Thoracic spine X-ray examination of patients with back pain using different breathing technique and exposure times - A diagnostic study.

INTRODUCTION: The breathing and suspended inspiration techniques are often used interchangeably for spine X-ray examinations. However, these techniques are not always adequately supported by clinical evidence. This study aimed to determine the two techniques' diagnostic value and adverse image outcomes. METHODS: A total of 400 participants were examined on a Siemens Ysio Max system and randomized into four examination groups: suspended inspiration or breathing techniques with exposure times of 1, 2, and 3.2 s, respectively. Two consultant radiologists conducted the evaluation of the X-ray images. If disagreement was present, the radiologists collaboratively reviewed the X-ray images until a consensus was reached. RESULTS: The final 394 study population comprised 275 women and 119 men with a mean age of 64 years (range:18-96 years). The proportions of visually sharp reproduction of the endplates and trabecular structures did not differ significantly with regards to differences in exposure times between groups. The breathing technique groups had significantly higher proportions of blurring and motion artifacts (p < 0.001). However, adverse image outcomes (motions artifacts) were significantly lower in the 1-s exposure group. CONCLUSIONS: The suspended inspiration and breathing techniques performed equally well regarding visually sharp reproduction. However, the suspended inspiration technique was superior to the breathing technique. regarding adverse image outcomes, although the latter could be improved by using a shorter exposure time. IMPLICATIONS FOR PRACTICE: The suspended inspiration and breathing technique appeared to perform at equal diagnostic levels. The suspended inspiration technique should be preferred due to its reduced risk of adverse image outcomes. However, the risk could also be reduced using a short exposure time with the breathing technique.

Antibody response in patients with autoimmune inflammatory rheumatic disease after pneumococcal polysaccharide prime vaccination or revaccination.

OBJECTIVE: The aim of the study was to assess the pneumococcal antibody response in autoimmune inflammatory rheumatic disease (AIIRD) patients receiving 23-valent pneumococcal polysaccharide vaccine (PPV23) as a prime vaccination or revaccination. METHOD: Antibodies to 12 serotypes occurring in the commonly applied pneumococcal vaccines in Denmark were measured in AIIRD patients receiving biological disease-modifying anti-rheumatic drug (bDMARD) treatment for rheumatoid arthritis, spondyloarthritis, or psoriatic arthritis. Patients with a non-protective level of pneumococcal antibodies (geometric mean pneumococcal antibody level < 1 µg/mL) were invited to receive vaccination with PPV23 followed by control of antibody titre 3 months later. RESULTS: In total, 224 (74%) of 301 patients were included in the analyses, of whom 126 patients had previously received PPV23 vaccination. Post-vaccination antibody measurement revealed that only 80 patients (36%) achieved a protective level of antibodies. In a multivariable logistic regression analysis, significantly more patients without a previous PPV23 vaccination history achieved a protective antibody level compared with patients with a history of PPV23 vaccination less than 5 years ago (p = 0.005). This difference was not seen when comparing the former group with patients vaccinated 5 years ago or more. Methotrexate (MTX) treatment at the time of vaccination was associated with a non-protective antibody level (p < 0.001). CONCLUSION: Only 36% of patients with a non-protective antibody level achieved a protective level in response to pneumococcal vaccination. Pneumococcal vaccination within the last 5 years and MTX treatment at the time of vaccination were independently associated with a poor antibody response.

Pneumococcal antibody protection in patients with autoimmune inflammatory rheumatic diseases with varying vaccination status.

Objectives: The aims of this cross-sectional study were to assess the pneumococcal antibody coverage in patients with autoimmune inflammatory rheumatic disease (AIRD) and to identify predictors associated with inadequate protective antibody levels. Method: Antibodies to 12 serotypes occurring in the commonly applied pneumococcal vaccines in Denmark were measured in AIRD patients with a diagnosis of rheumatoid arthritis, spondyloarthritis, or psoriatic arthritis attending the Department of Rheumatology at the North Denmark Regional Hospital. Immunization against pneumococcal infection was defined as a geometric mean level ≥ 1 µg antibodies/mL. Clinical information about vaccination status and disease/treatment history was retrieved from the medical file system. Results: Results of antibody measurement and vaccination status were available from 346 AIRD patients, of whom 200 (58%) were registered as receiving pneumococcal vaccination, whereas the remaining 146 patients (42%) were not. Of all 346 patients, only 61 (18%) were measured with an adequate level of protective antibodies (30% vs 1%, respectively). Methotrexate treatment at the time of vaccination and increasing age were identified as predictors of poor vaccination outcome in multiple logistic regression analysis. Conclusions: This post-vaccination study showed that less than one-fifth of the AIRD patients are adequately protected against pneumococcal infection, although the immunization programme had been implemented in more than half of the study population. Development of improved vaccination strategies is required to achieve a higher immunization coverage rate and more efficient lasting antibody response.

Detection of Schistosoma DNA in genital specimens and urine: A comparison between five female African study populations originating from S. haematobium and/or S. mansoni endemic areas.

Female Genital Schistosomiasis (FGS) is a neglected disease affecting millions, however challenging to diagnose. This explorative descriptive study compares Schistosoma real-time PCR analysis of cervico-vaginal lavages (CVL) with corresponding urine and stool samples of 933 women from five different previously described study populations. Sampling included 310 women from an S. mansoni endemic region in Mwanza, Tanzania and 112 women from a nearby S. haematobium endemic region. Findings were compared with samples collected from S. haematobium endemic regions in South Africa from 394 women and from 117 women from Madagascar of which 79 were urine pre-selected microscopy positive cases from highly-endemic communities and 38 were urine microscopy negatives from a low-endemic community. As anticipated, urine and stool microscopy and gynecological investigations varied substantially between study populations; however, the same Schistosoma real-time PCR was performed in one reference laboratory. Schistosoma DNA was detected in 13% (120/933) of the CVL, ranging from 3% in the S. mansoni Tanzanian endemic region to 61% in the pre-selected Malagasy urine microscopy positive cases. Detectable Schistosoma DNA in CVL was associated with Schistosoma DNA in urine but not with microscopic detection of eggs in urine or by cytological examination. This study confirmed real-time PCR for the detection of Schistosoma DNA in gynecological samples to be a valuable diagnostic tool to study the distribution of FGS within schistosomiasis endemic areas.

How can schistosome circulating antigen assays be best applied for diagnosing male genital schistosomiasis (MGS): an appraisal using exemplar MGS cases from a longitudinal cohort study among fishermen on the south shoreline of Lake Malawi.

We provide an update on diagnostic methods for the detection of urogenital schistosomiasis (UGS) in men and highlight that satisfactory urine-antigen diagnostics for UGS lag much behind that for intestinal schistosomiasis, where application of a urine-based point-of-care strip assay, the circulating cathodic antigen (CCA) test, is now advocated. Making specific reference to male genital schistosomiasis (MGS), we place greater emphasis on parasitological detection methods and clinical assessment of internal genitalia with ultrasonography. Unlike the advances made in defining a clinical standard protocol for female genital schistosomiasis, MGS remains inadequately defined. Whilst urine filtration with microscopic examination for ova of Schistosoma haematobium is a convenient but error-prone proxy of MGS, we describe a novel low-cost sampling and direct visualization method for the enumeration of ova in semen. Using exemplar clinical cases of MGS from our longitudinal cohort study among fishermen along the shoreline of Lake Malawi, the portfolio of diagnostic needs is appraised including: the use of symptomatology questionnaires, urine analysis (egg count and CCA measurement), semen analysis (egg count, circulating anodic antigen measurement and real-time polymerase chain reaction analysis) alongside clinical assessment with portable ultrasonography.

Simple and practical screening approach to identify HIV-infected individuals with depression or at risk of developing depression.

OBJECTIVES: Studies have shown that depression and other mental illnesses are under-diagnosed among HIV-infected individuals. The aim of this study was to evaluate the use of mental health history and questionnaire-based screening instruments to identify HIV-infected individuals at risk of depression. METHODS: The Beck Depression Inventory II (BDI-II) was used to assess the prevalence and severity of depressive symptoms among HIV-infected individuals attending two out-patient clinics in Denmark. HIV-infected individuals with a BDI-II score ≥ 20 were offered a clinical evaluation by a consultant psychiatrist. The BDI-II score was compared to the outcome of mental health history review, and to results obtained using the European AIDS Clinical Society (EACS) two-item depression screening tool. RESULTS: A total of 501 HIV-infected individuals were included in the study. Symptoms of moderate/major depression (BDI-II score ≥ 20) were observed in 111 patients (22%); 65 of these patients consulted a psychiatrist, of whom 71% were diagnosed with a co-existing disorder. The BDI-II score was compared to the outcome of a mental health history review, and to results obtained using the European AIDS Clinical Society (EACS) two-item depression screening tool. The two questions showed a sensitivity and specificity of 95% and 68%, respectively, for diagnosis of current depression or risk of depression. A previous psychiatric history and substance abuse were independently associated with an increased risk of depression. CONCLUSIONS: We suggest that the mental health of HIV-infected individuals should be reviewed and a "risk-flag" three-step approach should be used (1) to screen routinely with the two verbal questions suggested by the EACS, (2) to identify whether there is a risk of depression and then screen with the BDI-II, and (3) to identify whether there is still a risk and then perform a full evaluation and obtain an accurate psychiatric diagnosis by a psychiatrist.

Ultrasonographical findings in the urogenital organs in women and men infected with Schistosoma haematobium in northern Madagascar.

Ultrasonography (US) was applied in this community-based study in northern Madagascar to compare urogenital findings in Schistosoma haematobium-positive individuals (105 women and 116 men) from the high-endemic Sirama village, with urinary egg negative controls (100 women and 108 men) from the neighboring low-endemic Mataipako village. In addition to examination of the urinary tract, the female genitals were examined by transvaginal US, whereas the male genitals were examined by transrectal and transscrotal US. Pathology of the urinary tract was significantly more prevalent among women and men in Sirama. There were no differences in female genital tract between the two study populations, whereas significantly higher proportions of men in Sirama were detected with hyperechogenic and calcified lesions in the seminal vesicles and the prostate. Moreover, the mean size of the seminal vesicles was significantly larger in Sirama. There were no differences with respect to the external male genitals. Six months after anti-schistosome treatment, no changes were observed in the female genital tract in Sirama, whereas hyperechogenicity of the prostate and the seminal vesicles, in addition to size of the seminal vesicles, declined significantly. This study has provided new insight into genital pathology in S. haematobium-infected men and women. However, the clinical significance of these findings needs further exploration.

[The current epidemiological situation of cysticercosis in Madagascar]. / Situation épidémiologique actuelle de la cysticercose à Madagascar.

Being associated to fecal-oral transmission, cysticercosis is contracted either by auto-infection or by ingestion of food contaminated with eggs from the pork tape worm (Taenia solium). In the stomach, the larvae named cysticercus (Cysticercus cellulosae) hatches from the eggs and invades the host through the mucosa membrane. Human cysticercosis occurs in highly prevalent proportions in many developing countries including Madagascar where hygiene conditions are deplicable. Serology tests applicable to epidemiological surveillance of cysticercosis and associated pathology in the Malagasy population have been developed: an enzyme-linked immunosorbent assay (ELISA) for screening purpose, and an enzyme-linked immunoelectrotransfer blot assay (EITB) for confirmative testing. Two specific bands (13 and 14 kDa) have been identified as significant markers of the cysticercus in an active (vesicle) stage of the infection when cestocidal treatment is strongly indicated. The same bands may on the other hand be absent at early (cyste) as well as late (calcified) stages of the infection. Series of studies, including 4,375 serum samples, have been undertaken from 1994 until 1999 aiming at determinating the cysticercosis sero-prevalence in different provinces of Madagascar. It was confirmed that cysticercosis is highly frequent on the island, and that there exists a marked variation in the prevalence from 7 to 21% between the different provinces: less than 10% in coastal regions (Mahajanga and Toamasina) increasing to 20% in central regions (Ihosy, Ambositra and Mahasolo). It has also been observed that cysticercosis may occur in individuals at any age, and that it is equally distributed in urban as in rural areas. However, it is more frequently detected in women than in men. Madagascar is an endemic country for cysticercosis, which causes major and severe disease with implications in the public health sector. A national control program is, therefore, urgently warranted.

Morbidity assessment in urinary schistosomiasis infection through ultrasonography and measurement of eosinophil cationic protein (ECP) in urine.

In a Schistosoma haematobium-endemic village in western Madagascar we evaluated ultrasonography and Eosinophil Cationic Protein (ECP) in urine as means to detect the associated urinary tract pathology. 192 individuals were matched according to age and sex, and grouped into infected persons with bladder and, if present, kidney pathology (n = 96); infected persons without pathology (n = 48) and noninfected persons without pathology (n = 48). The median urinary egg count was significantly higher in individuals with ultrasonographically detectable urinary tract pathology (115 eggs/10 ml urine) than in infected persons without (45 eggs/10 ml of urine). At 136 ng/ml, the median ECP level was significantly higher in the 144 infected individuals than in the 48 noninfected persons (0.35 ng/ml). Egg excretion correlated positively with ECP level. The median ECP level was significantly higher in the group with ultrasonographically detectable urinary tract pathology than in the group without (183 ng/ml vs. 67 ng/ml). The results suggest that minor degrees of pathology, particularly at an early stage of infection with S. haematobium, might be overlooked by ultrasonography despite the presence of marked inflammation, as indicated by markedly increased urinary ECP levels in infected individuals without ultrasonographically detectable urinary tract pathology. ECP may therefore provide important information on the evolution of S. haematobium-associated urinary tract morbidity.

Community-based study of genital schistosomiasis in men from Madagascar.

Detection of Schistosoma haematoblum eggs in 43% of semen samples with Increased levels of eosinophil cationic protein suggests that the genital organs of men are frequently affected with schistosomiasis.

PIP: This community-based cross-sectional study was undertaken to assess the frequency of genital schistosomiasis among men in Androvakely, Madagascar, where Schistosoma haematobium is prevalent. Egg excretion and levels of eosinophil cationic protein (ECP) were measured in paired urine and semen samples obtained from 44 males eligible for the study. Findings revealed that the eggs of S. haematobium were detected in 25 urine samples (57%) and in 19 semen samples (43%). The median egg output (range) in urine was 10 eggs/ml (1-950); in semen, 3 eggs/ejaculate (1-19). Median ECP concentration in urine was 2.2 mcg/l; in semen, 109.0 mcg/l. Moreover, the concentration of ECP in urine was positively correlated with the number of eggs excreted in urine, and increased levels of seminal ECP were significantly associated with the presence of eggs in semen. The presence of eggs in 43% of the semen samples indicated that genitals were common sites for oviposition in men with S. haematobium infection. Based on the findings, a similar effect of genital schistosomiasis on HIV shedding in men, with egg deposition in the genital organs, can lead to an inflammatory response, which may then increase the viral load in semen from HIV-positive people.

[Prevalence of uro-nephrologic complications of urinary bilharziasis in hyperendemic focus in Madagascar]. / Prévalence des retentissements uro-néphrologiques de la bilharziose urinaire dans un foyer hyperendémique de Madagascar.

This prospective study was designed to look for and describe urologic and nephrologic consequences of urinary bilharziosis due to schistosoma haematobium in a hyperendemic hotbed in the middle west of Madagascar. Methodology included clinical examination, kidney and bladder ultrasonography, urine dipsticks and creatininemia. Amongst a population of 574 persons aged 5 years ore more, 436 (76%) had bilharziosis ova in the urine (filtration method). From the clinical point of view, 257 patients (58.9%) had microscopic hematuria, 178 (40.8%) had presently an hematuria; 111 patients (25.5%) suffered from dysuria; 18 patients (4.1%) had limb oedema when 3 patients had present oedema (0.7%). Among 436 checked people, 267 (61.2%) had an ultrasonography abnormality. In 252, it was bladder wall abnormalities (57.8%). They were wall irregularities in 182 cases (41.7%); vesico-ureteral reflux in 22 cases (5.3%); ureteral dilatations in 22 cases (5.3%) and pyelocalyceal dilatations in 61 cases (13.9%). Prevalence of proteinuria 75.2% (316 amongst 420 checked people) of whom 5.7% (24 cases) had 5 g/l or more. Hematuria was found in 352 patients (83.8%) of whom 238 (56.7%) had more than 250 erythrocytes per microliter. Prevalence of leucocyturia was 56.7% (238 cases). Creatininemia was measured in 140 people with positive filtration; it was normal in all except two patients. This study highlights the parallel evolution between parasitic infection and uronephrological manifestations of the disease.

[Effect of praziquantel on the uro-nephrologic complications of urinary bilharziasis]. / Effet du praziquantel sur les retentissements uro-néphrologiques de la bilharziose urinaire.

This study shows the effect of praziquantel as a 12 month treatment on the uro-nephrological consequences of Schistosoma haematobium chronic infection. This was done in a hyperendemic setting in the middle west of Madagascar. 435 people with ova in their urine filtration test were followed up with clinical examination, ultrasonography, urinary sticks and creatininemia. The prevalence of macroscopic hematuria decreased significantly from 32.5% (153 patients) to 4.3% (20 patients) (p < 0.05). Other abnormalities decreased but not significantly. The prevalence of proteinuria decreased from 62.3% (271 cases) to 20.2% (88 cases) (p < 0.05%) when microscopic hematuria varied from 72.4% (315 cases) to 31.5% (271 cases). Leukocyturia remained stable from 49% (213 cases) to 47.8% (207 cases). On ultrasonography, the whole abnormalities varied from 54.1% (256 patients) to 16.7% (79 patients). Prevalence of bladder abnormalities decreased from 50% (237 cases) to 16.3% (77 cases) (p < 0.05); prevalence of vesico-ureteral reflux decreased from 5.1% (23 cases) to 0.2% (1 case) (p < 0.05) and that of pyelocaliceal from 14.6% (54 cases) to 2.5% (12 cases). The reference drug, praziquantel has a clear-cut effect on this chronic pathology. Bladder wall abnormalities are particularly interested by this favourable effects.

Clinical findings in female genital schistosomiasis in Madagascar.

To assess the morbidity of S. haematobium infection in women of reproductive age (15-49 years) in the western part of Madagascar, the village of Betalatala with a prevalence of urinary schistosomiasis in women of 75.6% (95% confidence limit 69.3 to 81.9%) was compared with a neighbouring village with similar socio-economic characteristics and a prevalence of 5.0% (95% confidence limit 0 to 11.75%). The women were questioned in Malagasy about obstetrical history and urogynecological symptoms. They were examined gynaecologically, parasitologically and by ultrasonography. Important STDs were excluded by appropriate diagnostics. In Betalatala significantly more women reported a history of spontaneous abortion (P < 0.01), complaints of irregular menstruation (P < 0.001), pelvic pain (<0.05), vaginal discharge (P < 0.0001), dysuria (P < 0.05) and haematuria (P < 0.01) than in the control village. Biopsies were obtained from the cervix of 36 women with macroscopical lesions, and in 12 cases S. haematobium eggs were found by histological sectioning (33.3%). In the control village no eggs were detected in the histological sections of biopsies taken from 14 women. (P < 0.05). Infections with Candida albicans, Trichomonas vaginalis, Gardnerella vaginalis and Treponema pallidum were found in similar frequencies in both villages. In 9.8% of the women in Betalatala abnormalities of the upper reproductive tract were revealed by ultrasonography versus none in the women from the control village (P < 0.05). Echographic abnormalities of the urinary tract were present in 24% and 3% of the women in the study village and in the control village, respectively (P < 0.0001). These findings were accompanied by an elevated frequency of haematuria (55% versus 20%) and proteinuria (70.4% versus 25%) in the study population (P < 0.0001). Our study indicates that S. haematobium infection in women may not only cause symptoms in the urinary tract, but also frequently in the lower and upper reproductive tract.

[Doxycycline induced photoonycholysis]. / Doxycyclinudløst fotoonykolyse.

A case of phototoxic onycholysis secondary to treatment with doxycycline is presented. Tetracyclines are known to provoke photosensitivity reactions in some individuals exposed to sunlight. The typical photo-toxic manifestation is erythema, but cases with onycholysis have also been reported in the past. With travel to regions with sunny climates it will be important to be aware of the risk of developing onycholysis following the use of tetracyclines and to avoid the most potential phototoxic derivates, especially doxycycline.

Schistosoma haematobium induced lesions in the female genital tract in a village in Madagascar.

Female genital schistosomiasis, FGS, was investigated in a gynaecological study as part of an overall community based morbidity survey, including parasitological and ultrasonographical examination, of a Schistosoma haematobium endemic area in Madagascar. Women (103), of childbearing age (15-49 years), were included for a gynaecological examination and visible lesions of vagina and cervix were biopsied in order to determine the origin of the lesion. Furthermore all women were screened for the presence of schistosome ova using PAP smears from the vagina and the endo/exo cervix. In total 15 women showed schistosome ova in the vagina and/or cervix (median age 24 years and range 15-36 years). Of 36 women with cervical abnormalities, 12 eggs were detected by cervical biopsy (33%). In addition, two of the 12 presented vaginal induration, which contained eggs. Six women had eggs in their PAP smears of which three were egg negative by cervical biopsy. The prevalence of positive S. haematobium egg excretion in the urine among the 103 women was 69% and the geometric mean egg count of positive individuals was 51 eggs/10 ml of urine. Five of the 15 women with confirmed FGS had < or = 1 egg/10 ml of urine. Bladder lesions and congestive changes in the kidneys were demonstrated by ultrasonographic examination in 33 and 9% of the 103 women, respectively. None of the 15 women with confirmed FGS had renal congestion. Our study demonstrates that FGS is a common manifestation of the infection with S. haematobium, even in lightly infected individuals.

Schistosoma haematobium infection in western Madagascar: morbidity determined by ultrasonography.

To assess the morbidity related to Schistosoma haematobium infection in western Madagascar, an ultrasonographic examination was performed of 574 inhabitants > 5 years old in a village in an old-established endemic area where no prior systematic antischistosomal treatment had been given. The overall prevalence of infection was 75.9% and the geometric mean egg count of positive individuals was 36 eggs/10 mL of urine. Recent haematuria had been experienced by 31.8% of individuals. Echographic abnormalities of the urinary tract were present in 50.5% of individuals: they were more frequent in males. Bladder wall lesions were observed in 93.1% of individuals with ultrasonographic changes, irregularities of the inner surface being the most common finding. Congestive changes were noted in 8.4% of kidneys, but we observed only 4 severe congestions. Bladder lesions and congestive changes in kidneys predominated in youth; their presence and severity were significantly correlated with egg excretion. In 12 inhabitants, grade 1 periportal fibrosis was observed, but no significant association was found with S. haematobium infection. In a control village, where the prevalence of S. haematobium infection was 7%, moderate congestion of kidneys was observed in 2% of examined inhabitants, and bladder changes in 6%, with a significant relationship with S. haematobium infection.