Screening for chronic hepatitis B and C in migrants from Afghanistan, Iran, Iraq, the former Soviet Republics, and Vietnam in the Arnhem region, The Netherlands.

Migrants born in hepatitis B virus (HBV) and hepatitis C virus (HCV) endemic countries are at increased risk of being infected with these viruses. The first symptoms may arise when liver damage has already occurred. The challenge is to identify these infections early, since effective treatment has become available. In 2011 we conducted a screening project in first-generation migrants (FGMs) born in Afghanistan, Iran, Iraq, the former Soviet Republics, and Vietnam and living in Arnhem and Rheden. All participants were offered free blood screening for HBV and HCV. In total 959 participants were tested, with the country of origin known for 927, equating to 28·7% of all registered FGMs from the chosen countries. Nineteen percent (n = 176) had serological signs of past or chronic HBV infection and 2·2% (n = 21) had chronic HBV infection. The highest prevalence of chronic HBV infection was found in the Vietnamese population (9·5%, n = 12). Chronic HCV was found in two persons from the former Soviet Republics and one from Vietnam. Twenty-four percent (n = 5) of the newly identified patients with chronic HBV and one of the three patients with chronic HCV received treatment. Three of the patients, two with HCV and one with HBV, already had liver cirrhosis. The highest (9·5%) HBV prevalence was found in FGMs from Vietnam, indicating a high need for focusing on that particular immigrant population in order to identify more people with silent HBV infection. The fact that three patients already had liver cirrhosis underlines the necessity of early identification of HBV and HCV infection in risk groups.

Hepatitis B prevalence in the Turkish population of Arnhem: implications for national screening policy?

Despite the increased prevalence of hepatitis B and C in most migrant groups in The Netherlands, a national screening policy for these infections is not available. In order to estimate the prevalence of hepatitis B and C in the largest group of first-generation migrants (FGM) in The Netherlands, we conducted a screening project in the Turkish community of Arnhem. In a separate project we identified patients from the target population with chronic hepatitis B and C from hospital records (1990-2008). Educational meetings concerning hepatitis were organized, with all participants being offered a blood screening test. Participants were tested for hepatitis B surface antigen (HBsAg), antibodies to hepatitis B core antigen (anti-HBc) and antibodies to hepatitis C virus (anti-HCV). In total 709 persons were tested, a complete dataset was available for 647 patients. We found that 3·0% and 0·4% of Turkish FGM aged >24 years in Arnhem had active hepatitis B, defined as HBsAg positive, and tested positive for anti-HCV, respectively. The hospital records revealed another 32 patients, 28 with hepatitis B and four with hepatitis C representing 0·7% for hepatitis B and 0·1% for hepatitis C in relation to the total number of Turkish FGM in Arnhem. We believe that active hepatitis screening of FGM from Turkey should be part of the national health policy as it will benefit the individual and public health.

Clostridium glycolicum isolated from a patient with otogenic brain abscesses.

We describe a case of brain abscesses with gas formation following otitis media, for which the patient treated himself by placing clay in his ear. Several microorganisms, including Clostridium glycolicum, were cultured from material obtained from the patient. This is the first report of an infection in an immunocompetent patient associated with this microorganism.

The measurement of fatigue in patients with multiple sclerosis. A multidimensional comparison with patients with chronic fatigue syndrome and healthy subjects.

OBJECTIVE: To provide a multidimensional characterization of fatigue in patients with multiple sclerosis (MS). DESIGN: Cross-sectional design. Fifty patients with clinically definite MS were compared on the dimensions of fatigue with 51 patients with chronic fatigue syndrome (CFS) and 53 healthy subjects. RESULTS: Fourty-six percent of the patients with MS reported fatigue to be present at least once a week. Patients with MS and patients with CFS had significantly higher subjective fatigue severity scores than healthy subjects. Patients with MS and patients with CFS had significantly higher scores on measures of psychological well-being than healthy subjects. Patients with MS had scores similar to those of patients with CFS, except that patients with CFS had significantly higher somatization scores. High somatization scores reflect strong focusing on bodily sensations. Both groups of patients were significantly less active than the healthy subjects. The Kurtzke Expanded Disability Status Scale (EDSS) and the Beck Depression Inventory scores were not related to subjective fatigue severity. In patients with MS and in patients with CFS, subjective fatigue severity was related to impairment in daily life, low sense of control over symptoms, and strong focusing on bodily sensations. In CFS, but not in MS, evidence was found for a relationship between low levels of physical activity and attributing symptoms to a physical cause and between subjective fatigue severity and physical activity. CONCLUSIONS: Patients with MS experienced significant fatigue, which had a significant impact on daily functioning and was not related to depression on Expanded Disability Status Scale score. Psychological factors, such as focusing on bodily sensations and low sense of control play a role in the experience of fatigue in MS and CFS.

Physical activity in chronic fatigue syndrome: assessment and its role in fatigue.

This paper describes the assessment of physical activity in chronic fatigue syndrome (CFS) and investigated the following questions: Do patients with CFS have low levels of physical activity; is there a relationship between actual level of physical activity and fatigue; can self-report measures adequately assess actual level of physical activity; what is the role of cognitions with respect to physical activity; and are results with respect to physical activity specific to CFS? Three different types of activity measures were used: self-report questionnaires, a 12-day self-observation list, and a motion-sensing device (Actometer) which was used as a reference for actual activity level. Fifty-one patients with CFS, 50 fatigued patients with multiple sclerosis (MS), and 53 healthy subjects participated in this study. Although none of the self-report questionnaires showed high correlations with the Actometer, questionnaires that require simple ratings of specified activities were related to the Actometer and can be used as acceptable substitutes, in contrast to instruments that require general subjective interpretations of activity that had low or non-significant correlations with the Actometer. Actometer results showed that CFS patients and MS patients had similar activity levels and both groups were significantly less active than healthy subjects. Compared to MS patients, CFS patients were more likely to indicate that they had been less active than other persons they knew. Activities which patients expected to result in higher fatigue levels were less frequently performed. Patients with CFS had significantly higher scores on this measure than MS patients and healthy subjects. Low levels of physical activity were related to severe fatigue in CFS but not in MS. In conclusion, although CFS patients have similar low activity levels than MS patients, there are also important differences between both groups: in CFS cognitive factors are more prominently involved in producing the low activity levels than in MS and in CFS patients activity level is related to fatigue but not in MS.

The persistence of fatigue in chronic fatigue syndrome and multiple sclerosis: development of a model.

The cause of chronic fatigue syndrome (CFS) is unknown. With respect to factors perpetuating fatigue, on the other hand, a model has been postulated in the literature in which behavioral, cognitive, and affective factors play a role in perpetuating fatigue. In the present study, this hypothesized model was tested on patients with CFS and on fatigued patients with multiple sclerosis (MS). The model was formulated in terms of cause-and-effect relationships and an integral test of this model was performed by the statistical technique, "structural equation modeling," in 51 patients with chronic fatigue syndrome and 50 patients with multiple sclerosis matched for age, gender, and education. Attributing complaints to a somatic cause produced low levels of physical activity, which in turn had a causal effect on fatigue severity. Depression had to be deleted from the model. Sense of control over symptoms and focusing on bodily symptoms each had a direct causal effect on fatigue. The model showed an excellent fit for CFS patients, but was rejected for MS patients. Therefore, a new model for MS patients had to be developed in which sense of control had a causal effect on fatigue. In the MS model, no causal relationship was found between the physical state as measured by the Expanded Disability Status Score (EDSS) and fatigue or functional impairment. The present study shows that cognitive and behavioral factors are involved in the persistence of fatigue. Treatment should be directed at these factors. The processes involved in the subjective experience of fatigue in CFS were different from the processes related to fatigue in MS.

Dimensional assessment of chronic fatigue syndrome.

The absence of laboratory tests and clear criteria to identify homogeneous (sub)groups in patients presenting with unexplained fatigue, and to assess clinical status and disability in these patients, calls for further assessment methods. In the present study, a multi-dimensional approach to the assessment of chronic fatigue syndrome (CFS) is evaluated. Two-hundred and ninety-eight patients with CFS completed a set of postal questionnaires that assessed the behavioural, emotional, social, and cognitive aspects of CFS. By means of statistical analyses nine relatively independent dimensions of CFS were identified along which CFS-assessment and CFS-research can be directed. These dimensions were named: psychological well-being, functional impairment in daily life, sleep disturbances, avoidance of physical activity, neuropsychological impairment, causal attributions related to the complaints, social functioning, self-efficacy expectations, and subjective experience of the personal situation. A description of the study sample on these dimensions is presented.

Yersinia enterocolitica and the chronic fatigue syndrome.

OBJECTIVES: To investigate the potential role of Yersinia enterocolitica in patients with chronic fatigue syndrome (CFS). METHODS: An immunoblot technique was used to detect antibodies to various Yersinia outer membrane proteins (YOPs) in serum samples from 88 patients with CFS and 77 healthy neighbourhood controls, matched for gender and age. RESULTS: The prevalence of IgG and IgA antibodies to various Yersinia outer membrane proteins (YOPs) did not differ between patients with CFS and healthy controls. Twenty-four patients (27%) and nineteen controls (25%) had IgG antibodies to one or more YOPs. Four patients and two controls had both serum IgG and IgA antibodies to at least two different YOPs, compatible with a recent or persistent infection. Although all patients with positive IgG and IgA reactions to two or more YOPs had symptoms that could point to persistent Yersinia infection, these symptoms were also found frequently in patients without antibodies to YOPs. CONCLUSIONS: We conclude that Y. enterocolitica is unlikely to play a major role in the aetiology of CFS.

Primary haemochromatosis: a missed cause of chronic fatigue syndrome?

OBJECTIVE: To determine whether patients previously diagnosed as chronic fatigue syndrome (CFS) actually have primary haemochomatosis (PH). METHODS: The setting was a Dutch referral centre. Transferrin saturation (TS) was retrospectively evaluated in banked blood samples of 88 patients diagnosed as CFS. Patients with elevated TS values were asked to provide a new overnight fasting blood sample for a second determination of TS and measurement of serum ferritin. The DNA was investigated for mutations in the HFE gene when one of these iron parameters was elevated. RESULTS: For 19 out of 88 patients with CFS an elevated TS was found. A new blood sample was obtained from 11 of these 19: six had increased TS and two had elevated serum ferritin values. These eight patients were neither C282Y homozygotes nor compound C282Y-H63D heterozygotes. In the eight cases where no new blood samples could be obtained, the TS was > 50% for two of the five men and < 45% for the three female patients. CONCLUSION: In a group of 88 CFS patients we could exclude PH in all but two of them (prevalence 2.3%; 95% confidence interval 0-5.5%). In our population of CFS patients PH is not more common than in a control population of northern European descent (prevalence 0.25-0.50%).

[Infections in elderly patients]. / Infecties bij de bejaarde patiënt.

Infections are an increasing problem in the elderly population, because of the often atypical presentation and the more frequent occurrence of complications, which lead to increased morbidity and mortality. The increased prevalence of infections in the elderly is due to a number of factors: increased exposure to micro-organisms (especially in nursing homes); degeneration of various organs (atherosclerosis, pulmonary emphysema, diverticulosis, prolapse); decreased immune response; concomitant diseases (e.g. diabetes mellitus) and (or) use of medication. There is often a delay in the diagnosis because the presentation of infection in the elderly is frequently atypical and symptoms are attributed to old age, rather than to infection. Treatment may be hampered by increased resistance of micro-organisms, interaction with other drugs and toxicity problems.

[Fetal and neonatal outcome prolonged ruptured membranes in a gestational age of less than 24 weeks]. / Foetaal en neonataal beloop na langdurig gebroken vliezen bij een termijn van minder dan 24 weken.

The view appears to be generally held that the survival chances of fetuses in cases of very early rupture of the membranes are low. We report a retrospective study of 12 pregnancies with prolonged rupture of the membranes less than or equal to 24 weeks menstrual age. There was no significant maternal morbidity. After birth special attention was given to respiratory problems, deformities and infections. Four children were born at menstrual age less than 26 weeks. In all cases an intrauterine infection was found (chorioamnionitis). The eight children born greater than or equal to 26 weeks had good chances of survival despite oligohydramnios (all) and deformities (four). Severe intrauterine infections were not present in this group. An expectant obstetric management in cases of very early prolonged rupture of the membranes seems justified.

Comparison of two commercial molecular assays for simultaneous detection of respiratory viruses in clinical samples using two automatic electrophoresis detection systems.

Two molecular assays were compared with real-time RT-PCR and viral culture for simultaneous detection of common viruses from respiratory samples: a multiplex ligation-dependant probe amplification (MLPA) and a dual priming oligonucleotide system (DPO). In addition, the positive detections of MLPA and DPO were identified using two different automatic electrophoresis systems. A panel of 168 culture-positive and negative samples was tested by the molecular assays for the presence of influenza A and B virus, respiratory syncytial virus, human metapneumovirus, rhinovirus, coronaviruses, parainfluenza viruses and adenovirus. One hundred and twenty-nine (77%) samples were positive as detected by at least one method. Sixty-nine (41%) samples were positive by cell culture (excluding human metapneumovirus and coronaviruses), 116 (69%) by RT-PCR, 127 (76%) by MLPA and 100 (60%) by DPO. The MLPA yielded results in one attempt for all samples included while 12 (7.2%) samples had to be repeated by the DPO assay due to inconclusive results. The MLPA assay performed well in combination with either electrophoresis system, while the performance of the DPO assay was influenced by the electrophoresis systems. Both molecular assays are comparable with real-time RT-PCR, more sensitive than viral culture and can detect dual infections easily. Results can be obtained within 1 day.

Coxsackievirus B1-based antibody-capture enzyme-linked immunosorbent assay for detection of immunoglobulin G (IgG), IgM, and IgA with broad specificity for enteroviruses.

An antibody-capture enzyme-linked immunosorbent assay (ELISA) with coxsackievirus B1 as the antigen was evaluated for detection of immunoglobulin G (IgG), IgM, and IgA antibodies and showed broad specificity for enteroviruses. In total, 116 serum or cerebrospinal fluid samples from 62 patients were tested by ELISA and the complement fixation test (CFT). Additionally, 15 serum samples that contained poliovirus-specific IgM antibody were tested. Serum samples from 200 healthy blood donors were used for standardization of the assays. The sensitivity of the ELISA varied with time of serum sampling, with a relatively low sensitivity when serum was collected within 3 days after the onset of symptoms (23%; 5 of 22) but good sensitivity when serum was collected later (83%; 20 of 24). The sensitivity was better than that of the CFT. The ELISAs were broadly reactive as concluded from typing of virus isolates that were simultaneously obtained. The assay did, furthermore, detect antibody against poliovirus type 3. Sera that contained rheumatoid factor, antinuclear antibody, or cardiolipin antibody (by the Venereal Disease Research Laboratory test) did not react in this ELISA. Nonspecific reactivity did occur, however, in cases of infectious mononucleosis and in Mycoplasma pneumoniae infection. The enterovirus-specific ELISA is found to be simple to perform, more sensitive than the CFT, and far less laborious than the neutralization test.

Specificity of a sandwich enzyme-linked immunosorbent assay for detecting Aspergillus galactomannan.

The specificity of a sandwich enzyme-linked immunosorbent assay (ELISA) for detecting Aspergillus galactomannan was tested with exoantigens of 29 fungi cultured from clinical specimens. Cross-reactivity was observed with Penicillium chrysogenum, Penicillium digitatum, and Paecilomyces variotii. Furthermore, 40 serum samples obtained from bacteremic patients with hematologic malignancies were retrospectively tested by sandwich ELISA. False-positive reactions with the serum were reproducible but did not correspond with the results of culture of specific microorganisms. Moreover, the microorganisms cultured from the blood showed no reactivity by the sandwich ELISA.

Chronic fatigue syndrome: a clinical and laboratory study with a well matched control group.

OBJECTIVE: To investigate the relation between severity of complaints, laboratory data and psychological parameters in patients with chronic fatigue syndrome (CFS). SUBJECTS: Eighty-eight patients with CFS and 77 healthy controls matched for age, sex and geographical area. METHODS: Patients and controls visited our outpatient clinic for a detailed medical history, physical examination and psychological tests: Checklist Individual Strength (CIS). Beck Depression Inventory (BDI) and Sickness Impact Profile (SIP). Venous blood was drawn for a complete blood cell count, serum chemistry panel, C-reactive protein and serological tests on a panel of infectious agents. RESULTS: All patients fulfilled the criteria for CFS as described by Sharpe et al. (J R Soc Med 1991; 84: 118-21), only 18 patients (20.5%) fulfilled the CDC criteria. The outcome of serum chemistry tests and haematological tests were within the normal range. No significant differences were found in the outcome of serological tests. Compared to controls, significant differences were found in the results on the CIS, the BDI, and the SIP. These results varied with the number of complaints (CDC criteria). When the number of complaints was included as the covariate in the analysis, there were no significant differences on fatigue severity, depression, and functional impairment between patients who fulfilled the CDC criteria and patients who did not. CONCLUSION: It is concluded that the psychological parameters of fatigue severity, depression and functional impairment are related to the clinical severity of the illness. Because the extensive panel of laboratory tests applied in this study did not discriminate between patients and controls, it was not possible to investigate a possible relation between the outcomes of psychological and laboratory testing.

Evaluating neuropsychological impairment in chronic fatigue syndrome.

This study was designed to provide an estimate of the prevalence of neuropsychological impairment in chronic fatigue syndrome (CFS), to evaluate the concordance between impairment found on standardized tests and self-reported neuropsychological problems, and to study the relationship between neuropsychological functioning and fatigue severity and psychological processes. We adopted an individual approach to determine neuropsychological impairment as contrasted with the group-comparisons approach used in previous studies. Also, correction for premorbid functioning and confounders was done on an individual basis. The results show that a minority of participants were impaired in neuropsychological functioning. There was no relationship between neuropsychological impairment on standardized tests and self-reported memory and concentration problems. Neuropsychological functioning was not related to fatigue or depression. Slowed speed of information processing and motor speed were related to low levels of physical activity.