Green tea extract and catechol-O-methyltransferase genotype modify the post-prandial serum insulin response in a randomised trial of overweight and obese post-menopausal women.

BACKGROUND: Green tea extract (GTE) may be involved in a favourable post-prandial response to high-carbohydrate meals. The catechol-O-methyltransferase (COMT) genotype may modify these effects. We examined the acute effects of GTE supplementation on the post-prandial response to a high-carbohydrate meal by assessing appetite-associated hormones and glucose homeostasis marker concentrations in women who consumed 843 mg of (-)-epigallocatechin-3-gallate (EGCG) or placebo capsules for 11-12 months. METHODS: Sixty Caucasian post-menopausal women (body mass index ≥ 25.0 kg m-2 ) were included in a randomised, double-blind feeding study. GTE was consumed with a breakfast meal [2784.0 kJ (665.4 kcal); 67.2% carbohydrate]. Blood samples were drawn pre-meal, post-meal, and every 30 min for 4 h. Participants completed six satiety questionnaires. RESULTS: Plasma leptin, ghrelin and adiponectin did not differ between GTE and placebo at any time point; COMT genotype did not modify these results. Participants randomised to GTE with the high-activity form of COMT (GTE-high COMT) had higher insulin concentrations at time 0, 0.5 and 1.0 h post-meal compared to all COMT groups randomised to placebo. Insulin remained higher in the GTE-high COMT group at 1.5, 2.0 and 2.5 h compared to Placebo-low COMT (P < 0.02). GTE-high COMT had higher insulin concentrations at times 0, 0.5, 1.0, 1.5 and 2.0 h compared to the GTE-low COMT (P ≤ 0.04). Area under the curve measurements of satiety did not differ between GTE and placebo. CONCLUSIONS: GTE supplementation and COMT genotype did not alter acute post-prandial responses of leptin, ghrelin, adiponectin or satiety, although it may be involved in post-meal insulinaemic response of overweight and obese post-menopausal women.

Modelling canine leishmaniasis spread to non-endemic areas of Europe.

Expansion of sandflies and increasing pet travel have raised concerns about canine leishmaniasis (CanL) spread to new areas of Europe. This study aimed to estimate the probability of CanL introduction and persistence following movements of infected dogs. Stochastic modelling was used to estimate the probabilities of (1) CanL infection during travels or imports of infected dogs (P inf and P infCA, respectively), (2) CanL persistence in a dog network with sandflies after introduction of an infected dog (P per), and (3) persistence in a CanL-free region (P per region) for N dogs moving between endemic and free regions. Different mitigation measures (MMs) were assessed. P inf [7.8%, 95% predictive interval (PI) 2.6-16.4] and P per (72.0%, 95% PI 67.8-76.0) were reduced by use of repellent, vaccine, prophylactic medication, and insecticide, in decreasing order of effectiveness. Testing and exclusion of positive dogs was most effective in reducing P per region for a small N. The spread of CanL to CanL-free areas with sandflies is thus likely, but can be reduced by MMs.

Evaluation of performance of bacterial culture of feces and serum ELISA across stages of Johne's disease in cattle using a Bayesian latent class model.

The objective of this study was to evaluate the performance of bacterial culture of feces and serum ELISA to correctly identify cows with Mycobacterium avium ssp. paratuberculosis (MAP) at heavy, light, and non-fecal-shedding levels. A total of 29,785 parallel test results from bacterial culture of feces and serum ELISA were collected from 17 dairy herds in Minnesota, Pennsylvania, and Colorado. Samples were obtained from adult cows from dairy herds enrolled for up to 10 yr in the National Johne's Disease Demonstration Herd Project. A Bayesian latent class model was fitted to estimate the probabilities that bacterial culture of feces (using 72-h sedimentation or 30-min centrifugation methods) and serum ELISA results correctly identified cows as high positive, low positive, or negative given that cows were heavy, light, and non-shedders, respectively. The model assumed that no gold standard test was available and conditional independency existed between diagnostic tests. The estimated conditional probabilities that bacterial culture of feces correctly identified heavy shedders, light shedders, and non-shedders were 70.9, 32.0, and 98.5%, respectively. The same values for the serum ELISA were 60.6, 18.7, and 99.5%, respectively. Differences in diagnostic test performance were observed among states. These results improve the interpretation of results from bacterial culture of feces and serum ELISA for detection of MAP and MAP antibody (respectively), which can support on-farm infection control decisions and can be used to evaluate disease-testing strategies, taking into account the accuracy of these tests.

Evaluation of the sample needed to accurately estimate outcome-based measurements of dairy welfare on farm.

Dairy welfare assessment programs are becoming more common on US farms. Outcome-based measurements, such as locomotion, hock lesion, hygiene, and body condition scores (BCS), are included in these assessments. The objective of the current study was to investigate the proportion of cows in the pen or subsamples of pens on a farm needed to provide an accurate estimate of the previously mentioned measurements. In experiment 1, we evaluated cows in 52 high pens (50 farms) for lameness using a 1- to 5-scale locomotion scoring system (1 = normal and 5 = severely lame; 24.4 and 6% of animals were scored ≥ 3 or ≥ 4, respectively). Cows were also given a BCS using a 1- to 5-scale, where 1 = emaciated and 5 = obese; cows were rarely thin (BCS ≤ 2; 0.10% of cows) or fat (BCS ≥ 4; 0.11% of cows). Hygiene scores were assessed on a 1- to 5-scale with 1 = clean and 5 = severely dirty; 54.9% of cows had a hygiene score ≥ 3. Hock injuries were classified as 1 = no lesion, 2 = mild lesion, and 3 = severe lesion; 10.6% of cows had a score of 3. Subsets of data were created with 10 replicates of random sampling that represented 100, 90, 80, 70, 60, 50, 40, 30, 20, 15, 10, 5, and 3% of the cows measured/pen. In experiment 2, we scored the same outcome measures on all cows in lactating pens from 12 farms and evaluated using pen subsamples: high; high and fresh; high, fresh, and hospital; and high, low, and hospital. For both experiments, the association between the estimates derived from all subsamples and entire pen (experiment 1) or herd (experiment 2) prevalence was evaluated using linear regression. To be considered a good estimate, 3 criteria must be met: R(2)>0.9, slope = 1, and intercept = 0. In experiment 1, on average, recording 15% of the pen represented the percentage of clinically lame cows (score ≥ 3), whereas 30% needed to be measured to estimate severe lameness (score ≥ 4). Only 15% of the pen was needed to estimate the percentage of the herd with a hygiene score ≥ 3, whereas 30% to estimate the prevalence of severe hock lesions. Estimating very thin and fat cows required that 70 to 80% of the pen be measured. In experiment 2, none of the pen subsamples met our criteria for accurate estimates of herd prevalence. In conclusion, we found that both a higher percentage of the pen must be sampled to generate accurate values for relatively rare parameters and that the population measured plays an important role in prevalence estimates.

[Sport: practiced from birth?]. / Le sport: dès la naissance?

Physical activity in children is on the decline, leaving room for sedentary behaviour. Children are mentally over stimulated through the use of screens, but their physical condition is diminishing. The benefits of physical activity in adults are well known. Although paediatric literature is less abundant, the benefits of regular physical activity in young children are real and extend into adulthood. The promotion of physical activity can be made by any responsible adult in a child's entourage. It means clarifying the confusion between physical activity and sport, evaluating the balance between the physical and sedentary behaviour of the children and their families and establishing with them the possible necessary changes. PAPRICA--young childhood is 4 hour interdisciplinary training session approaching these various themes.

Reduction in incidence of Johne's disease associated with implementation of a disease control program in Minnesota demonstration herds.

This prospective longitudinal observational study was conducted to evaluate the effect of a standardized control program on the incidence of Johne's disease in 8 dairy herds in Minnesota. Depending on recruitment year, herds were followed for between 5 and 10 yr. Program compliance was evaluated using a cohort risk assessment score by birth cohort. Fecal samples from cows in study herds were tested annually using bacterial culture to detect Mycobacterium avium ssp. paratuberculosis (MAP), and serum samples from study cows were tested using an ELISA to detect antibodies to MAP. Clinical Johne's disease was also recorded. Cohort risk assessment score decreased along birth cohorts. Depending on the follow-up period in each herd, 5 to 8 birth cohorts were followed to describe changes in time to MAP bacterial culture positivity, serum ELISA positivity, MAP heavy shedding status, and clinical Johne's disease. The analysis of time to bacterial culture positivity, serum ELISA positivity, heavy fecal shedding status, and clinical Johne's disease using a time-dependent Cox regression indicated a reduction of the instantaneous hazard ratio by birth cohorts and by cohort risk score; however, the strength of association between the cohort risk score and each of the 4 disease outcomes decreased over time. The age at which the cows first tested positive for bacterial culture, serum ELISA, and heavy fecal shedding, and the age of the cows at onset of clinical Johne's disease signs remained constant for all birth cohorts. Based on herd risk scores, overall herds complied with the recommended management practices in the program. Results were consistent with a within-herd reduction of Johne's disease transmission, and that reduction was associated with herd-level management practices implemented as part of the control program.

Feeding management and characteristics of rations for high-producing dairy cows in freestall herds.

The objectives of this cross-sectional observational study were to 1) describe the feeding management and characteristics of rations for high-producing Holstein cows housed in freestall barns in Minnesota, 2) evaluate ration change over time, and 3) investigate herd-level risk factors for ration change. Each of 50 randomly selected freestall dairy herds was visited once during the study. Samples of TMR were collected from the high-production group feed bunk to represent the initial ration as delivered to the cows, 3 additional samples were collected every 2 to 3h after feed delivery, and the accumulated orts were cleaned out of the feed bunk. Feeding management practices and TMR formulation were also collected at the time of visit. Seventy percent of herds fed once daily, 22% fed twice daily, and 8% fed 3 times daily. Frequency of feed push-up was 5.4+/-2.3 times daily. Linear feed bunk space per cow was 0.45+/-0.11m. Sixty-two percent of the farms had 3-row pens and 38% had 2-row pens. Linear feed bunk space per cow was greater in 2-row pens (0.56 m/cow) than in 3-row pens (0.39 m/cow). Post and rail was the most common type of feed barrier; it was used by 60% of the herds. Headlocks were used by 28% of the herds, combination of post and rail with headlocks was used by 8%, and diagonal bars were used by 4%. Water trough linear space was 4.6+/-2.1 cm/cow. Estimated dry matter intake was 24.3 kg/cow per day. The forage content of the formulated ration was 52% of the ration DM, and corn silage was the most commonly used forage. The NDF content of the analyzed ration was greater than the NDF content of the formulated ration (30.6 and 29.8%, respectively). In contrast, the CP content was lower (17.5 and 17.9%, respectively). Some feeding management practices (e.g., feeding frequency) were associated with ration NDF content change over time. This association may be minimized by implementing ration and management changes.

Effect of Johne's disease status on reproduction and culling in dairy cattle.

Among the costs attributed to Mycobacterium avium ssp. paratuberculosis (MAP) infection in dairy cattle, the effects on reproduction and culling are the least documented. To estimate the cost of MAP infections and Johne's disease in a dairy herd, the rates of calving and culling were calculated for cows in each stage of MAP infection relative to uninfected cows. Data from 6 commercial dairy herds, consisting of 2,818 cows with 2,754 calvings and 1,483 cullings, were used for analysis. Every cow in each study herd was tested regularly for MAP, and herds were followed for between 4 and 7 yr. An ordinal categorical variable for Johne's disease status [test-negative, low-positive (low-shedding or ELISA-positive only), or high-shedding] was defined as a time-dependent variable for all cows with at least 1 positive test result or 2 negative test results. A Cox regression model, stratified on herd and controlling for the time-dependent infection variable, was used to analyze time to culling. Nonshedding animals were significantly less likely to be culled in comparison with animals in the low-shedding or ELISA-positive category, and high-shedding animals had nonsignificantly higher culling rates than low-shedding or ELISA-positive animals. Time to calving was analyzed using a proportional rates model, an analog to the Andersen-Gill regression model suitable for recurrent event data, stratifying on herd and weighted to adjust for the dependent censoring caused by the culling effects described above. High-shedding animals had lower calving rates in comparison with low-shedding or ELISA-positive animals, which tended to have higher calving rates than test-negative animals.

Herd-level risk factors for lameness in high-producing holstein cows housed in freestall barns.

The objective of this study was to investigate the association of some herd-level factors with the prevalence of lameness in 53 high-production groups of Holstein cows housed on 50 commercial dairy farms having freestall barns in Minnesota. Cows in the high-production group (n = 5,626) were scored for locomotion (score of 1 to 5, where 1 = normal and 5 = severely lame) to estimate prevalence of lameness (locomotion score >or=3) in the group. Herd-level variables were used to explain the variation in prevalence among groups. Among the variables tested, herd size, pen space per cow, type and size of milking parlor, total mixed ration content of crude protein and neutral detergent fiber, feeding frequency, linear feedbunk space per cow, type of feed barrier, and use of footbath did not show any association with the prevalence of lameness in the univariate analysis screening test and were not included in the multivariate model. Pen stocking density (cows per 100 stalls), total daily distance between pen and milking parlor, number of cows per full-time employee equivalent, cud chewing index, and pen type were eliminated from the multivariate model in the backwards stepwise procedure. Daily time away from the pen for milking was positively associated with the prevalence of lameness, whereas cow comfort quotient was negatively associated with prevalence of lameness. Prevalence of lameness was greater when farms performed hoof trimming only when the manager decided cows needed it because of hoof overgrowth or lameness compared with farms on which the feet of all cows were trimmed on a maintenance schedule once or twice annually. Brisket board height of more than 15.24 cm and presence of the area behind the brisket board filled with concrete were associated with greater prevalence of lameness. Most of these herd-level factors could be managed to reduce lameness prevalence in commercial dairy farms.

Prevalence of lameness in high-producing holstein cows housed in freestall barns in Minnesota.

A cross-sectional study was conducted to estimate the prevalence of clinical lameness in high-producing Holstein cows housed in 50 freestall barns in Minnesota during summer. Locomotion and body condition scoring were performed on a total of 5,626 cows in 53 high-production groups. Cow records were collected from the nearest Dairy Herd Improvement Association test date, and herd characteristics were collected at the time of the visit. The mean prevalence of clinical lameness (proportion of cows with locomotion score >or=3 on a 1-to-5 scale, where 1 = normal and 5 = severely lame), and its association with lactation number, month of lactation, body condition score, and type of stall surface were evaluated. The mean prevalence of clinical lameness was 24.6%, which was 3.1 times greater, on average, than the prevalence estimated by the herd managers on each farm. The prevalence of lameness in first-lactation cows was 12.8% and prevalence increased on average at a rate of 8 percentage units per lactation. There was no association between the mean prevalence of clinical lameness and month of lactation (for months 1 to 10). Underconditioned cows had a higher prevalence of clinical lameness than normal or overconditioned cows. The prevalence of lameness was lower in freestall herds with sand stalls (17.1%) than in freestall herds with mattress stall surfaces (27.9%). Data indicate that the best 10th percentile of dairy farms had a mean prevalence of lameness of 5.4% with only 1.47% of cows with locomotion score = 4 and no cows with locomotion score = 5.

Microspheres containing insulin-like growth factor I for treatment of chronic neurodegeneration.

The therapeutic potential of peptide growth factors as insulin-like growth factor I (IGF-I) is currently under intense scrutiny in a wide variety of diseases, including neurodegenerative illnesses. A new poly(lactic-co-glycolide)-based microsphere IGF-I controlled release formulation for subcutaneous (SC) delivery has been developed by a triple emulsion method. The resulting microspheres displayed a mean diameter of 1.5microm, with an encapsulation efficiency of 74.3%. The protein retained integrity after the microencapsulation process as evaluated by circular dichroism and SDS-PAGE. The administration of IGF-I in microspheres caused at least a 30-fold increase in IGF-I mean residence time in rats and mice when compared with the conventional SC solution. Therefore, dosing can be changed from the conventional twice a day to once every 2 weeks. Therapeutic efficacy of this new formulation has been studied in mutant mice with inherited Purkinje cell degeneration (PCD). These mice show a chronic limb discoordination that is resolved after continuous systemic delivery of IGF-I. Normal motor coordination was maintained as long as IGF-I microsphere therapy is continued. Moreover, severely affected PCD mice, with marked ataxia, muscle wasting and shortened life-span showed a significant improvement after continuous IGF-I microsphere therapy as determined by enhanced motor coordination, marked weight gain and extended survival. This new formulation can be considered of great therapeutic promise for some chronic brain diseases.

Role of mast cells in the pathogenesis of postburn inflammatory response: reactive oxygen species as mast cell stimulators.

Thermal trauma has a direct effect on mast cells, triggering the secretion of histamine. This secretion leads to an enhanced xanthine oxidase activity and an increased production of reactive oxygen species (ROS), the latter being produced after burns through differing mechanisms. As ROS have been shown to have deleterious effects on cellular membranes, a lesion of the mast cell membrane could close the circle of autoinjury due to the vasoactive actions of mast cell mediators. Our studies were designed to assess the potentiality of ROS as stimulators of mast cell degranulation after burns by comparing two groups of rats treated, respectively, with SOD and saline solution after a scald injury. Plasma levels of tryptase and histamine were analyzed as markers of mast cell activity. A comparison of the mean increases of tryptase between baseline and 3-h postburn levels in the two groups shows significant differences (p < 0.001) (control: 0.13+/-0.04, SOD: 0.03+/-0.01). When comparing the mean increases between the baseline and 3 h postburn levels of histamine in the two groups, significant differences were also found (p < 0.001) (control group: 2.70+/-0.57. SOD group: 1.22+/-0.32). The lower levels of histamine and tryptase induced by SOD provides indirect evidence that ROS are involved in the process, causing the release of such mediators by mast cells, which may in turn suggest that ROS can act as stimulators of mast cell degranulation in burns.

Effect of gamma-sterilization process on PLGA microspheres loaded with insulin-like growth factor-I (IGF-I).

The influence of gamma-sterilization on the physicochemical properties of a controlled release formulation for the insulin-like growth factor-I (IGF-I) was investigated in this study. Recombinant human insulin-like growth factor-I (rhIGF-I) was efficiently entrapped in poly (D,L-lactide-co-glycolide) (PLGA) microspheres by water-in-oil-in-water (W/O/W) solvent evaporation technique. Microspheres were irradiated at a dose of 25kGy and evaluated by means of scanning electron microscopy (SEM) and differential scanning calorimetry (DSC). The stability of the released protein was investigated by circular dichroism (CD) and sodium dodecyl sulfate polyacrilamide gel electrophoresis (SDS-PAGE). No difference was noticed in microsphere size and morphology before and after irradiation. Drug loading remains essentially the same after the sterilization process. However, rhIGF-I aggregation was detected by electrophoresis. In addition, subtle changes in DSC pattern were noticed for irradiated microspheres. In vitro drug release from irradiated microspheres was also affected, showing an increased burst effect. From this results it can be concluded that gamma-sterilization process causes changes in the properties of rhIGF-I loaded microspheres.

[Multiple disc herniation after chiropractic manipulation]. / Herniación discal múltiple tras manipulación quiropráctica cervical.

We present a case of multiple cervical spine disc herniation in a previously healthy patient following chiropractic manipulation. The aim of this paper is to review the medical literature about the complications following spinal manipulation to emphasize the potential risks of this widely extended therapeutic procedure, performed in many cases by non-qualified personnel without medical training.

Long-Term Survival of Mycobacterium avium subsp. paratuberculosis in Fecal Samples Obtained from Naturally Infected Cows and Stored at -18°C and -70°C.

The objective was to evaluate the survival of Mycobacterium paratuberculosis (Map) in naturally infected dairy cows feces under long periods of freezing at -18°C and -70°C. Samples were collected from cows previously tested positive with serum ELISA or fecal culture, or with clinical signs of Johne's disease. Samples were stored at -18°C and/or -70°C and recultured in Herrold's egg yolk media every 3-6 months. A proportional odds mixed model was used for data analysis. Sixty nine fecal samples were stored for different periods between September 2002 and January 2005. Of these, 45 (65%) were stored at -18°C and 24 (35%) at -70°C. Average number of days between repeated culture dates was 98 and 84 for -18°C and -70°C, respectively. Median number of repeated cultures was 6 and 4 for samples stored at -18°C and -70°C, respectively. After adjusting for initial sample bacterial load, the effects of temperature or number of thawing and refreezing cycles on Map viability were not significant. The probability that a sample decreases from high to moderate-low bacterial load and from moderate-low to negative bacterial load was 13.5% per month. Although this study found gradual reduction of Map concentration in stored fecal samples through time, overall survival in -18°C can ease fecal samples management in laboratories with low-processing capacity or lack of -70°C freezer.

Facilitadores de la alianza terapéutica en la anorexia nerviosa: una mirada desde la diada terapeuta-paciente / Facilitators of therapeutic alliance in anorexia nervosa: a look from the therapist-patient dyad

Antecedentes: En el contexto terapéutico de pacientes con anorexia nerviosa, es relevante el establecimiento de la alianza terapéutica (AT). Objetivo: Describir los aspectos identificados como facilitadores del logro de una AT positiva desde la perspectiva de pacientes con anorexia nerviosa y sus respectivas terapeutas. Método: Estudio exploratorio, descriptivo-relacional realizado con metodología cualitativa, cuyo análisis de datos se basó en la Grounded Theory, incluyéndose a dos pacientes anorécticas con sus respectivas terapeutas. Resultados: Las pacientes y sus terapeutas valoraron los siguientes parámetros, respectivamente: 1. Ambiente emocional: la incondicionalidad, el interés genuino y la confianza versus el no enjuiciamiento y mayor disponibilidad; 2. Conductas y actitudes deseables (en la terapeuta): flexibilidad, libertad para hablar y la disponibilidad, (en las pacientes): la necesidad de cambiar y tener recursos; 3. Técnicas valoradas: terapia centrada en recursos (o capacidades), co-participación con el tratamiento, conocer testimonios de otras pacientes, hablar libremente con empatía, chequear constantemente el tratamiento y responsabilizar a la paciente de su terapia. Surge un modelo de facilitadores de la AT que incluye subsistema paciente, subsistema terapeuta, atmósfera relacional y espacio terapéutico con sus características particulares. Conclusiones: La generación de una buena AT es un factor destacable en el éxito del proceso terapéutico que implica una relación consciente y una aceptación recíproca, integrada por las influencias de la díada terapeuta/paciente.

Background: The settlement of a therapeutic alliance (TA) is relevant within the therapeutic context of patients suffering from anorexia nervosa. Objective: To describe the aspects identified as facilitators in order to achieve a positive therapeutic alliance from the perspective of anorexic patients and their a positive therapeutic alliance from the perspective of anorexic patients and their therapists. Method: It was an exploratory, relational-descriptive and qualitative study and its data analysis was based in the Grounded Theory, including two anorectic patients and their in the Grounded Theory, including two anorectic patients and their therapists. Results: Both, patients and therapists valued the following parameters, respectively: 1. Emotional environment: unconditional genuine interest and confidence versus non judgment and higher availability; 2. Desirable behaviors and attitudes (in the therapist): flexibility, freedom of speech and availability, (in patients): to change and to have resources; 3. Valued techniques: centered in resources, co-participation in the treatment, to know testimonies of other patients versus focalization in skills, emphatic freedom of speech, to check the treatment constantly and to make the patient responsible of her therapy. A model of TA facilitators emerges that includes patient subsystem, therapist subsystem, relational atmosphere and therapeutic space with their particular characteristics. Conclusions: The generation of a good TA is a remarkable factor in the success of the therapeutic process that implies a conscious relationship and a reciprocal acceptation integrated by the influences of the therapist/patient dyad.

Neglected traumatic posterior dislocations of the shoulder: controversies on indications for treatment and new CT scan findings.

We report seven missed traumatic posterior dislocations of the shoulder in six patients. In all seven shoulders, anteroposterior radiographs did not provide the diagnosis in the emergency room after the trauma (epileptic seizure in four patients) and diagnosis was delayed for at least 24 h. The final diagnosis was reached by clinical suspicion and computed tomography (CT) scan of the seven shoulders. Two shoulders were treated by closed reduction and three were treated by closed reduction and percutaneous pinning, although four of these five shoulders presented a defect in the humeral head involving 20%-25% of the articular surface. Two shoulders dislocated for more than 6 months were treated according to Mc Laughlin's technique modified by Hawkins instead of an arthroplasty. At a minimum follow-up of 2 years and 2 months, the functional results according to Hawkins were good in all seven shoulders. There was no recurrence of the dislocation in any patient. Radiographs showed mild degenerative changes. The establishment of indications for treatment, based on the proportion of articular surface of the humeral head involved and the time of evolution of the dislocation, needs more clinical or experimental evidence. In epileptic patients, strict control of medication is of the utmost importance.

[Asymmetric crying facies syndrome]. / Síndrome de facies asimétrica con el llanto.

We report four cases with syndrome of asymmetric crying facies, analyzing particularly the etiology, embryology, and incidence of the congenital hypoplasia of depressor anguli oris muscle. In one of the cases, with multiple malformations, the patient had an abnormal karyotype, 47,XX, +i(18p). We stress the high incidence of associations with congenital malformations (eight fold the general population) and more specifically with congenital heart disease, musculoskeletal, and genito-urinary defects. The diagnosis of MDAO agenesis is basically clinic, being as differential diagnosis the paralysis of the 7th cranial nerve, defining it with electrophysiological techniques.

Severe life-threatening cholera associated with blood group O in Peru: implications for the Latin American epidemic.

A household survey in 1991, at the onset of the Latin American cholera epidemic, investigated high attack rates in Trujillo, Peru, and determined the association between blood group O and severe cholera. Of 463 persons in 69 households, 173 (37%) reported diarrhea, 21% required rehydration therapy, and 4% were hospitalized; these treatment requirements greatly exceeded estimates based on other populations. Elevated vibriocidal or antitoxic antibody titers were present in 52% of 321 from whom serum was obtained; 73% were blood group O. Blood group O was strongly associated with severe cholera: Infected persons had more diarrheal stools per day than persons of other blood groups, were more likely to report vomiting and muscle cramps, and were almost eight times more likely to require hospital treatment. Since prevalence of blood group O in Latin America may be the world's highest, estimates of treatment requirements should be increased to prevent unnecessary deaths.

Waterborne transmission of epidemic cholera in Trujillo, Peru: lessons for a continent at risk.

The epidemic of cholera that began in Peru in January, 1991, marked the first such epidemic in South America this century. Subsequently, over 533,000 cases and 4700 deaths have been reported from nineteen countries in that hemisphere. We investigated the epidemic in Trujillo, the second largest city in Peru. Trujillo's water supply was unchlorinated and water contamination was common. Suspect cholera cases were defined as persons presenting to a health facility with acute diarrhoea between Feb 1, and March 31, 1991. We studied a cohort of 150 patients who had been admitted to hospital and conducted a matched case-control study with 46 cases and 65 symptom-free and serologically uninfected controls; we also carried out a water quality study. By March 31, 1991, 16,400 cases of suspected cholera (attack rate 2.6%), 6673 hospital admissions, and 71 deaths (case-fatality rate 0.4%) had been reported in the province of Trujillo. 79% of stool cultures of patients with diarrhoea presenting to a single hospital yielded Vibrio cholerae O1. In the case-control study, drinking unboiled water (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.3-7.3), drinking water from a household water storage container in which hands had been introduced into the water (4.2, 1.2-14.9), and going to a fiesta (social event) (3.6, 1.1-11.1) were associated with illness. The water quality study showed progressive contamination during distribution and storage in the home: faecal coliform counts were highest in water from household storage containers and lowest in city well water. V cholerae O1, biotype El Tor, serotype Inaba, was isolated from three city water samples. Cholera control measures in Trujillo should focus on treatment of water and prevention of contamination during distribution and in the home. Trujillo's water and sanitation problems are common in South America; similar control measures are needed throughout the continent to prevent spread of epidemic cholera.

PIP: Researchers conducted various studies simultaneously in Trujillo. Peru (population 626,456) in March 1991 to set up a cholera surveillance system and to determine clinical characteristics of suspect cholera cases, modes of transmission, and municipal water quality during distribution and storage. These studies occurred after the population received information on how to avoid cholera. The cholera attack rate for the 1st 2 months of the epidemic stood at 2.6% (16,400 cases). The case fatality rate was 0.4% (71 deaths). The median hours between onset of symptoms and arrival at Belen hospital were 12 hours. 56% of the patients were treated with oral rehydration solution before coming to the hospital and 13% with homemade rehydration solution. Laboratory personnel isolated toxigenic nonhemolytic Vibrio cholera 01, biotype El Tor, serotype Inaba from the rectal swabs of 79% of cholera patients. None of the hospital patients died. 29% of controls from the case control study claimed to not have witnessed a personal or household attack of diarrhea recently, yet their vibrocidal antibody titers indicated a recent cholera infection. 58% of cases drank unboiled water within 3 days of falling ill compared to only 28% of controls (matched odds ratio [OR] 3.1; p.05). Other significant risk factors (p.05) were drank water from container also used to dip hands (OR 4.2) and attended a fiesta (OR 3.6). There were significantly more total coliforms in water containers than tap water and municipal water (mean 794 vs. 6 and 1 respectively; p.05). The same was true for fecal coliforms (20 vs. 2 and 1 respectively). In conclusion, the drinking water was contaminated with V. cholera. Eventually the city should eliminate cross connections, provide continuous supplies of water at high pressure, and improve the sewage system.