The level of agreement between the numerical rating scale and visual analogue scale for assessing pain intensity in adults with chronic pain.

The numerical rating scale and visual analogue scale are used to quantify pain intensity. However, it has not yet been explored whether these scores are interchangeable in adults with chronic pain. Data from the prospective multicentre cross-sectional INTERVAL study were used to evaluate the one-dimensionality and agreement between numerical rating scale scores and visual analogue scale scores in adults with chronic pain. Pain intensity scores using the numerical rating scale and visual analogue scale were provided by 366 patients with chronic pain for current, average, minimal and maximal pain. To evaluate whether pain intensity scales are completed in accordance with each other, the proportion of patients who satisfied the following condition was calculated: minimal pain intensity ≤ maximal pain intensity. A factor analysis confirmed the one-dimensionality of the pain measures. A significant difference was found between numerical rating scale and visual analogue scale scores for average, current, minimum and maximum pain. Intra-class correlation coefficient estimates ranged from 0.739 to 0.858 and all measures failed to show sufficient and acceptable agreement at the 95% level. The strength of agreement between pain severity categories was classified as 'moderate' for average and minimal pain and 'substantial' for current and maximal pain. The proportion of patients who scored minimal pain ≤ maximal pain was 97.5% for the numerical rating scale and 89.5% for the visual analogue scale. This study failed to show an acceptable agreement between the numerical rating scale and visual analogue scale when pain intensity was rated by adults with chronic pain, despite showing both scales measure the same information.

Optimizing Trehalose-Based Quantification of Live Eggs in Potato Cyst Nematodes (Globodera rostochiensis and G. pallida).

Integrated management of potato cyst nematodes (PCN; Globodera rostochiensis and G. pallida) relies heavily on the determination of cyst population densities in soil as well as the viability of the eggs inside the cysts. This study aimed to optimize a quantitative method to determine the number of viable eggs of PCN based on trehalose present in live eggs. Trehalose was extracted from cysts and from a dilution series of eggs and quantified. More trehalose was detected when cysts were crushed than when left intact. Reaction volumes were adapted to the number of eggs because small reaction volumes hampered an accurate extraction of trehalose. A maximum of 10.5 eggs/µl of reaction volume should be used to obtain a significant linear relationship between detected trehalose content and egg numbers. The sensitivity of the trehalose-based method was evaluated by determining the lowest egg detection limit and was defined as five viable eggs. The reliability of this method was tested by comparing efficacy with that of two commonly used assays, visual assessment and hatching test. The trehalose-based method gave viability results similar to those of the visual assessment, which is time consuming, requires trained personnel, and can involve some subjectivity. The hatching test identified fewer viable eggs than the other two methods. In addition, the viability of dead eggs (heated and naturally dead) was tested. No false-positive results (dead eggs declared viable) were obtained with the trehalose-based method. The robustness of the test was demonstrated by measuring the viability of eggs of PCN in different experiments repeated in time. The viability assessment method based on trehalose proved to be an objective as well as sensitive, reliable, robust, fast, and cheap technique for assessing the number of viable eggs in PCN cysts.

First Report of the Dagger Nematode Xiphinema diversicaudatum in Citrus Orchards in Morocco.

Xiphinema species are migratory ectoparasitic nematodes that feed on an extensive range of hosts, and several species are vectors of nepoviruses. In May 2012, during a survey of the citrus-growing areas in the Gharb region of Morocco, several Xiphinema nematodes were detected in three locations: Kénitra (INRA, plot P1), Sidi Kacem, and Sidi Slimane. Samples were taken 30 cm deep at 50 cm distance from the tree trunks, in 40-year-old orange groves planted with the variety Maroc Late, grafted on rootstocks of Sour Orange and Citrange Carrizo. The trees showed yellowing of leaves, reduced tree vigor, and swellings at the tips of the roots. There were no weeds or grasses in the sampled area. Nematodes were extracted from soil using an automated centrifuge for extracting free-living nematode stages (2) and identified morphologically and by sequencing. All specimens were identified as Xiphinema diversicaudatum based on key morphological features from females and males. The average measurements of six females were: body length 4.1 mm, body width 60.4 µm, odontostylet 133.5 µm, odontophore 64.0 µm, spear 197.5 µm, tail length 45 µm, body width at anus 31 µm, and vulval position 48%. The females had two genital branches of similar length and structure, which contained a pseudo-Z differentiation. The average measurements of four males were: body length 4.3 mm, body width 51 µm, odontostylet 139 µm, odontophore 70 µm, spear 209 µm, tail length 45 µm, body width at anus 35 µm. To confirm the morphological identification, molecular observations were made. DNA was extracted from one nematode of each location. The D3 expansion region of the 26S rRNA gene was amplified using the primers D3A (5'-GACCCGTCTTGAAACACGGA-3') and D3B (5'-TCGGAAGGAACCAGCTACTA-3') (1). The PCR products were purified and sequenced (Macrogen, Inc., Seoul, Korea). All sequences obtained (GenBank Accession Nos. KF057879, KF057880, and KF057881) were compared with sequences available from the GenBank database including several species of Xiphinema. This comparison revealed a sequence similarity of 99 to 100% with X. diversicaudatum. Morphological and molecular identification demonstrated that the isolates of dagger nematodes from three citrus growing areas in Gharb belonged to X. diversicaudatum. An average of six X. diversicaudatum per 100 cm3 soil were found. This is the first report of this species in Morocco. X. diversicaudatum can transmit Arabis mosaic and Strawberry latent ringspot viruses (3). Arabis mosaic virus is of great economic importance in viticulture as it is associated with grapevine fanleaf degeneration disease, together with Grapevine fan leaf virus transmitted by X. index (4). As vineyards are planted amid citrus orchards in the Gharb region, particular attention should be given to this nematode, especially to the risk of its spread by soil. Our finding of X. diversicaudatum in a citrus orchard does not necessarily imply that X. diversicaudatum causes damage in citrus. However, its presence indicates that this nematode species can survive in this environment from where it could spread to other, more susceptible, crops. References: (1) L. Al-Banna et al. Mol. Phylogenet. Evol. 7:94, 1997. (2) G. Hendrickx. Nematologica 41:30, 1998. (3) J. Hübschen et al. Eur. J. Plant Pathol. 110:779, 2004. (4) A. Marmonier et al. J. Plant Pathol. 92:275, 2010.

Spinal cord stimulation modulates cerebral function: an fMRI study.

INTRODUCTION: Although spinal cord stimulation (SCS) is widely used for chronic neuropathic pain after failed spinal surgery, little is known about the underlying physiological mechanisms. This study aims to investigate the neural substrate underlying short-term (30 s) SCS by means of functional magnetic resonance imaging in 20 patients with failed back surgery syndrome (FBSS). METHODS: Twenty patients with FBSS, treated with externalized SCS, participated in a blocked functional magnetic resonance imaging design with stimulation and rest phases of 30 s each, repeated eight times in a row. During scanning, patients rated pain intensity over time using an 11-point numerical rating scale with verbal anchors (0 = no pain at all to 10 = worst pain imaginable) by pushing buttons (left hand, lesser pain; right hand, more pain). This scale was back projected to the patients on a flat screen allowing them to manually direct the pain indicator. To increase the signal-to-noise ratio, the 8-min block measurements were repeated three times. RESULTS: Marked deactivation of the bilateral medial thalamus and its connections to the rostral and caudal cingulate cortex and the insula was found; the study also showed immediate pain relief obtained by short-term SCS correlated negatively with activity in the inferior olivary nucleus, the cerebellum, and the rostral anterior cingulate cortex. CONCLUSIONS: Results indicate the key role of the medial thalamus as a mediator and the involvement of a corticocerebellar network implicating the modulation and regulation of averse and negative affect related to pain. The observation of a deactivation of the ipsilateral antero-medial thalamus might be used as a region of interest for further response SCS studies.

Changed cervical kinematics after fusion surgery.

PURPOSE: Analyzing and comparing the range of motion and movement pattern of subjects who underwent an anterior cervical fusion using trabecular metal with control subjects. METHODS: Three-dimensional kinematics of planar active axial rotation and active lateral bending of 50 experimental and 41 control subjects were registered by means of an electromagnetic tracking system. RESULTS: Comparing the experimental group with the control group reveals that the range of the main motion component differs significantly (p < 0.01) during the active axial rotation and lateral bending movement. During active axial rotation, the coupled lateral bending motion component also differs between both groups. The root mean square value of the jerkiness (derivative of the acceleration) and de deviation from the 6-polynomial smoothed function of the main as well as the coupled motion component express the qualitative aspects of kinematics and are significantly different between the experimental and the control group for both movements (p < 0.05). CONCLUSIONS: Subjects who have an anterior cervical fusion with trabecular metal show significant quantitative as well as qualitative differences in cervical kinematics during active axial rotation and lateral bending compared to control subjects.

First Report of the Cereal Cyst Nematode Heterodera latipons on Wheat in Morocco.

From May to June 2011, during a survey of the wheat-growing areas in Meknes in the Saïs Region of Morocco, several cyst nematode populations were detected. Sampling was performed 1 month before wheat (Triticum durum) harvest, in fields showing patches of stunted plants. Plants were growing poorly, had chlorotic lower leaves, and a reduced numbers of ears. Root systems were short and had a bushy appearance because of increased secondary root production. No cysts were visible on the roots, but were found in the soil. Cysts were collected from soil on 200-µm sieves by the modified Cobb decanting and sieving method (1) and identified by morphology and internal transcribed spacer (ITS)-rDNA sequencing. All isolates were identified as Heterodera avenae except the isolate from Aïn Jemâa. From the latter, key morphological features from cysts and second-stage juveniles (J2) were determined. The cysts (n = 10) had the following characteristics: bifenestrate vulval cone, body length without neck 590 µm (551 to 632 µm), body width 393 µm (310 to 490 µm), neck length 75 µm (65 to 90 µm), fenestra length 64 µm (60 to 72 µm) and width 21 µm (18 to 25 µm), underbridge length 96 µm (85 to 115 µm), vulval slit length 8 µm (7 to 9 µm), vulva bridge width 27 µm (24 to 33 µm), and bullae absent. The J2s (n = 10) had the following characteristics: body length 445 µm (412 to 472 µm), body width 19 µm (19 to 21 µm), stylet length 24 µm (23 to 25 µm), four lateral lines, tail length 50 µm (46 to 54 µm), and hyaline terminal tail 28 µm (24 to 31 µm). Values of the morphological characters were within the range of H. latipons reported by Handoo (3). The bifenestrate cysts with a strong underbridge and no bullae and J2 with a tail length greater than 40 µm, a stylet longer than 15 µm, and four incisures in the lateral field were typical for H. latipons. To confirm the identification, molecular observations were made. DNA was extracted from three juveniles from three different cysts separately (4). The ITS-rDNA region was amplified using the primers 5'-CGT AAC AAG GTA GCT GTA G-3' and 5'-TCC TCC GCT AAA TGA TAT G-3' as described by Ferris et al. (2). This resulted in a 1,040-bp DNA fragment. The PCR-products were purified and sequenced (Macrogen, Inc., Seoul, Korea). All sequences obtained (GenBank Accession Nos. per cyst: JQ319035, JQ319036, and JQ319037) were compared with sequences available from the GenBank database ( www.ncbi.nlm.nih.gov ), including several species of Heterodera. This comparison revealed a sequence similarity of 97 to 99% with H. latipons and 89% or lower with any other species of Heterodera. Morphological and molecular identification demonstrated that the population of cyst nematodes from a wheat field in Aïn Jemâa, Morocco was H. latipons. In the patches with poor growing plants, 65 cysts per 100 cm3 soil were found. To our knowledge, this detection represents a new record of H. latipons. Since the nematode can cause considerable damage to wheat, one of the main cereals produced in Morocco, care should be taken to prevent the spread to other regions. References: (1) K. R. Barker. Page 19 in: An Advanced Treatise on Meloidogyne. Vol II. Methodology. C. C. Carter and J. N. Sasser, eds. North Carolina State University Graphics, Raleigh, 1985. (2) V. R. Ferris et al. Fundam. Appl. Nematol. 16:177, 1993. (3) Z. A. Handoo. J. Nematol. 34:250, 2002. (4) M. Holterman et al. Mol. Biol. Evol. 23:1792, 2006.

Accelerated HIV testing for PMTCT in maternity and labour wards is vital to capture mothers at a critical point in the programme at district level in Malawi.

Round the clock (24 hours×7 days) HIV testing is vital to maintain a high prevention of mother to child transmission (PMTCT) coverage for women delivering in district health facilities. PMTCT coverage increases when most of the pregnant women will have their HIV status tested. Therefore routine offering of HIV testing should be integrated and seen as a part of comprehensive antenatal care. For women who miss antenatal care and deliver in a health facility without having had their HIV status tested, the labour and maternity ward could still serve as other entry points.

Intraspecific variability of Steinernema feltiae strains from Cemoro Lawang, eastern Java, Indonesia.

Four strains of Steinernema feltiae from Eastern Java, Indonesia were characterized based on morphometric, morphological and molecular data. In addition, their virulence against last instar Tenebrio molitor and heat tolerance was tested. Infective juvenile have a mean body length ranging from 749 to 792 microm. The maximum sequence difference among the four strains was 7 bp (8.8%) in the ITS and 2 bp (0.3%) in D2D3 regions of the rDNA. All the strains are not reproductively isolated and can reproduce with European strain S. feltiae Owiplant. The lowest LC50 was observed for strain SCM (373) and the highest for S. feltiae strain Owiplant (458) IJs/40 T. molitor. All four strains showed relatively better mean heat tolerance when compared with S. feltiae Owiplant, both in adapted and non-adapted heat tolerance experiments.

Comparison of the effect of anterior and posterior neurosurgical treatment for cervical spondylotic myelopathy: a clinical outcome.

Cervical degenerative disease is the most common cause of acquired disability in patients over the age of 50. The incidence of cervical spondylotic myelopathy (CSM) is increasing with aging of the population. Surgical decompression is indicated for severe CSM. There is, however, insufficient evidence to prefer anterior over posterior surgical decompression technique for CSM. Our purpose was to identify groups of patients that would benefit from a chosen surgical approach with a better clinical outcome. We conducted a retrospective analysis of patients operated for CSM between 2007 and 2011. Patients were assessed according to the Nurick grading system. Preoperative and postoperative clinical details and MR imaging were analyzed. Treatment consisted of either anterior cervical discectomy with fusion (ACDF) or laminectomy without fusion. Over a period of 4 years, 90 patients were included. The mean age of patients was 64.5 ± 1.3 years. Of 90 included patients, 42 patients were treated with ACDF and 48 with laminectomy. Mean total Nurick grade recovery rate (NGRR) was 29.6% with 31.2% in ACDF and 27.7% in laminectomy. Mid-sagittal diameter of the cervical canal measured on MRI-T2 increased significantly more with laminectomy (4.4 mm) than ACDF (2.2 mm) (p < 0.001). The presence of preoperative spasticity or quadriparesis or a multilevel compression indicated a higher recovery on the Nurick scale. Surgical treatment of CSM leads to a significant improvement of the functional neurological status of the patient as well as an increase in the diameter of the cervical canal. No significant difference in Nurick recovery was found between ACDF and laminectomy indicating that clinical decision-making in our series was adequate. We were able to demonstrate that even severely disabled patients have a good chance of neurologic recovery after surgical treatment for CSM.

Apraxia of speech and cerebellar mutism syndrome: a case report.

BACKGROUND: Cerebellar mutism syndrome (CMS) or posterior fossa syndrome (PFS) consists of a constellation of neuropsychiatric, neuropsychological and neurogenic speech and language deficits. It is most commonly observed in children after posterior fossa tumor surgery. The most prominent feature of CMS is mutism, which generally starts after a few days after the operation, has a limited duration and is typically followed by motor speech deficits. However, the core speech disorder subserving CMS is still unclear. CASE PRESENTATION: This study investigates the speech and language symptoms following posterior fossa medulloblastoma surgery in a 12-year-old right-handed boy. An extensive battery of formal speech (DIAS = Diagnostic Instrument Apraxia of Speech) and language tests were administered during a follow-up of 6 weeks after surgery. Although the neurological and neuropsychological (affective, cognitive) symptoms of this patient are consistent with Schmahmann's syndrome, the speech and language symptoms were markedly different from what is typically described in the literature. In-depth analyses of speech production revealed features consistent with a diagnosis of apraxia of speech (AoS) while ataxic dysarthria was completely absent. In addition, language assessments showed genuine aphasic deficits as reflected by distorted language production and perception, wordfinding difficulties, grammatical disturbances and verbal fluency deficits. CONCLUSION: To the best of our knowledge this case might be the first example that clearly demonstrates that a higher level motor planning disorder (apraxia) may be the origin of disrupted speech in CMS. In addition, identification of non-motor linguistic disturbances during follow-up add to the view that the cerebellum not only plays a crucial role in the planning and execution of speech but also in linguistic processing. Whether the cerebellum has a direct or indirect role in motor speech planning needs to be further investigated.

Diversity in pathogenicity of Steinernema carpocapsae and its symbiotic bacterium for Spodoptera spp.

Pathogenicity of five isolates of Steinernema carpocapsae (GER: Germany, BUW: Becker Underwood, KOP: Koppert, CZ: Czech Republic, BEL: Belgium) were tested against the fourth instar larvae of the cotton leaf worm, Spodoptera littoralis and the beet armyworm, Spodoptera exigua (Lepidoptera: Noctuidae) at different concentrations (0, 5, 10, 25, and 50 infective juveniles/cm2) in Petri dishes (9 cm dia.) lined with filter paper. Results obtained after 48 h exposure indicated that the pathogenicity varied in time, dose of application and host species. On S. littoralis, KOP, BUW, CZ and GER were more virulent than BEL, whereas all isolates showed 100% control of S. exigua after 72 h. The LC50 values of all five isolates were lower for S. exigua than for S. littoralis. Among the isolates tested, KOP showed the lowest LC50 value in both S. exigua (3.84) and S. littoralis (4.44 infective juveniles). To further check the pathogenicity, the symbiotic bacterium of S. carpocapsae, Xenorhabdus nematophilus, was isolated from Galleria mellonella 30 h after its infection with the nematode. Ten microlitres of 50 mM phosphate buffer containing 0, 10, 100, 1000, or 10,000 cfu were injected into the haemocel of fifth instar larvae of S. exigua. Significant differences in mortality of S. exigua larvae were observed 96 h post-injection with different bacterial doses. Cell-free filtrates of X. nematophilus were isolated from a bacterial suspension; 10 microlitres of filtrates were injected into fifth instars of S. exigua. All larvae had died 72 h post-injection. To check the insecticidal capability of X. nematophilus via oral uptake, suspensions of bacteria at concentrations of 0, 1010, 109, and 108 cfu/ml were sprayed onto tomato leaves cv. Moneymaker infected with fourth instar larvae of S. exigua. None of the larvae were killed after 24 h. Finally, we tested the virulence of selected isolates of S. carpocapsae (KOP, BUW, and BEL) in the glass-house on tomato plants infested with S. exigua or S. littoralis larvae. Nematodes were sprayed at a concentration of 2.5 billion/ha. After 48 h isolate KOP caused higher mortality (99% and 85% on S. exigua and S. littoralis, respectively), than other tested isolates. S. carpocapsae isolates BUW and BEL caused 61-65% mortality on S. exigua and S. littoralis, respectively. As most of the isolates had the same origin, viz. the ALL strain, these results demonstrate differences in pathogenicity of the production.

Detection of malignant cells in serous body fluids by counting high-fluorescent cells on the Sysmex XN-2000 hematology analyzer.

INTRODUCTION: The body fluid mode of the Sysmex XN-2000 hematology analyzer differentiates cells into mononuclear and polymorphonuclear white blood cells (WBC) and high-fluorescent cells (HFC). The aim of this study was to evaluate the performance of the HFC count for detecting malignant cells in serous body fluids. METHODS: Two-hundred and thirty serous fluids were analyzed on the Sysmex XN body fluid mode. HFC were measured as relative count (HFC/100 WBC) and absolute count (HFC/µL). All samples were microscopically screened on cytospin slides for the presence of malignant cells. RESULTS: Malignant cells were found by microscopic examination in 49 of 230 samples (21.3%). Malignant samples contained significantly higher percentages (10.2 vs. 2.6/100 WBC) and absolute numbers (65 vs. 10/µL) of HFC than nonmalignant samples (P < 0.001). Areas under the ROC curve for relative and absolute HFC count were 0.69 and 0.77, respectively. A cutoff level of ≥17 HFC/µL showed the best performance to predict malignancy, with 88% sensitivity and 61% specificity. CONCLUSION: As serous body fluids will be more analyzed on automated analyzers in the future, HFC count can be a useful tool to select samples for microscopic review. Microscopic evaluation should be performed if HFC values are above a certain threshold (e.g. ≥17 HFC/µL) or in case of clinical suspicion of malignancy.

Use of fluorescent dyes in the determination of adherence of human leucocytes to endothelial cells and the effect of fluorochromes on cellular function.

A number of supravital fluorochromes are available to study leucocyte functions in vitro and in vivo. The fluorescein ester most widely used, fluorescein diacetate, has the disadvantage of rapid cellular efflux, whereas more recently developed fluorescent probes do not exhibit this inconvenient trait. However, their effect on cellular functions has not been thoroughly investigated in humans. In this study, we describe a simple and rapid fluorometric method for measuring cell adhesion to endothelium, comparing 5 different fluorochromes. Furthermore, we evaluated the effect of fluorescent dye labelling (with CFDA, CFSE, BCECF-AM, calcein-AM or DiI), on various cell functions, including, apart from adhesion, lymphocyte proliferation, granulocyte chemotaxis and superoxide production. calcein-AM and DiI proved to be the fluorochromes with the least effect on cellular function. BCECF-AM did not interfere with lymphocyte proliferation, but exhibited some influence on superoxide production and chemotaxis of granulocytes. CFDA showed a detrimental effect on both lymphocyte and granulocyte functions whereas CFSE gave intermediate results. In the adhesion assay, calcein-AM, CFSE and DiI performed comparably well. Since labelling with C12-DiI was homogeneous, this probe was also appropriate for the adhesion test, although somewhat higher background staining was present. We conclude that the fluorochromes are powerful tools when analysing the adhesion of human leucocytes to endothelial cells. However, since fluorochrome labelling can interfere with other cellular functions, the fluorescent probe has to be carefully chosen with regard to the cell type and function to be studied.

Detection of hypodense eosinophils by Percoll multilayer density gradient centrifugation in subjects with normal or slightly elevated eosinophilia. Poor reproducibility and eosinophils of density < 1.077 g/ml.

In patients with marked hypereosinophilia 'hypodense' and 'normodense' eosinophils have been found after density gradient centrifugation. Subsequently this terminology has also been used in studies of patients with milder eosinophilia. However, in these cases the differentiation between normo- and hypodense eosinophils was less clear. This might be due to the high imprecision of the test of density gradient centrifugation, as demonstrated in the first part of this study: the mean within-assay variance of the number of eosinophils in the different density layers was 35%. It was calculated that the test must be performed eight times to obtain an estimate of the true mean for the individual patient. In the second part of the study, the absolute number of 'hypodense eosinophils' in groups of patients with asthma (adults and children) and rheumatoid arthritis (adults) were compared to normal controls. Although a difference in the absolute number of hypodense eosinophils between groups of patients and controls could be demonstrated, the high imprecision of the test of density gradient centrifugation suggested that the technique used was not useful in an individual with normal or slightly elevated eosinophils in the peripheral blood.

Levamisole in ascariasis. A multicenter controlled evaluation.

An analysis is presented of 10 clinical studies from various countries where levamisole 50--150 mg was compared to pyrantel, piperazine, and placebo in a total of 1,734 patients, mostly children (levamisole: 830, controls: 904), suffering from ascariasis either as a single infection or usually mixed with other nematode infections. Degree of infection and efficacy of treatment were determined by quantitative coproparasitological methods. Levamisole produced higher cure rates (91%) and egg reduction rates (98%) than pyrantel, piperazine, or placebo. The efficacy of levamisole was unrelated to the patients' sex and age, the severity of infection, the presence of another worm infection, the type of associated worm infections, or the egg-counting technique. The overall incidence of reported adverse reactions was lower after levamisole than after piperazine, pyrantel or placebo; abdominal pain and headache, the most frequent complaints after levamisole, were related to the initial severity of ascariasis. Follow-up examinations 6 months after treatment suggested that levamisole might delay reinfection.

Bone Dysplasia as a Key Feature in Three Patients with a Novel Congenital Disorder of Glycosylation (CDG) Type II Due to a Deep Intronic Splice Mutation in TMEM165.

Three patients belonging to two families presented with a psychomotor-dysmorphism syndrome including postnatal growth deficiency and major spondylo-, epi-, and metaphyseal skeletal involvement. Other features were muscular hypotrophy, fat excess, partial growth hormone deficiency, and, in two of the three patients, episodes of unexplained fever. Additional investigations showed mild to moderate increases of serum transaminases (particularly of aspartate transaminase (AST)), creatine kinase (CK), and lactate dehydrogenase (LDH), as well as decreased coagulation factors VIII, IX, XI, and protein C. Diagnostic work-up revealed a type 2 serum transferrin isoelectrofocusing (IEF) pattern and a cathodal shift on apolipoprotein C-III IEF pointing to a combined N- and O-glycosylation defect. Known glycosylation disorders with similar N-glycan structures lacking galactose and sialic acid were excluded. Through a combination of homozygosity mapping and expression profiling, a deep intronic homozygous mutation (c.792 + 182G>A) was found in TMEM165 (TPARL) in the three patients. TMEM165 is a gene of unknown function, possibly involved in Golgi proton/calcium transport. Here we present a detailed clinical description of the three patients with this mutation. The TMEM165 deficiency represents a novel type of CDG (TMEM165-CDG). This disorder enlarges the group of CDG caused by deficiencies in proteins that are not specifically involved in glycosylation but that have functions in the organization and homeostasis of the intracellular compartments and the secretory pathway, like COG-CDG and ATP6V0A2-CDG.

Adjunctive steroid treatment in acute bacterial meningitis. "To do or not to do: that is the question".

In experimental bacterial meningitis, adjunctive steroid treatment reduces the inflammatory response in the cerebrospinal fluid and subarachnoidal space, thereby improving neurological outcome. The clinical application of this concept was sustained by the European Dexamethasone Study which showed a beneficial effect of dexamethasone on neurological outcome and mortality in adult patients with bacterial--in particular S. pneumoniae-- meningitis. A thorough analysis of the data of this landmark trial as well as results from more recent trials in children and adults with bacterial meningitis worldwide do not support the use of adjunctive dexamethasone in meningitis. Moreover, dexamethasone may have detrimental effects with regard to antibiotic efficacy and late severe neurological complications. Until further data about steroid use in bacterial meningitis becomes available, we propose that dexamethasone therapy in this setting should be abandoned.