Preoperative and perioperative use of levosimendan in cardiac surgery: European expert opinion.

In cardiac surgery, postoperative low cardiac output has been shown to correlate with increased rates of organ failure and mortality. Catecholamines have been the standard therapy for many years, although they carry substantial risk for adverse cardiac and systemic effects, and have been reported to be associated with increased mortality. On the other hand, the calcium sensitiser and potassium channel opener levosimendan has been shown to improve cardiac function with no imbalance in oxygen consumption, and to have protective effects in other organs. Numerous clinical trials have indicated favourable cardiac and non-cardiac effects of preoperative and perioperative administration of levosimendan. A panel of 27 experts from 18 countries has now reviewed the literature on the use of levosimendan in on-pump and off-pump coronary artery bypass grafting and in heart valve surgery. This panel discussed the published evidence in these various settings, and agreed to vote on a set of questions related to the cardioprotective effects of levosimendan when administered preoperatively, with the purpose of reaching a consensus on which patients could benefit from the preoperative use of levosimendan and in which kind of procedures, and at which doses and timing should levosimendan be administered. Here, we present a systematic review of the literature to report on the completed and ongoing studies on levosimendan, including the newly commenced LEVO-CTS phase III study (NCT02025621), and on the consensus reached on the recommendations proposed for the use of preoperative levosimendan.

A biofilm exists on healthy mucosa of the paranasal sinuses: a prospectively performed, blinded, scanning electron microscope study.

OBJECTIVES: Based on our hypothesis that biofilm is nothing else but normal, otherwise abundantly colonised mucosal mucous blanket, the aim of this study was to check out whether bacterial biofilm exists exclusively at the diseased mucosal surfaces or at healthy mucosa of paranasal sinuses as well. DESIGN: Prospective and blinded. SETTING: Tertiary academic hospital. PARTICIPANTS: The patients suffering from the diseases not related to the chronic inflammation of the paranasal sinuses. Mucosal tissue samples from healthy sphenoid sinuses were taken from 48 patients who underwent pituitary gland surgery and from ethmoidal sinuses mucosa of the 17 patients who underwent endonasal endoscopic orbital decompression because of Graves' disease. MAIN OUTCOME MEASURES: The samples were submitted blindly along with similar samples from patients with chronic rhinosinusitis to two scanning electron microscope experts. In all samples the looked for the main signs of biofilm presence of: the 'towers', rod-shaped bacteria and water channels. RESULTS: Signs of biofilm presence were found in 45 out of 48 pituitary gland surgery patients (94%) and in all of 17 EEOD patients (100%). CONCLUSIONS: Our study showed the presence of the biofilm at the surface of the healthy mucosa of the paranasal sinuses. This suggests that perhaps so called bacterial biofilm is nothing else but regular respiratory mucosal blanket, a part of the mucociliary system itself, containing a great number of bacteria.

Human visual function in the North Carolina clinical study on possible estuary-associated syndrome.

The U.S. Environmental Protection Agency assisted the North Carolina Department of Health and Human Services in conducting a study to investigate the potential for an association between fish kills in the North Carolina estuary system and the risk for persistent health effects. Impetus for the study was recent evidence suggesting that estuarine dinoflagellates, including members of the toxic Pfiesteria complex (TPC), P. piscicida and P. schumwayae, may release a toxin(s) that kills fish and adversely affects human health. This report describes one component of the study in which visual system function was assessed. Participants working primarily in estuaries inhabited by TPC or in off-shore waters thought not to contain TPC were studied. The potentially exposed estuary (n = 22) and unexposed offshore (n = 20) workers were matched for age, gender, and education. Visual acuity did not differ significantly between the cohorts, but visual contrast sensitivity (VCS), an indicator of visual pattern-detection ability for stimuli of various sizes, was significantly reduced by about 30% in the estuary relative to the offshore cohort. A further analysis that excluded participants having a history possibly predictive of neuropsychological impairment showed a similar VCS reduction. Additional analyses indicated that differences between the cohorts in age, education, smoking, alcohol consumption, and total time spent on any water did not account for the difference in VCS. Exploratory analyses suggested a possible association between the magnitude of VCS reduction and hours spent in contact with a fish kill. The profile of VCS deficit across stimulus sizes resembled that seen in organic solvent-exposed workers, but an assessment of occupational solvent, and other neurotoxicant, exposures did not indicate differences between the cohorts. These results suggest that factor(s) associated with the North Carolina estuaries, including the possibility of exposure to TPC toxin(s), may impair visual system function.

Estuary-associated syndrome in North Carolina: an occupational prevalence study.

Atlantic coast estuaries recently have experienced fish kills and fish with lesions attributed to Pfiesteria piscicida and related dinoflagellates. Human health effects have been reported from laboratory exposure and from a 1997 Maryland fish kill. North Carolina has recorded Pfiesteria-related fish kill events over the past decade, but human health effects from environmental exposure have not been systematically investigated or documented here. At the request of the state health agency, comprehensive examinations were conducted in a cross-sectional prevalence study of watermen working where Pfiesteria exposure may occur: waters where diseased or stressed fish were reported from June to September 1997, and where Pfiesteria had been identified in the past. Controls worked on unaffected waterways. The study was conducted 3 months after the last documented Pfiesteria-related fish kill. The goal was to document any persistent health effects from recent or remote contact with fish kills, fish with lesions, or affected waterways, using the 1997 U.S. Centers for Disease Control and Prevention case description for estuary-associated syndrome (EAS). Examinations included comprehensive medical, occupational, and environmental history, general medical, dermatologic, and neurologic examinations, vision testing, and neuropsychologic evaluations. Seventeen of 22 watermen working in affected waters and 11 of 21 in unaffected waters reported exposure to a fish kill or to fish with lesions. We found no pattern of abnormalities on medical, neurologic, neuropsychologic, or NES-2 evaluation. By history, one subject in each group met the EAS criteria, neither of whom had significant neuropsychological impairment when examined. Watermen from affected waterways had a significant reduction in visual contrast sensitivity (VCS) at the midspatial frequencies, but we did not identify a specific factor or exposure associated with this reduction. The cohorts did not differ in reported occupational exposure to solvents (qualitative) or to other neurotoxicants; however, exposure history was not sufficiently detailed to measure or control for solvent exposure. This small prevalence study in watermen, conducted 3 months after the last documented fish kill related to Pfiesteria, did not identify an increased risk of estuary-associated syndrome in those working on affected waterways. A significant difference between the estuary and ocean watermen was found on VCS, which could not be attributed to any specific factor or exposure. VCS may be affected by chemicals, drugs, alcohol, and several developmental and degenerative conditions; it has not been validated as being affected by known exposure to dinoflagellate secretions. VCS should be considered for inclusion in further studies, together with documentation or quantification of its potential confounders, to assess whether it has utility in relationship to dinoflagellate exposure.

Statewide adolescent asthma surveillance.

We assessed the prevalence of diagnosed asthma, wheezing, healthcare utilization, and environmental triggers in children ages 13-14 years, and evaluated the feasibility of statewide asthma surveillance in North Carolina. A cross-sectional study (N = 1,596) was conducted using the International Survey for Asthma and Allergies in Childhood (ISAAC) questionnaire. Ten percent reported current diagnosed asthma. Nineteen percent reported wheezing symptoms with no diagnosis of asthma. Children with frequent wheezing were more likely to be poor, African-American, and female. Thirty percent of diagnosed asthmatics made 1 or more emergency room visits in the last year. Undiagnosed asthmatics were unmedicated. These results highlight the magnitude of the asthma epidemic in early adolescence, and illustrate that statewide surveillance using ISAAC is feasible.

Evaluation of a single dose of diphtheria toxoid among adults in the Republic of Georgia, 1995: immunogenicity and adverse reactions.

To determine the immunogenicity and safety of a single dose of diphtheria toxoid among adults, blood samples for detecting serum antitoxin levels were obtained from 18- to 59-year-old subjects (n=248) before and 30 days after immunization with Td (tetanus-diphtheria toxoids; manufactured by Serum Institute of India). By day 30, the seroprevalence of antitoxin levels >/=0.1 IU/mL increased from 22.6% to 81.5%; median antitoxin levels increased from 0.01 to 4.0 IU/mL. These parameters were lowest among subjects who were 40-59 years old, especially among those 40-49 years old. Adverse reactions (local redness, swelling, induration, fever>39 degrees C) were reported by 5.3% of participants. Our findings suggest that, in general, one dose of the Indian-produced Td vaccine is efficacious and safe in inducing an adequate immune response against diphtheria in adults; however, in Georgia, persons 40-59 years old, especially those 40-49 years old, will require additional doses of toxoid to achieve protective levels of antitoxin.

Outbreak of vertigo in Wyoming: possible role of an enterovirus infection.

An epidemiologic investigation was conducted to characterize and evaluate the possibility of a viral aetiology of an outbreak of acute vertigo in Hot Springs Country, Wyoming, during autumn 1992. Case-finding identified Hot Springs County residents who sought medical attention for new onset vertigo during 1 August, 1992-31 January 1993. Thirty-five case-patients and 61 matched controls were interviewed and serum specimens were obtained during January 1993. Case-patients were more likely than controls to report symptoms (e.g. fatigue, sore throat, fever, diarrhoea) of antecedent acute illness. Case-patients did not have a significantly greater prevalence or mean titre of IgG antibodies to respiratory syncytial virus, parainfluenza viruses, Epstein-Barr virus, and cytomegalovirus than controls. Serologic evidence of recent enterovirus infection (IgM antibodies) was found for 74% of case-patients compared with 54% of controls (P < 0.05), suggesting a possible association between vertigo and enterovirus infection. Future studies are needed to define the role of enteroviruses in innerear diseases.

Comparative efficacy of ceftriaxone and rifampicin in eradicating pharyngeal carriage of group A Neisseria meningitidis.

During an outbreak of meningococcal meningitis in Saudi Arabia, oral rifampicin (four doses in two days) was compared with a single intramuscular dose of ceftriaxone for prophylaxis in family contacts of patients with meningococcal disease. Pharyngeal samples were taken for culture before and 1 and 2 weeks after administration. Both follow-up cultures indicated that ceftriaxone was significantly more effective. At 1 week the eradication rates for ceftriaxone and rifampicin were 97% and 75%; at 2 weeks they were 97% and 81%, respectively. No serious side-effects were associated with either agent. Ceftriaxone may provide an effective alternative to rifampicin for prophylaxis in meningococcal contacts.

Acute water shortage and health problems in Haiti.

During a severe drought Port-au-Prince, Haiti, lost hydroelectric power for 10 weeks. This led to water shortages in areas of the city dependent on water supplied from electrically driven pumps. In a study of the impact of water restriction on disease, 400 families were randomly selected from two urban areas differentially affected by the water shortage. Disease in children was found to be related to quantity of water used, socioeconomic status, employment of head of household, and family size. The methods used in this study are recommended for the investigation of the relationship between water quantity and health.

Comparative efficacy of chloramphenicol, ampicillin, and co-trimoxazole in the treatment of typhoid fever.

Two clinical trials were conducted to compare the efficacy of 3 antimicrobial agents often recommended for the treatment of typhoid fever. Chloramphenicol was more effective than parenteral ampicillin or oral co-trimoxazole (trimethaprim/sulphamethoxazole) in reducing the duration of fever. Oral chloramphenicol was more effective than parenteral chloramphenicol probably because oral doses resulted in higher blood concentrations of the drug. However, parenteral chloramphenicol was given during the initial period of acute illness, without loss of efficacy.

Live oral cholera vaccine: evaluation of the clinical effectiveness of two strains in humans.

El Tor Ogawa C14-S5 and EW-6, two live vaccine candidate strains, were given to volunteers in varying doses with and without bicarbonate. Vibrios were found in the stool of one of 32 men given the vaccine strain, and only three men developed a significant titer rise (fourfold or greater) at 2 weeks of vibriocidal or antitoxic antibody. Five men who had previously received 10(9) organisms of the C14-S5 strain were challenged subsequently with virulent Ogawa 395 Vibrio cholerae. The rate of clinical infection in these men was no different than in unvaccinated controls. It was demonstrated that the live oral cholera vaccines did not remain viable in the intestine long enough to act antigenically.