Multi-Domain Interventions for Dementia Prevention - A Systematic Review.

OBJECTIVES: There is a growing incidence of cognitive decline and dementia associated with the ageing population. Lifestyle factors such as diet, physical activity, and cognitive activities may individually or collectively be undertaken to increase one's odds of preventing cognitive decline and future dementia. This study will examine whether clinical trials using multidomain lifestyle intervention can significantly decrease the risk of cognitive decline and therefore dementia. DESIGN, SETTING AND PARTICIPANTS: This systematic literature review of multidomain lifestyle interventions for the prevention of cognitive decline and dementia followed the PRISMA guidelines. Clinical trials involving multidomain intervention (i.e., diet and physical activity, or without cognitive training) in older adults (≥ 49 years old) at higher risk of dementia were identified through 5 electronic databases (EMBASE, MEDLINE, CINAHL, Cochrane, and Scopus). A comprehensive search was performed to identify and retrieve publications until 15 November 2022. Trials were published in English. RESULTS: The included studies (n=15) assessed change in cognition in response to a multidomain lifestyle intervention. However, the cognitive outcome measures used in these studies were heterogeneous. Despite this heterogeneity, two thirds of the studies showed improvement in cognition following a multidomain intervention (n=10 with a total of 9,439 participants). However, five studies reported no improvement in cognition following the multidomain intervention. The most common form of dietary intervention included higher amount of fruit and vegetable intake; whole-grain cereal products instead of refined; low fat options in milk and meat products; and limiting sucrose intake to less than 50 g/day. Most clinical trial studies were powered to examining the effects of multidomain interventions in cognition but were not designed to test the contribution of individual domains (i.e., dietary changes, increased physical activity, or increased cognitive stimulation alone). CONCLUSION: This systematic review aimed to determine the effect of multimodal lifestyle interventions on cognitive outcomes in older adults at risk of dementia. We found that participants with conditions that may increase the risk of dementia, (e.g., hypertension, cardiovascular fragility) do benefit from multi-modal lifestyle changes including diet, physical activity, and cognitive training. Two thirds of studies using multidomain lifestyle interventions showed improvements in cognitive function. Trials with a focus on cognitive training, dietary improvement, and physical activity may prevent or delay cognitive decline in older adults including those at risk of developing dementia. Future studies should consider longer follow-up periods and adequate power to be able to examine the effects of each lifestyle component in the context of multimodal interventions.

Antimicrobial resistance in Aeromonas species isolated from aquatic environments in Brazil.

AIM: The current study was conducted to determine the antimicrobial resistance profile and genetic relatedness of Aeromonas sp. isolated from healthcare and urban effluents, wastewater treatment plant (WWTP) and river water. METHODS AND RESULTS: We detected the presence of genes conferring resistance to ß-lactam, quinolone and aminoglycoside. Multilocus sequence typing was carried out to differentiate the strains, and multilocus phylogenetic analysis was used to identify the species. A total of 28 cefotaxime-resistant Aeromonas sp. strains were identified, harbouring uncommon Guiana-extended-spectrum (GES)-type ß-lactamases (GES-1, GES-5, GES-7 and GES-16). Multidrug-resistant Aeromonas sp. were found in hospital wastewater, WWTP and sanitary effluent, and A. caviae was identified as the most prevalent species (85·7%). CONCLUSION: The release of untreated healthcare effluents, presence of antimicrobials in the environment, in addition to multidrug-resistant Aeromonas sp., are all potential factors for the spread of resistance. SIGNIFICANCE AND IMPACT OF THE STUDY: We identified a vast repertoire of antimicrobial resistance genes (ARG) in Aeromonas sp. from diverse aquatic ecosystems, including those that encode enzymes degrading broad-spectrum antimicrobials widely used to treat healthcare-associated infections. Hospital and sanitary effluents serve as potential sources of bacteria harbouring ARG and are a threat to public health.

Inhibition of the NorA efflux pump of Staphylococcus aureus by synthetic riparins.

AIM: The goal of this study was to increase knowledge about the antimicrobial activity of some synthetic Riparin-derived compounds, alone or in combination with fluoroquinolone antibiotics, against a strain of Staphylococcus aureus resistant to fluoroquinolone by way of overexpression of the NorA efflux pump. METHODS AND RESULTS: Microdilution tests showed that Riparins A and B did not show any significant antibacterial activity against Staph. aureus strains. On the other hand, the intrinsic antibacterial activity increased with increasing lipophilicity of the compounds, in the following order: Riparin-D (MIC 256 µg ml-1 ; Log P 2·95) < Riparin-C (MIC 102 µg ml-1 ; Log P 3·22) < Riparin-E (MIC 16 µg ml-1 ; Log P 3·57). The addition of all riparins to growth media at subinhibitory concentrations caused an increase in the antibacterial activity of antibiotics against the NorA-overexpressing test strain. Riparin-B, which has two methoxyl groups at the phenethyl moiety, showed the best modulatory effect. CONCLUSIONS: Riparin-E is a good anti-staphylococci agent, while Riparin-B functions as a NorA efflux pump inhibitor. SIGNIFICANCE AND IMPACT OF THE STUDY: Our data suggest the possibility of using Riparin-B in combination with norfloxacin or ciprofloxacin for therapy of infections caused by multi-drug resistant Staph. aureus.

[Fixed-dose combination fluticasone propionate/formoterol for the treatment of asthma: a review of its pharmacology, efficacy and tolerability]. / Combinación a dosis fija de fluticasona propionato/formoterol fumarato para el tratamiento del asma: una revisión de la farmacología, eficacia y tolerabilidad.

The fixed-dose combination fluticasone propionate/formoterol (FPF) is a novel combination of a widely known and used inhaled glucocorticoid (IGC) and a long-acting ß2-adrenergic agonist (LABA), available for the first time in a single device. This fixed-dose combination of FPF has a demonstrated efficacy and safety profile in clinical trials compared with its individual components and other fixed-dose combinations of IGC/LABA and is indicated for the treatment of persistent asthma in adults and adolescents. FPF is available in a wide range of doses that can adequately cover the therapeutic steps recommended by treatment guidelines, constituting a fixed-dose combination of GCI/LABA that is effective, rapid, well tolerated and with a reasonable acquisition cost. Various assessment agencies of the Spanish Autonomous Communities consider this combination to be an appropriate alternative therapy for asthma in the primary care setting.

Active surveillance cultures: comparison of inguinal and rectal sites for detection of multidrug-resistant bacteria.

BACKGROUND: Rectal swabs are the most widely used surveillance technique for detecting multidrug-resistant bacteria colonizing the intestinal tract. Obtaining these samples may cause embarrassment and discomfort to patients. Prior studies indicate that perirectal swabs are as sensitive and specific as rectal swabs with greater patient acceptance. AIM: To compare inguinal and rectal swabs for the detection of multidrug-resistant bacteria colonizing the intestinal tract. METHODS: An epidemiological, comparative, prospective, and controlled study was undertaken with 102 Brazilian patients. Inguinal and rectal swabs were collected for culture and compared. FINDINGS: Compared to rectal swabs, the sensitivity and specificity of inguinal swabs was 91.8% and 88.7%, respectively. Even when there were low colony counts from rectal samples, there were more than 100 colonies from inguinal samples. CONCLUSION: The inguinal region can be considered an acceptable alternative for collecting surveillance cultures for multidrug-resistant bacteria colonizing the intestinal tract. The inguinal swab technique is sensitive and specific for assessing multidrug-resistant micro-organisms, less embarrassing for patients, and simple to implement in hospital practice.

Nosocomial infections with metallo-beta-lactamase-producing Pseudomonas aeruginosa: molecular epidemiology, risk factors, clinical features and outcomes.

BACKGROUND: Metallo-ß-lactamases (MBLs) have emerged as one of the most important bacterial resistance mechanisms because of their ability to hydrolyse virtually all ß-lactam agents. MBL-producing Pseudomonas aeruginosa (MBL-PA) are an important cause of nosocomial infections, particularly in intensive care units (ICUs), where they are associated with serious infections and present a significant clinical risk. AIM: To assess the molecular epidemiology, risk factors and outcomes of nosocomial infections caused by MBL-PA in a teaching hospital in Southern Brazil. METHODS: From January 2001 to December 2008, 142 carbapenem-resistant P. aeruginosa strains were isolated from distinct clinical samples from hospitalized patients. These isolates were screened for MBLs, and underwent polymerase chain reaction, sequencing and pulsed-field gel electrophoresis (PFGE). Patients infected with carbapenem-resistant MBL-PA were considered as cases, and patients infected with non-MBL-PA were considered as controls. FINDINGS: Eighty-four of 142 patients with positive carbapenem-resistant P. aeruginosa cultures met the criteria of the Centers for Disease Control and Prevention for infection. Fifty-eight patients were infected with MBL-PA (69%) and 26 patients were infected with non-MBL-PA (31%). Multi-variate analysis revealed that ICU stay [P = 0.003, odds ratio (OR) 4.01, 95% confidence interval (CI) 1.15-14.01] and urinary tract infection (P = 0.001, OR 9.67, 95% CI 1.72-54.48) were important risk factors for MBL-PA infection. Patients infected with MBL-PA showed faster onset of infection (P = 0.002) and faster progression to death (P = 0.04). CONCLUSIONS: These results showed the severity of MBL-PA infections, and demonstrated the urgent need for strategies to improve infection control measures to prevent an increase in these nosocomial infections.

Evaluation of the Alere Pima™ for CD4+ T lymphocytes counts in HIV-positive outpatients in Southern Brazil.

CD4 + lymphocyte counts are routinely ordered during the early phases of antiretroviral therapy and for prophylaxis of opportunistic infections in HIV-positive patients. Flow cytometry is the standard methodology for CD4 counts in Brazilian reference laboratories. However, these laboratories are located in large cities, frequently distant from patients, thus limiting patient access and delaying results. We compared a point-of-care test with flow cytometry determination of CD4(+) T lymphocyte counts in HIV patients. We analysed 107 consecutive samples by both methods. Overall, the point-of-care test performed well, with excellent agreement between it and the standard method. Test results were concordant for patients with CD4(+) T lymphocyte values above and below 200 cells/mm (3). The performance characteristics obtained were sensitivity 94% (95% CI 89.5-98.5%), specificity 93% (95% CI 88.2-97.8%), positive predictive value 86% (95% CI 79.4-92.6%), and negative predictive value 97% (95% CI 94-100%). The high sensitivity and specificity of the point-of-care test methodology suggest its utility as an alternative method for rapid measurement of CD4(+) T lymphocytes in patients with limited access to reference laboratories, enabling prompt therapeutic intervention for patients at risk of progression to AIDS.

Factors associated with migration in individuals affected by leprosy, maranhão, Brazil: an exploratory cross-sectional study.

In Brazil, leprosy is endemic and concentrated in high-risk clusters. Internal migration is common in the country and may influence leprosy transmission and hamper control efforts. We performed a cross-sectional study with two separate analyses evaluating factors associated with migration in Brazil's Northeast: one among individuals newly diagnosed with leprosy and the other among a clinically unapparent population with no symptoms of leprosy for comparison. We included 394 individuals newly diagnosed with leprosy and 391 from the clinically unapparent population. Of those with leprosy, 258 (65.5%) were birth migrants, 105 (26.6%) were past five-year migrants, and 43 (10.9%) were circular migrants. In multivariate logistic regression, three independent factors were found to be significantly associated with migration among those with leprosy: (1) alcohol consumption, (2) separation from family/friends, and (3) difficulty reaching the healthcare facility. Separation from family/friends was also associated with migration in the clinically unapparent population. The health sector may consider adapting services to meet the needs of migrating populations. Future research is needed to explore risks associated with leprosy susceptibility from life stressors, such as separation from family and friends, access to healthcare facilities, and alcohol consumption to establish causal relationships.

Do young Carollia perspicillata (Chiroptera: Phyllostomidae) present higher infestation rates of Streblidae (Diptera)?

Ecological aspects related to parasitism are one of the less studied issues in parasitology research, and the scarce evidence available supports that younger specimens present higher infestation rates. The purpose of this work is to establish if higher infestation rates are observed in nursing females and their young captured inside their roost. Bats were captured inside a shelter located in RPPN Estação Veracel, Santa Cruz de Cabrália, Bahia state, Brazil. A total of 56 individuals of Carollia perspicillata were observed, 17 captured inside the roost during the day and 39 in trails at night. Captures of C. perspicillata during the day in a shelter yielded similar infestation rates to bats netted in trails and higher prevalence. The hypothesis that young were more infected was confirmed, based on the higher infestation of nursing females with neonates and on the significant inverse relation between body weight and number of parasites in young and subadults.

Use of a Real Time PCR for detecting subspecies of Babesia canis.

This paper reports the development and use of a Real Time PCR for detection of Babesia canis canis, B. canis rossi, and B. canis vogeli in endemic areas of Brazil. The sequences of the internal transcribed spacer (ITS) of several organisms were aligned and five primers and four probes were designed for amplification of a fragment (around 125 bp) which differentiates subspecies of B. canis. Blood samples collected from dogs living in farms in three distinct rural regions within the State of Minas Gerais (Lavras, Belo Horizonte and Nanuque) were tested. Blood samples had been collected during a dry season (Lavras, n=100; Belo Horizonte, n=50; Nanuque, n=102); the dogs were re-sampled in the subsequent rainy season (Lavras, n=71; Belo Horizonte, n=29; Nanuque, n=66). From each sample, DNA was extracted and Giemsa stained smears were microscopically examined for direct detection of Babesia parasites. B. canis vogeli was the only subspecies found, with an overall prevalence of 9.9% during the dry season and 10.8% during the rainy season. Dogs living in Nanuque and Belo Horizonte showed significantly higher prevalence rates than those living in Lavras (13.7%, 12.0% and 5.0%, respectively). The Real Time PCR developed proved to be appropriate to detect B. canis subspecies in endemic areas.

3D-RISM-KH molecular theory of solvation and density functional theory investigation of the role of water in the aggregation of model asphaltenes.

We applied a multiscale modeling approach that involves the statistical-mechanical three-dimensional reference interaction site model with the Kovalenko-Hirata closure approximation (3D-RISM-KH molecular theory of solvation) as well as density functional theory (DFT) of electronic structure to study the role of water in aggregation of the asphaltene model compound 4,4'-bis(2-pyren-1-yl-ethyl)-2,2'-bipyridine (PBP) [X. Tan, H. Fenniri and M. R. Gray, Energy Fuels, 2008, 22, 715]. The solvation free energy and potential of mean force predicted by 3D-RISM-KH reveal favorable pathways for disaggregation of PBP dimers in pure versus water-saturated chloroform solvent. The water density distribution functions elucidate hydrogen bonding preferences and water bridge formation between PBP monomers. The ΔG(298) values of -5 to -7 kcal mol(-1) for transfer of water molecules in chloroform to a state interacting with PBP molecules are in agreement with experimental results. Geometry optimization and thermochemistry analysis of PBP dimers with and without water bridges using WB97Xd/6-31G(d,p) predict that both PBP dimerization and dimer stabilization by water bridges are spontaneous (ΔG(298) < 0). The (1)H NMR chemical shifts of PBP monomers and dimers predicted using the gauge-independent atomic orbital method and polarizable continuum model for solvation in chloroform are in an excellent agreement with the experimental results for dilute and concentrated PBP solutions in chloroform, respectively [X. Tan, H. Fenniri and M. R. Gray, Energy Fuels, 2009, 23, 3687]. The DFT calculations of PBP dimers with explicit water show that bridges containing 1-3 water molecules lead to stabilization of PBP dimers. Additional water molecules form hydrogen bonds with these bridges and de-shield the PBP protons, negating the effect of water on the (1)H(C3) NMR chemical shift of PBP, in agreement with experiment. The ΔG(298) results show that hydrogen bonding to water and water-promoted polynuclear assembly bridging is as important as π-π interactions for asphaltene aggregation.

Desmodus rotundus (Mammalia: Chiroptera) on the southern coast of Rio de Janeiro state, Brazil.

Since the 1990s, attacks by hematophagous bats on humans and domestic animals have been reported both on the continent and on the islands on the southern coast of Rio de Janeiro state. The density of vampire bats was investigated based on percentage of captures during control of Desmodus rotundus samplings and during bat diversity research. In the present work, 203 individuals of D. rotundus were captured from 1993 to 2009, which corresponds to 11.88% of all bat captures carried out for species control in local villages and 1.58% of all captures in faunistic inventories. The density of D. rotundus is high even on the recently occupied islands where domestic animals have been introduced. It is probable that this species dispersed from the continent to the islands due to the introduction of domestic animals.

Efficiency of sulphur in garlic extract and non-sulphur homeopathy in the control of the cattle tick Rhipicephalus (Boophilus) microplus.

The objective of the present work was to evaluate the efficacy of a non-sulphur-based homeopathic preparation and a sulphur-containing natural product derived from Allium sativum (Linnaeus) against infestation by the cattle tick Rhipicephalus (Boophilus) microplus (Canestrini) (Acari: Ixodidae). A total of 24 crossbred calves (7 : 8 Holstein : Zebu), aged 6-8 months and maintained in individual stables under tick-free conditions, were divided into three groups. Group 1 (control group) received no treatment; Group 2 was treated with 0.01 g/day of the homeopathic preparation Fator C&MC(®), and Group 3 was treated with 20 g/day of Enxofre-Allium sativum(®). After adaptation to the diet for 1 month, each calf was subjected to artificial infestation with 8000 R. (B.) microplus larvae (aged 7-14 days) twice per week over a 5-month period. Numbers of engorged females were recorded every 14 days and samples of freely released engorged females were collected at 14-day intervals commencing 3 months after the start of the experiment. The engorged females were weighed, incubated for 15 days under biochemical oxygen demand conditions at 27 ± 1 °C and relative humidity >85%, and the weights of the egg masses produced were recorded. Other biological parameters, including reproduction estimate, reduction in oviposition and efficiency of treatment, were determined. A significant reduction in the number of engorged females was detected on animals treated with Enxofre-Allium sativum(®) (Group 3) in comparison with the other two groups. The overall efficiency of the treatment with the sulphur-containing product was 64%, whereas that of the homeopathic preparation was 26%. Under the experimental conditions established, Enxofre-Allium sativum(®) can reduce the intensity of the R. (B.) microplus infestation.

Colony size, sex ratio and cohabitation in roosts of Phyllostomus hastatus (Pallas) (Chiroptera: Phyllostomidae).

Phyllostomus hastatus bat is species broadly distributed over the Neotropical region, which uses as diurnal roosts caves, hollow trees, palm leaves and human buildings. Thirteen diurnal roosts of P. hastatus were analysed from 1990 to 2009 in several localities of Rio de Janeiro State, regarding environment (rural, urban or protected area), type of roost (hollow tree, basement or roof), sex ratio and cohabitation. A nocturnal roost was also analysed. Sex ratio of P. hastatus varied considerably among roosts what may be explained by the fact this species can roost alone, in couples, in harems or in groups of bachelor males. Phyllostomus hastatus was observed in cohabitation with three other species: Molossus rufus, Molossus molossus and Myotis nigricans. Due to the frequency of cohabitation observed between P. hastatus and species of the genus Molossus, one or more advantages for the members of this association may be expected. The simultaneous usage of a feeding roost by a group of bachelor males is unknown information in the literature, and may suggest that this kind of group may interact with each other even when away from their diurnal roosts.

Bat diversity of Ilha da Marambaia, Southern Rio de Janeiro State, Brazil (Chiroptera, Mammalia).

Few sites have been well sampled for bats, and samplings in islands are even scarcer. Therefore, the objectives of the present study were: (1) to list the bat species of Ilha da Marambaia; (2) to compare richness, abundance and biomass of bat guilds found there; (3) to analyse abundance patterns of bat species; and (4) to compare richness, abundance and composition of the bat fauna among different kinds of environment. To capture bats we used mist nets set in five different environments, totalising 3559.2 net-hours, during 37 nights between October 2006 and August 2008. A total of 1,133 captures were accomplished, comprising 34 species from five families. The most abundant species was Molossus molossus. Frugivorous bats exhibited higher richness, abundance and biomass if compared to other guilds. Most species (N = 22) exhibited abundances between 1 to 10% of all captures. Sixteen species were restricted to just one of the environments sampled. The high richness may be attributed to sampling carried out in several environments, and to the capture of insectivorous species over water bodies.

Bat diversity of Ilha da Marambaia, Southern Rio de Janeiro State, Brazil (Chiroptera, Mammalia) / Diversidade de morcegos da Ilha da Marambaia, Sul do Rio de Janeiro, Brasil (Chiroptera, Mammalia)

Few sites have been well sampled for bats, and samplings in islands are even scarcer. Therefore, the objectives of the present study were: (1) to list the bat species of Ilha da Marambaia; (2) to compare richness, abundance and biomass of bat guilds found there; (3) to analyse abundance patterns of bat species; and (4) to compare richness, abundance and composition of the bat fauna among different kinds of environment. To capture bats we used mist nets set in five different environments, totalising 3559.2 net-hours, during 37 nights between October 2006 and August 2008. A total of 1,133 captures were accomplished, comprising 34 species from five families. The most abundant species was Molossus molossus. Frugivorous bats exhibited higher richness, abundance and biomass if compared to other guilds. Most species (N = 22) exhibited abundances between 1 to 10 percent of all captures. Sixteen species were restricted to just one of the environments sampled. The high richness may be attributed to sampling carried out in several environments, and to the capture of insectivorous species over water bodies.

Poucos são os locais satisfatoriamente amostrados para morcegos e menos ainda as ilhas. Os objetivos deste estudo foram listar as espécies de morcegos da Ilha da Marambaia, comparar a riqueza, abundância e biomassa das guildas de morcegos encontradas, analisar o padrão de abundância das espécies de morcegos e comparar a riqueza, abundância e composição entre os diferentes ambientes amostrados. O método de amostragem consistiu do uso de redes de neblina armadas em cinco ambientes diferentes, totalizando 3559,2 redes-hora, em 37 noites entre outubro de 2006 e agosto de 2008. Foram obtidas 1.133 capturas, compreendendo 34 espécies de cinco famílias. A espécie mais abundante foi Molossus molossus. Os frugívoros apresentaram maior riqueza, abundância e biomassa. A maior parte das espécies (N = 22) apresentou abundâncias entre 1 e 10 por cento do total de capturas. Dezesseis espécies foram restritas a apenas um dos ambientes amostrados. A elevada riqueza encontrada pode ser atribuída à realização de coletas em vários ambientes, e a captura de espécies insetívoras sobre a água.

Utilidad e indicaciones de Omaluzumab en el asma bronquia / No disponible

No disponible

Soil and vegetation carbon stocks in Brazilian Western Amazonia: relationships and ecological implications for natural landscapes.

The relationships between soils attributes, soil carbon stocks and vegetation carbon stocks are poorly know in Amazonia, even at regional scale. In this paper, we used the large and reliable soil database from Western Amazonia obtained from the RADAMBRASIL project and recent estimates of vegetation biomass to investigate some environmental relationships, quantifying C stocks of intact ecosystem in Western Amazonia. The results allowed separating the western Amazonia into 6 sectors, called pedo-zones: Roraima, Rio Negro Basin, Tertiary Plateaux of the Amazon, Javari-Juruá-Purus lowland, Acre Basin and Rondonia uplands. The highest C stock for the whole soil is observed in the Acre and in the Rio Negro sectors. In the former, this is due to the high nutrient status and high clay activity, whereas in the latter, it is attributed to a downward carbon movement attributed to widespread podzolization and arenization, forming spodic horizons. The youthful nature of shallow soils of the Javari-Juruá-Purus lowlands, associated with high Al, results in a high phytomass C/soil C ratio. A similar trend was observed for the shallow soils from the Roraima and Rondonia highlands. A consistent east-west decline in biomass carbon in the Rio Negro Basin sector is associated with increasing rainfall and higher sand amounts. It is related to lesser C protection and greater C loss of sandy soils, subjected to active chemical leaching and widespread podzolization. Also, these soils possess lower cation exchangeable capacity and lower water retention capacity. Zones where deeply weathered Latosols dominate have a overall pattern of high C sequestration, and greater than the shallower soils from the upper Amazon, west of Madeira and Negro rivers. This was attributed to deeper incorporation of carbon in these clayey and highly pedo-bioturbated soils. The results highlight the urgent need for refining soil data at an appropriate scale for C stocks calculations purposes in Amazonia. There is a risk of misinterpreting C stocks in Amazonia when such great pedological variability is not taken into account.

Oral ulceration: an unusual manifestation of Churg-Strauss syndrome.

Churg-Strauss Syndrome (CSS) is a relatively rare entity characterized by asthma, transient pulmonary infiltrates, eosinophilia and systemic vasculitis. Oral ulceration is a possible clinical manifestation of some systemic vasculitides, such as Wegener's granulomatosis (WG) or giant cell arteritis, but has never been reported with Churg-Strauss syndrome. We report the first observation of a palatine ulceration in a 15-year-old girl with Churg-Strauss syndrome.