The effect of the acute phase of infection on absorption of and exposure to orally administered antibiotics in non-critically ill, hospitalized patients.

OBJECTIVES: During the acute phase of infection, IV antibiotics are preferred to ensure adequate systemic exposure. To assess whether adequate exposure may also be achieved with oral antibiotics, we investigated exposure to oral antibiotics and PTA during the acute phase of infection and after defervescence. METHODS: We enrolled hospitalized, non-critically ill febrile patients treated with IV antibiotics other than amoxicillin or ciprofloxacin. The study consisted of two visits: when patients had received <24 h IV treatment; and when patients had become afebrile. On both visits, patients received one additional dose of 750 mg amoxicillin, or 500 mg ciprofloxacin, depending on the presumed infection, after which serial blood samples were obtained. The primary endpoint was the ratio of the AUC during the febrile and the afebrile phase. The AUCs were considered to be equivalent when the ratio of the mean AUCs and its 90% CI was contained within the acceptance interval of 80%-125%. The secondary endpoint was PTA. RESULTS: Forty-four patients (15 amoxicillin, 29 ciprofloxacin) completed both study visits. The median time between the two study visits was 65.8 h (range 33.8-427.4). The ratio of the mean AUCs (study visit 1/study visit 2) was 97% (90% CI of 80%-117%) for amoxicillin and 112% (90% CI of 108%-116%) for ciprofloxacin. The PTA for amoxicillin and ciprofloxacin did not differ between the two phases and was adequate to treat common pathogens. CONCLUSIONS: The acute phase of infection in non-critically ill febrile patients does not influence the exposure to, or PTA of, orally administered amoxicillin and ciprofloxacin. This might justify earlier IV-to-oral switching.

[Adaptation to changing needs in mental health care: mental health centers]. / Aanpassing aan veranderende zorgbehoefte in de ggz: mentale gezondheidscentra.

BACKGROUND: The increasing healthcare needs in the Netherlands lead to increasing healthcare costs and waiting lists and warrants sufficient (staff-)capacity. The current market-driven organization of care affects qualitative, accessible, and affordable care. Whether the Dutch mental healthcare system can adapt efficiently is questioned in this article. AIM: Gaining insight into the developments and bottlenecks that can contribute to the realization of appropriate care in mental health. METHOD: An overview of literature is given regarding developments and necessary adjustments in mental healthcare. RESULTS: Appropriate care is value-driven, focused on health (instead of the absence of illness), based on management of health of the client and his network, is accessible, affordable and is offered at the right time and place. The collaborative innovation of Mental Healthcare Centers, in which GGz Breburg (specialized mental health care), Indigo Brabant (general mental health care), and health insurance company, form a sustainable coalition which is presented as a solution for manageability of the mental healthcaresystem. This coalition aims to improve the public values of mental healthcare as a response to the required paradigm shift and future model of mental healthcare. CONCLUSION: As a regional network model, the Mental Healthcare Centers offer a desirable answer to the demand for an appropriate and future-proof mental healthcare. w.

Mental health recovery: evaluation of a recovery-oriented training program.

AIM: This study investigates the effectiveness of a recovery-oriented training program on knowledge and attitudes of mental health care professionals towards recovery of people with serious mental illness. METHODS: Using data from a longitudinal study of recovery, changes in knowledge and attitudes of 210 mental health care professionals towards recovery were explored using the Recovery Attitude Questionnaire and the Recovery Knowledge Inventory. The study uses a two-group multiple intervention interrupted time-series design which is a variant of the stepped-wedge trial design. A total of six measurements occasions took place. RESULTS: This study shows that professionals' attitudes towards recovery from mental illness can improve with training. After two intensive recovery-oriented training sessions, mental health care professionals have a more positive attitude towards recovery in clinical practice. CONCLUSION: A recovery-oriented training program can change attitudes of mental health care professionals towards recovery of serious mental illness.

Complete genomic characterization in patients with cancer of unknown primary origin in routine diagnostics.

BACKGROUND: In ∼3%-5% of patients with metastatic disease, tumor origin remains unknown despite modern imaging techniques and extensive pathology work-up. With long diagnostic delays and limited and ineffective therapy options, the clinical outcome of patients with cancer of unknown primary (CUP) remains poor. Large-scale genome sequencing studies have revealed that tumor types can be predicted based on distinct patterns of somatic variants and other genomic characteristics. Moreover, actionable genomic events are present in almost half of CUP patients. This study investigated the clinical value of whole genome sequencing (WGS) in terms of primary tumor identification and detection of actionable events, in the routine diagnostic work-up of CUP patients. PATIENTS AND METHODS: A WGS-based tumor type 'cancer of unknown primary prediction algorithm' (CUPPA) was developed based on previously described principles and validated on a large pan-cancer WGS database of metastatic cancer patients (>4000 samples) and 254 independent patients, respectively. We assessed the clinical value of this prediction algorithm as part of routine WGS-based diagnostic work-up for 72 CUP patients. RESULTS: CUPPA correctly predicted the primary tumor type in 78% of samples in the independent validation cohort (194/254 patients). High-confidence predictions (>95% precision) were obtained for 162/254 patients (64%). When integrated in the diagnostic work-up of CUP patients, CUPPA could identify a primary tumor type for 49/72 patients (68%). Most common diagnoses included non-small-cell lung (n = 7), gastroesophageal (n = 4), pancreatic (n = 4), and colorectal cancer (n = 3). Actionable events with matched therapy options in clinical trials were identified in 47% of patients. CONCLUSIONS: Genome-based tumor type prediction can predict cancer diagnoses with high accuracy when integrated in the routine diagnostic work-up of patients with metastatic cancer. With identification of the primary tumor type in the majority of patients and detection of actionable events, WGS is a valuable diagnostic tool for patients with CUP.

Infestation of sheep with Psoroptes ovis, the sheep scab mite, results in recruitment of Foxp3(+) T cells into the dermis.

Regulatory T cells (Tregs) play a central role in maintenance of immune homeostasis by controlling harmful immune responses to inappropriate antigens and are thought to play a key role in modulating hypersensitivity reactions. Infestation of sheep with Psoroptes ovis results in a pronounced cutaneous hypersensitivity-type response, which appears to be crucial for mite survival. We hypothesize that (i) Tregs are involved in sheep scab lesions and (ii) Treg responses may crucially affect lesion development and subsequent mite survival. Foxp3 is a key transcription factor required for generation and maintenance of Tregs in rodents and humans, and is the most widely used marker for Tregs in these species. In this study, we sequence ovine foxp3 and show that it exhibits a high degree of homology with foxp3 from other species. Using a validated immunohistochemical staining technique, we demonstrate that infestation of sheep with P. ovis results in an influx of Foxp3(+) T cells into the skin. Future work will investigate the regulatory function of ovine Foxp3(+) T cells and determine whether the quality of the Treg response to P. ovis plays a role in individual susceptibility to the mite.

Significance of donor anuria differs between monoamniotic and diamniotic twin-twin transfusion syndrome.

Development of severe twin-twin transfusion syndrome (TTTS) in diamniotic-monochorionic twins includes five stages of increasing severity, i.e. recipient polyhydramnios and donor oligohydramnios, donor anuria, abnormal umbilical flow velocities in either twin, hydrops in the recipient, and intrauterine fetal death (IUFD) in either or both twins. In a severe case of TTTS in monoamniotic twins we observed donor anuria to appear after hydrops in the recipient. We conclude that donor anuria is a late and serious symptom in monoamniotic TTTS.

Focal metatarsal sinus tracts in a Weimaraner successfully managed with ciclosporin.

Focal metatarsal sinus tracts ('fistulation') are, to the authors knowledge, reported for the first time in a Weimaraner. The six-year-old, entire male had a five-month history of two symmetrical, well-demarcated sinuses on the plantar aspect of each metatarsus. The area surrounding each pair of sinuses was slightly fluctuant and a serosanguineous discharge could be expressed. Cytological examination of the discharge was characteristic of pyogranulomatous inflammation. Bacterial culture showed the material to be sterile. Examination of a skin biopsy revealed a severe inflammatory reaction involving the dermal collagen, with an infiltrate of neutrophils, macrophages, lymphocytes, plasma cells and multi-nucleated giant cells, with some micro-pustule formation. Treatment with ciclosporin induced total remission. Reduction of the dose of ciclosporin resulted in recurrence of the physical signs with further remission on re-introduction of the original dosage. This is the first report of the use of ciclosporin to control this condition.

Immune responses to Staphylococcus aureus and Psoroptes ovis in sheep infected with P. ovis--the sheep scab mite.

In sheep, lesions caused by Psoroptes ovis, the sheep scab mite, may become colonized by Staphylococcus aureus. The present study compares clinical signs, lesional area and the immune response to P. ovis and S. aureus in P. ovis-infested sheep with and without secondary S. aureus infection. No differences were detected in the clinical signs or lesional areas in the S. aureus-positive and -negative sheep. However, 6 weeks after infestation an IgG but not IgE isotype antibody response to S. aureus was detected in the S. aureus-positive but not the S. aureus-negative group of sheep. This response targeted S. aureus antigens with molecular weights of approximately 36, 38, 50 and 65 kDa. In addition, 6 weeks after infestation an IgE response to P. ovis was detected in the S. aureus-positive but not the S. aureus-negative group of sheep.

The EMBL nucleotide sequence database.

The EMBL Nucleotide Sequence Database (http://www.ebi.ac.uk/embl/) is maintained at the European Bioinformatics Institute (EBI) in an international collaboration with the DNA Data Bank of Japan (DDBJ) and GenBank at the NCBI (USA). Data is exchanged amongst the collaborating databases on a daily basis. The major contributors to the EMBL database are individual authors and genome project groups. Webin is the preferred web-based submission system for individual submitters, whilst automatic procedures allow incorporation of sequence data from large-scale genome sequencing centres and from the European Patent Office (EPO). Database releases are produced quarterly. Network services allow free access to the most up-to-date data collection via ftp, email and World Wide Web interfaces. EBI's Sequence Retrieval System (SRS), a network browser for databanks in molecular biology, integrates and links the main nucleotide and protein databases plus many specialized databases. For sequence similarity searching a variety of tools (e.g. Blitz, Fasta, BLAST) are available which allow external users to compare their own sequences against the latest data in the EMBL Nucleotide Sequence Database and SWISS-PROT.

Adipokinetic hormone-induced influx of extracellular calcium into insect fat body cells is mediated through depletion of intracellular calcium stores.

Adipokinetic hormone I (AKH I) needs extracellular Ca2+ for its activating action on glycogen phosphorylase in locust fat body in vitro. TMB-8 reduces this AKH effect significantly, indicating that for a major part, hormone action also requires the mobilization of Ca2+ from intracellular stores. Using 45Ca2+, AKH was shown to stimulate both the influx and the efflux of Ca2+. Thapsigargin also enhances the influx of extracellular Ca2+ into the fat body cells, indicating that the stimulating effect of AKH on Ca2+ influx may be mediated through depletion of intracellular Ca2+ stores as well. AKH is known to enhance cAMP levels in locust fat body. We show that elevation of cAMP with forskolin or theophylline leads to activation of glycogen phosphorylase, both in the presence and in the absence of extracellular Ca2+. The present data are discussed in an attempt to elucidate further the mechanism underlying transduction of the hormonal signal in locust fat body.

Characterisation of lesional infiltrates of dendritic cells and T cell subtypes during primary infestation of sheep with Psoroptes ovis, the sheep scab mite.

Earlier studies of cattle and sheep have demonstrated that Psoroptes ovis infestations provoke an intense immunoinflammatory response dominated by eosinophils accompanied by a substantial infiltrate of lymphocytes. However, the kinetics of the lymphocyte response and the subtypes involved have not been characterised. We employed two groups of sheep to investigate the early (1-21 days) and later (21-63 days) infiltration of lymphocyte subpopulations and dendritic cells in primary infestations of sheep with P. ovis. Immunohistochemistry indicated that by 4 days after infestation numbers of CD4+ and CD45RA+ cells in lesional skin had increased significantly (P<0.03 and P<0.005, respectively) and that a significant increase in gammadelta T cells and dendritic cells (CD1b+) had occurred by 8 days (P<0.02 and P<0.01, respectively). Numbers of lymphocyte and dendritic cells declined from 49 to 63 days after infestation. Our observations suggest that mite-derived products exert a profound influence on the early recruitment of lymphocytes that may significantly influence the genesis of the adaptive immune response.

[Late presentation of congenital diaphragmatic hernia]. / Late presentatie van aangeboren hernia diaphragmatica.

A boy aged 6 months and a girl aged 9 months were admitted due to vomiting, among others, and a boy aged 11 months due to pneumonia. It turned out that they had a congenital diaphragmatic hernia. Primary operative repair was performed successfully in all patients, followed by recovery. The older boy experienced a relapse nearly 1 year later, which was treated by surgical correction. Most congenital diaphragmatic hernias present directly after birth, with cyanosis and respiratory distress. However, 10-20% of the cases are discovered after this period. In these children diagnosis can be difficult because of the diverse symptoms such as vomiting, feeding difficulties, tachypnoea or recurrent respiratory tract infections. Physical signs include the absence of breath sounds or the presence of bowel sounds in the chest. Chest X-ray, contrast upper gastrointestinal series or ultrasound imaging confirms the diagnosis. Delay in treatment can lead to complications such as necrosis of the bowel. In young children with acute or chronic respiratory infections or gastrointestinal complaints, a congenital diaphragmatic defect should be considered.

Comparison of myocardial changes between pressure induced hypertrophy and normal growth in the rat heart.

To evaluate differences in tissue composition between hearts with pressure overload hypertrophy and normal hearts of comparable weight, 30 rat hearts with aortic constriction of 4, 10 and 30 days, and nine hearts of sham operated controls were studied. Surgery was performed at age 70 days. Morphometric analysis of myocardial tissue sections revealed (1) myocyte hypertrophy in left ventricular myocardium of hypertrophic hearts was proportional to heart weight, and in normal growth myocyte volume increased in proportion to heart weight; (2) myocyte number in left ventricular myocardium was identical in hypertrophic and normal hearts; (3) non-muscle cell proliferation was proportional to heart weight identically in hypertrophic and normal hearts; (4) volume fractions of myocytes were significantly lower in hypertrophic hearts [0.76(SD 0.05)] than in normal hearts [0.82(0.04)]; (5) volume fractions of all nuclei, myocyte nuclei and non-myocyte nuclei were similar in hypertrophic and normal hearts; (6) measured ventricular DNA content increased with heart weight identically in hypertrophic and normal hearts, and equalled DNA content calculated using the data on tissue composition. Neither right ventricular weight nor right ventricular DNA content were affected by the presence of left ventricular hypertrophy. We conclude that left ventricular hypertrophy due to aortic constriction in the rat resulted in changes of myocardial tissue composition similar to the changes associated with normal growth. Tissue composition of hypertrophic rat hearts corresponds strikingly to that of normal rat hearts with comparable heart weight, although myocardial changes in hypertrophy develop considerably faster than in normal growth.

Insect adipokinetic hormone stimulates inositol phosphate metabolism: roles for both Ins(1,4,5)P3 and Ins(1,3,4,5)P4 in signal transduction?

Adipokinetic hormones (AKHs) control the mobilization of energy reserves from the insect fat body as fuels for flight activity. As a part of our investigations on AKH signal transduction, we demonstrate in this study that the inositol lipid cycle may be involved in the action of AKH-I on fat body of the migratory locust. We show that [3H]inositol is incorporated into fat body phosphoinositides in vitro, whose hydrolysis leads to the formation of the following inositol phosphates (InsPs): Ins(1 and/or 3)P, Ins(4)P, Ins(1,3)P2, Ins(1,4)P2, Ins(3,4)P3, Ins(1,3,4)P3, Ins(1,4,5)P3 and Ins(1,3,4,5)P4. AKH stimulates the formation of these isomers, eliciting an increase in radioactivity of total InsPs already after 1 min. Mass measurements show that Ins(1,4,5)P3 levels are substantially enhanced by AKH, which is indicative of hormonal activation of phospholipase C. In cell-free tissue preparations, Ins(1,4,5)P3 is metabolized through dephosphorylation as well as further phosphorylation. Ins(1,3,4,5)P4 is dephosphorylated primarily to Ins(1,3,4)P3, although the ability for its reconversion to Ins(1,4,5)P3 suggests that in vivo Ins(1,3,4,5)P4 may function as a rapidly mobilizable pool for Ins(1,4,5)P3 generation. Metabolic pathways for the conversion of InsPs to inositol in the locust fat body are proposed.

Differential induction of inositol phosphate metabolism by three adipokinetic hormones.

Many (in)vertebrates simultaneously release several structurally and functionally related hormones; however, the relevance of this phenomenon is poorly understood. In the locust e.g. each of three adipokinetic hormones (AKHs) is capable of controlling mobilization of carbohydrate and lipid from fat body stores, but it is unclear why three AKHs coexist. We now demonstrate disparities in the signal transduction of these hormones. Massive doses of the AKHs stimulated total inositol phosphate (InsPn) production in the fat body biphasicly, but time courses were different. Inhibition of phospholipase C (PLC) resulted in attenuation of both InsPn synthesis and glycogen phosphorylase activation. The AKHs evoked differential formation of individual [3H]InsPn isomers (InsP(1-6)), the effect being most pronounced for InsP3. 40 nM of AKH-I and -III induced a substantial rise in total InsPn and [3H]InsP3 at short incubations, whereas the AKH-II effect was negligible. At a more physiological dose of 4 nM, the AKHs equally enhanced Ins(1,4,5)P3 levels. The InsP3 effect was most prolonged for AKH-III. These subtle differences in InsPn metabolism, together with earlier findings on differences between the AKHs, support the hypothesis that each AKH exerts specific biological functions in the overall syndrome of energy mobilization during flight.

The EMBL Nucleotide Sequence Database. Contributing and accessing data.

The European Molecular Biology Laboratory Nucleotide Sequence Database receives sequence and sequence annotation data from genome projects, sequencing centers, individual scientists, and patent offices. Data may be most efficiently submitted to the database using the Internet based submission tool WEBIN or via previously established genome project accounts. Biologist curators will review the data and provide accession numbers within two working days. Non-confidential data are exchanged daily in an international collaboration between EMBL. DDBJ (the DNA Databank of Japan) and GenBank (USA) and may be accessed and retrieved via the Internet with the Sequence Retrieval System (SRS). Sequence database searching algorithms (e.g., Blitz, Fasta, Blast) are available for comparison of query to database sequences.

Wide-scale installation of insecticide-treated curtains confers high levels of protection against malaria transmission in a hyperendemic area of Burkina Faso.

In a region of Sudanese savannah in Burkina Faso, insecticide-treated curtains were installed in 8 out of 16 zones, each covering an area of about 50 km2. Longitudinal entomological monitoring using CDC light traps was performed in 4 villages (2 intervention, 2 control) over a period of 3 years (including 1 year prior to intervention). In the 3rd year a cross-sectional entomological survey using spray catches was performed in 84 villages (40 intervention). Indoor vector densities in protected houses showed large reductions (P = 0.01). The available data were also consistent with an impact on outdoor and unprotected indoor densities. The proportion of mosquitoes carrying sporozoites was 4.1% in protected villages compared with 11.5% in unprotected villages (P = 0.07). Entomological inoculation rates fell substantially (P = 0.01), reflecting these reductions. The impact of this intervention on mosquito survival appears to have been greater than those in similar trials conducted in the Gambia, Ghana and Kenya in which the intervention was applied over smaller areas.

Membrane cholesterol content of cholesterol/phospholipid vesicles determines the susceptibility to both damage and protection by bile salts: implications for bile physiology.

OBJECTIVES: To investigate the effect of membrane lipid composition on the susceptibility to bile salt damage and protection. DESIGN: Artificial model cholesterol/phospholipid (c/p) membranes (vesicles) with a varying cholesterol (0-15 mM) and phospholipid content (3-30 mM), and with a c/p ratio ranging up to 1.70, were prepared by sonication. We examined the effect of incubation with increasing concentrations of either tauroursodeoxycholate (TUDC), taurocholate (TC) or taurodeoxycholate (TDC) alone, or with proportionally varying mixtures of TUDC and TDC. METHOD: Vesicle integrity was assessed by the change in optical absorbance at 340 nm. RESULTS: Absorption of the bile salt-vesicle mixture decreased, with increasing bile salt concentration and hydrophobicity: TUDC less than TC less than TDC. Moreover, bile salt-induced damage also depended on membrane composition: vesicles containing more than 5 mM cholesterol and with a c/p ratio greater than 0.8 were less likely to be solubilized by 30 mM bile salt. Similarly, only in cholesterol-rich vesicles (c/p > 0.5) was a protective effect of TUDC against membrane disruption by TDC revealed upon incubation with various TUDC/TDC mixtures. CONCLUSION: Apart from the bile salt concentration and hydrophobicity, the cholesterol content of vesicles is pivotal, both in the bile salt-induced solubilization of cholesterol/phospholipid vesicles and in the potency of TUDC to prevent this.

Determination of actin content in gallbladder tissue and its relevance to normalization of tensiometry data.

OBJECTIVES: To compare the common procedure in tensiometry of normalization of the force (in N) produced by a gallbladder tissue strip to units of stress, with normalization of force to the strip content of contractile protein. DESIGN: A comparison was made in both healthy and in diseased gallbladder tissue strips between two normalization procedures involving anatomical parameters. The contractile response expressed in terms of tissue stress (in N/m2), which entails a normalization to the strip cross-sectional area, was set against normalization to the tissue content of contractile protein (in N/mg actin/g strip wet weight). METHOD: Dose-response curves for acetylcholine (ACh) (10(-8) to 10(-3) M) and sulphated cholecystokinin octapeptide (CCK) (10(-12) to 10(-6) M) were assessed in healthy guinea pig (n = 8) and in diseased human gallbladder tissue strips (n = 28). Assuming a tissue density of 1.05 g/cm3, the strip cross-sectional area was calculated from its weight and length. Actin content in homogenized strips was determined by polyacrylamide gel electrophoresis followed by densitometry. RESULTS: Actin content in human tissue was 19.06 +/- 1.42 mg/g strip wet weight, and 12.84 +/- 0.76 mg/g strip wet weight in guinea pig tissue. No correlation was found between strip cross-sectional area and actin content. In the diseased human tissue, no correlation was found between the inflammation score and either strip cross-sectional area or strip actin content. Maximal force (in mN) exerted in response to either ACh or CCK correlated much more closely in healthy guinea pig gallbladder (r = 0.97) than in diseased human tissue (r = 0.59). Normalization of maximal force to strip cross-sectional area (i.e. to stress) showed considerable more variation (% coefficient of variance) than the normalization to strip actin content in healthy guinea pig tissue, although both strip cross-sectional area and actin content per se showed little variation. Normalization to either parameter did not result in an improved correlation or a decreased variation in the case of diseased human gallbladder tissue. CONCLUSION: Normalization of muscle strip force in diseased tissue is questionable, as the assumptions made for healthy tissue are not valid.

Canine atopic disease: the prevalence of positive intradermal skin tests at two sites in the north and south of Great Britain.

Results of intradermal skin test responses to the same panel of 53 allergens were compared in 118 dogs with atopic disease presented at two geographical centres, Edinburgh (87 cases) and London (31 cases). The allergens most commonly positive at both centres were human dander and Dermatophagoides farinae, but positive tests to all of the allergens used occurred in at least one case. The mean number of allergens to which positive tests resulted in atopic dogs was 5.126 (Edinburgh) and 5.129 (London). The majority of animals were sensitive to allergens from more than one group. A significantly higher number of positive reactors to house dust allergen was observed at London than at Edinburgh (P < 0.05), while a significantly higher number of positive reactions to grass pollens was detected at Edinburgh than in London (P < 0.05). Sensitivity to Dermatophagoides pteronyssinus, in the absence of sensitivity to D. farinae, was uncommon and therefore both of these mite allergens should be incorporated in intradermal skin testing panels in Great Britain.