investigated in 14 patients with AIDS. The Pneumocystis carinii pneumonia often shows a rapid and severe course, and type I allergy against the parasite might be a pathogenic co-factor in the interstitial lung inflammation. In twelve of the AIDS patients the clinical symptoms and course of illness indicated a PC pneumonia. The basophil histamine release test was used as a sensitive test to detect type I allergy against PC. Eight of the patients showed significant histamine release when stimulated with PC. In contrast, only two patients in the group of 12 HIV antibody-positive homosexual men and none in the control group of 13 heterosexual men released histamine. The histamine release was mediated by an immunological reaction, since the release was abolished and regained by removal from and refixation to the cell surface of the cell-bound immunoglobulins before the antigen challenge. The results suggest an involvement of type I allergy as a pathogenic co-factor in Pneumocystis carinii pneumonia.

Parasitological, serological, and clinical studies of Wuchereria bancrofti in Limbe, Haiti.

A survey for Wuchereria bancrofti in Limbe, Haiti (est. pop. = 10,500) revealed that 17% (231/1,450) had a patent infection. Nearly half of those surveyed harbored fewer than 10 microfilariae (mf) per 20 mm3 of finger-prick blood; the median mf density for females and males was 12.4 and 9.5, respectively. Parasitemias occurred as early as age 4. Antibody titers greater than or equal to 1:20 against adult D. viteae antigen were observed in 38% of microfilaremic individuals and in 29% of amicrofilaremic individuals. Peak antibody responsiveness (40%) was observed between 5 and 9 years of age. In all age groups there was no correlation between mf density and antibody titer. Among the mf carriers, 5.6% had no clinical symptoms. Lymphangitis was a common feature with 14.3% having lymphedema, 8.2% with edema of the lower extremities, and 1.3% reporting episodes of chyluria. Genital involvement among women was rare, but in males 5.4% had genital swelling and 4.5% had hydroceles. Culex pipiens quinquefasciatus (Say) was observed to support the complete development of W. bancrofti in Limbe.

Albendazole: a new broad spectrum anthelmintic. Double-blind multicenter clinical trial.

A new anthelmintic drug, albendazole, has been tested in a multicenter double-blind placebo controlled study in 392 patients from France and West Africa in children and adults with single or mixed infections caused by roundworms, hookworms, whipworms, threadworms and tapeworms. All patients were closely observed before and after treatment for clinical side effects, hematological or clinical blood chemical changes. Fecal samples obtained before, and 7 days and 21 days after treatment were examined using a concentration technic (Ritchie), a coproculture (Harada-Mori) and an egg count (Kato). Following a single dose of 400 mg in adults, cure rates of 96% in ascaridiasis, 96% in ancylostomiasis caused by dose of 400 mg in adults, cure rates of 96% in ascaridiasis, 96% in ancylostomiasis caused by Ancylostoma duodenale, 90% in ancylostomiasis caused by Necator americanus and 76% in trichuriasis were recorded. About 48% of the patients infected by Strongyloides stercoralis were cured following administration of 400 mg per day for 3 consecutive days. The efficacy of half of the adult dose (200 mg) was much lower in children. None of the patients who received placebo were cured. The drug did not produce any significant side effects and approximately the same numbers were reported in the albendazole and the placebo groups. No variations of the hematology and clinical blood chemistry values were recorded.

Detection of Pneumocystis carinii DNA by PCR amplification in various rat organs in experimental pneumocystosis.

Pneumocystosis is usually a disease of the lungs, but the number of cases of extrapulmonary pneumocystosis has greatly increased during the AIDS epidemic. Much remains unknown about the frequency and mechanisms of dissemination. In the present study, a systematic search for Pneumocystis carinii by PCR with primers specific for mitochondrial rRNA was performed in the lung, liver, spleen and kidney of 12 immunosuppressed rats and two immunocompetent rats. The amplified products were analysed by Southern hybridisation with a digoxigenin-11-dUTP labeled probe. P. carinii DNA was found in lungs in all 14 rats and in at least one organ other than lung in 11 immunosuppressed rats and the two control rats. We suggest that extrapulmonary dissemination may not be an exceptional phenomenon in the course of pneumocystosis, but rather part of the natural evolution of the disease.

Identification and initial characterization of Pneumocystis carinii soluble antigens in rabbit serum and lung lavage.

Lung lavage and serum samples from Azathioprin-treated (acute-phase infection) and untreated (non acute-phase infection) rabbits were used in the immunoblotting technique to look for Pneumocystis carinii (Pc) soluble antigens, using rabbit polyclonal antibodies raised against rabbit-derived Pc antigens and labeled with peroxidase. Analysis of the supernatant of lavage fluid after centrifugation to sediment intact organisms revealed components of approximately 80, 60-65, 55, 39 and 27 kDa in acute-phase samples. The components in the regions of 80, 60-65, 55 kDa and to a lesser extent 39 kDa were also present in non acute-phase lung lavage samples. In acute-phase serum samples, a major component of 80 kDa and minor components of about 65 and 39 kDa are detectable. The 80 and 65 kDa components are also detectable in some of the serum samples from the untreated rabbits. Immunofluorescent staining with FITC-conjugated affinity-purified antibodies to the 80, 60-65, 55, 39 or 27 kDa-components showed that they shared epitopes with both Pc cysts and trophozoites. The affinity-purified antibodies also cross-reacted in immunoblotting with several antigens in the Pc whole preparations. The putative Pc soluble antigens in serum and lung lavage were then isolated by affinity chromatography with polyclonal antibodies to Pc. Preliminary characterization of the column-extracted antigens revealed complete inactivation by trypsin whereas only the 55 and 80 kDa antigens bind to Concanavalin A. In conclusion, the results of this study suggest that Pc soluble antigens are present even in non acute-phase samples and only the low-molecular weight antigens (39 and 27 kDa) seem specific for the acute-phase. These findings are consistent with previous investigations reported by others that development of Pc could occur in nonimmu-nosuppressed rabbits.

Analysis of Pneumocystis carinii antigens by CIEP, SDS-PAGE and immunoblotting.

Pneumocystis carinii (Pc) from rabbit and rat lungs were analyzed by counterimmunoelectro-phoresis (CIEP), Polyacrylamide gel electrophoresis and immunoblotting. In CIEP, considerable cross-reactivity was demonstrated using rabbit polyclonal antisera raised against the rabbit and the rat-derived Pc components. In immunoblotting, both the rat and the rabbit Pc antigens also showed reactivity with the two antisera. Rabbit-derived Pc antigens of about 24-27,39,42-45, 55, 110 and 116 kDa were revealed with infection-derived rabbit sera. The 39, 42-45 and 116 kDa antigens were further recognized by both human and rat immune sera. In addition, many human sera detected the rabbit Pc antigen of 42-45 kDa. Using rat infection-derived sera, rat Pc antigens of 39, 55 to 60, 110 and 116 kDa were identified. The sera from Pc infected rabbits and humans recognized the bands in the regions of 39, 55 and 116 kDa. Carbohydrate residues were further analyzed by Concanavalin A (Con A)-binding experiments, periodate Schiff (PAS) and Alcian Blue (AB) stainings. The 55 and 116 kDa bands of both rabbit and rat Pc strongly reacted with Con A and were stained by PAS indicating the presence of hydroxyl and mannosyl/glycosyl residues. The AB staining-bands were 39, 42-45 and 55 kDa for rabbit Pc isolates and 39, 45, 55-60 and 70 kDa for rat Pc isolates, indicating the presence of carbohydrate residues with acidic function. The rabbit Pc immunodominant 39, 55 and 116 kDa antigens then appeared to be glycoproteins with characteristics similar to those of their counterparts in rats. The implications of these findings are discussed.

Validity of a standard information protocol provided to end-stage renal disease patients and its effect on treatment selection.

OBJECTIVE: To evaluate the validity of a standard information package, comprising written and audiovisual aids, for end-stage renal disease (ESRD) patients in a predialysis program. STUDY DESIGN: A multicenter study comprising patients entering a predialysis program. Three questionnaires were developed to gather data in this study: (1) a pre-information package questionnaire that evaluates the patient's initial knowledge of ESRD and the treatment options available (pre-informed patients); (2) a post-information package questionnaire that evaluates the patient's knowledge of ESRD and treatment options after being informed according to the protocol (post-informed patients); (3) a "start of the treatment" questionnaire that deals with the patient's choice of treatment at the time of starting dialysis, as well as the reasons leading to that choice. In all three questionnaires the patient's age, gender, level of creatinine clearance (Ccr), and hematocrit were recorded. INCLUSION CRITERIA: Any patient who was on a predialysis program in the participating centers. RESULTS: Three hundred and four patients were evaluated across 14 participating centers. Initial knowledge was assessed in 216 pre-informed patients (questionnaire 1). Patients were then guided through the information package. One hundred and fifty-eight patients answered the post-information package (questionnaire 2). During the course of the study, 174 patients (of the initial 304) started renal replacement therapy. Of these, 49.4% (86 patients) had received predialysis information according to our study protocol. All the patients who received the information throughout the trial improved their knowledge of ESRD and treatment options; this improvement was statistically significant. CONCLUSIONS: The treatment options least well known at the start of the study were the peritoneal dialysis techniques. After receiving the information package, patients had an equal knowledge of all the different treatments, although hemodialysis was still the most familiar. This improvement in knowledge enabled patients who started a dialysis treatment to choose a therapy according to their own preferences. Their selections were as follows: 44% of the patients chose hemodialysis, 40% chose continuous ambulatory peritoneal dialysis, and 16% chose automated peritoneal dialysis. The standard information package, used as a patient education program, effectively resulted in patients having a significantly improved level of knowledge and understanding of ESRD and the different treatment options available.

The effect of isatin on the Echinococcus granulosus cyst in an experimental host.

The effect of isatin on the E. granulosus cyst was studied. NMRI mice, which were infected with E. granulosus of sheep origin, were treated daily with isatin at a dose of 50 mg kg-1 for 18 days. Ultrastructural damage was observed in the treated cysts, including accumulation of lamellar stacks, electron-dense granules, autophagosomes and lipid vesicles. Moreover, a biochemical study showed an inhibition of alkaline phosphatase activity, with a decrease in carbohydrate storage and an increase in acid phosphatase activity. In spite of the short duration of the treatment, the results obtained allowed us to conclude that isatin acts on E. granulosus cysts. This activity appears as a process of degeneration linked to the alkaline phosphatase inhibitory effect of isatin.

[Values and limitations of the detection of circulating Candida antigen (Cand-Tec) in the diagnosis of deep candidiasis]. / Intérêts et limites de la détection d'antigène Candida circulant (Cand-Tec) dans le diagnostic des candidoses profondes.

Diagnosis of systemic candidiasis is difficult and often performed lately. It can be improved by Candida antigen detection, using agglutination of latex particles sensitized with anti-Candida albicans antibody. Candida antigen search was made in 407 sera obtained from 123 patients, in Hematology and in intensive care units. Fourty three patients had, at least, one serum positive for antigen. The titer was 1/2, 1/4 and 1/8. Twenty seven of the 43 patients had C. albicans in one or several localizations. Eight of these 27 patients had a systemic candidiasis: C. albicans grown from three blood samples, at least, and/or from organ biopsy. In these eight patients, the antigen titer was 1/4 ou 1/8. Eighty patients were Candida antigen negative. Thirty eight out of 80 had C. albicans in one or more sites and two of these 38 had systemic candidiasis. Five other patients had other Candida species. Two out of five had C. tropicalis and C. guillermondii septicemia.

[Congenital toxoplasmosis, evaluation of the prevention policy]. / Toxoplasmose congénitale, évaluation de la politique de prévention.

OBJECTIVES: This study was performed to assess the effect of a prevention programme against congenital toxoplasmosis conducted as part of the French health policy developed in the Rhône department. METHODS: A descriptive epidemiological survey was conducted in 1991 including 806 post-partum women who were hospitalized in 22 maternities in the Rhône department. RESULTS: Forty-nine percent of the women had negative serology tests. French legislation requiring detecting non-immunized women at diagnosis of pregnancy was applied satisfactorily by the attending physicians. Inversely, women at risk were insufficiently informed: only 17% of the women at risk were aware of the three main routes of contamination; 63% believed vaccination is possible and 11% though they had been vaccinated. Deficient information was probably the cause of poor compliance to preventive measures as observed in this sample: only 17% of the serologically negative women stated they had applied anti-toxoplasmosis prophylaxy measures. CONCLUSION: Women at risk must be informed to convince them to modify their behaviour during pregnancy. The role of the attending physician and biologist is of major importance.

[Halofantrine: for new rules of prescription]. / Halofantrine: pour de nouvelles règles de prescription.

Halofantrine is an antimalarial drug widely prescribed for chloroquine-resistant strains of Plasmodium falciparum. It has been recognized to cause serious deleterious effects which have dampened early enthusiasm for this compound. Basically, the adverse effects involve lengthening of the QTc interval, torsade de pointes and induction of late ventricular potentials. These side effects are related to the quinidine-like effect of the drug which has a chemical structure similar to quinine and quinidinic drugs. More recently, severe haemolytic accidents have been reported suggesting an autoimmunization mechanism. These side effects imply new rules for prescription and more prudent use of halofantrine, especially for prophylaxic therapy against malarial attacks in travellers.

[Protein-energy malnutrition in an urban African milieu (Togo). Etiologic factors in kwashiorkor and marasmus-kwashiorkor]. / La malnutrition proteino-energetique en milieu urbain africain (Togo). Facteurs etiologiques du kwashiorkor et du marasme-kwashiorkor.

The etiologic factors of protein-energy malnutrition (P.E.M.) have been studied in 59 children with kwashiorkor (KWK) or marasmus-kwashiorkor (MKWK) and living in an african urban area. The decline of breast feeding leads to an earlier P.E.M., mainly MKWK. This decline is linked to urbanization, mother's activities, dislocation of traditional structures and use of artificial formulas. Essentially based on cereals, the diet is responsible of the post-weaning P.E.M. Poverty, ignorance and food taboos are related to a lack in weaning food varieties. A small number of infants with KWK had a rich protein diet putting back the cause of an hypoproteic diet on the KWK onset. Infections play a determinant role in the onset of KWK and of some MKWK, after 2 years of age. Diarrhoea, measles, bronchopulmonary and parasitic diseases are the most prevalent infections. Among socio-cultural factors, conjugal disorders are predominating with child-mother break-up and father's bonding failure. At the opposite of rural areas, the family size is reduced. The three first birth ranges are specially concerned with young inexperienced mothers.

[Cutaneous South-American Leishmaniasis. Parasitological and serological diagnosis by indirect immunofluorescence and enzyme linked immunoassay (ELISA). 94 cases]. / Leishmaniose cutanée sud-americaine. Diagnostic parasitologique et sérologique par immunofluorescence indirecte (IFI) et enzyme linked immuno assay (ELISA). A propos de 94 cas.

A parasitological (direct test and culture) and serological (IIF and ELISA) survey was carried out in 94 soldiers infested by a cutaneous South American leishmaniasis during a training in the guyanese forest. 52 p.c of the parasitological tests were positive, direct test being much more sensitive than cultures. By this technique, Leishmania Viannia guyanensis was detected 8 times, and Leishmania Viannia braziliensis twice. I.I.F. was negative in all cases because the utilization of a non-homologous antigen in the promastigote form and of the condition of its preparation. ELISA test utilizing the same antigen in a soluble form was specific and its sensitivity was 52 p.c. This technique was positive in 52 p.c of the cases, corroborating some diagnosis for which parasitological test was negative. 66 p.c of the total cases were confirmed.