Lower prevalence of chronic itch in haemodialysis patients on loop diuretics: results from GEHIS (German Epidemiological Hemodialysis Itch Study).

BACKGROUND: Chronic itch (CI) is a very tormenting symptom in haemodialysis (HD) patients. GEHIS (German Epidemiological Hemodialysis Itch Study) is a representative cross-sectional study showing that current chronic itch (CI) affects 25.2% of haemodialysis (HD) patients. OBJECTIVE: We investigated drug intake and possible associations between CI and medications of HD patients. METHODS: Eight hundred and sixty HD patients from a randomly selected cluster sample of 25 dialysis units (GEHIS) in Germany were investigated. Statistical analyses were performed using R (version 3.3.0) for Windows. Logistic regression was used to identify influential covariates for prevalence of chronic itch and intensity of itch. RESULTS: Taking loop diuretics (furosemide, torasemide) was significantly negatively associated with the occurrence of CI in HD patients meaning that those who had received any type of loop diuretics were significantly less likely to suffer from less CI compared to those who had not taken them. There were no associations of CI with other medications. No correlation was detected between the intensity of itch and the intake of loop diuretics or any other medication. CONCLUSION: Loop diuretics may have an impact on the development of CI in HD patients. As it is most likely that a multifactorial origin may explain CI in HD, future research should also focus on the role of loop diuretics in CI, both on a clinical as well as on a molecular level.

[Uncommon clinical manifestations of cutaneous leishmaniasis]. / Außergewöhnliche klinische Manifestationen der kutanen Leishmaniasis.

Cutaneous leishmaniasis is one of the most common dermatoses of the tropics. A major focus of this disease is the Syrian city of Aleppo, after which it was named in many textbooks ("Aleppo boil"). The first cases of cutaneous leishmaniasis were reported from Aleppo particularly more than 100 years ago. Syria is one of the most affected countries worldwide. This disease used to be well documented until the onset of the war in Syria in 2012, which is also supported by the numbers of the World Health Organisation (WHO), and Aleppo used to be the most affected Syrian city. Since 2012, the documentation of cutaneous leishmaniasis in Syria is no longer possible. An outbreak of cutaneous leishmaniasis has been detected especially in the besieged regions due to missing prevention measures against the sandflies and a lack of medical care. A short summary of the epidemiologic situation in Syria as well as outstanding and uncommon clinical manifestations of cutaneous leishmaniasis in Aleppo are presented.

Vitamin A and respiratory syncytial virus infection. Serum levels and supplementation trial.

OBJECTIVE: To determine the benefit of oral vitamin A supplementation for acute respiratory syncytial virus (RSV) infection. DESIGN: An observational study of vitamin A and retinol binding protein (RBP) levels in RSV-infected inpatients and two control groups; and a randomized, controlled trial of vitamin A supplementation for RSV-infected inpatients. SETTING: Two tertiary care, urban teaching hospitals. PARTICIPANTS: Thirty-two RSV-infected inpatients (aged 2 to 58 months), 35 hospitalized children without respiratory infections (aged 2 to 19 months), and 39 healthy outpatient controls (aged 2 to 67 months). INTERVENTION: The RSV-infected group was randomized to receive a single dose of 100,000 IU oral vitamin A or placebo. MAIN OUTCOME MEASURES: Serum vitamin A and RBP levels of all participants and clinical indicators of severity such as days of hospitalization, oxygen use, intensive care, intubation, and a daily severity score. RESULTS: Mean vitamin a and RBP levels were lower in RSV-infected children than in healthy controls (P > .05). Among RSV-infected children, those admitted to the intensive care unit had lower mean vitamin A (P = .03) and RBP levels (P = .04) than those not in intensive care. Among children hospitalized without respiratory infection, those admitted to the intensive care unit had lower mean vitamin A levels (P = .02) than those not in intensive care. In the RSV-infected children, no significant difference was seen between the vitamin A group (n = 21) and the placebo group (n = 11) in improvement in severity score, mean days of hospitalization, intensive care, or receipt of supplemental oxygen. CONCLUSIONS: Serum vitamin A and RBP levels were low in children hospitalized with RSV infection and were lower in children admitted to the intensive care unit. Hospitalized control patients in intensive care also had lower levels than those treated on the ward. We observed no benefit from oral vitamin A supplementation for children hospitalized with RSV infection.

Citrobacter koseri osteomyelitis in an infant.

A 3-week-old infant developed left shoulder swelling and was found to have septic arthritis and osteomyelitis of the humerus caused by Citrobacter koseri (formerly C. diversus). Citrobacter species are Gram-negative rods that are best known for their propensity to cause neonatal meningitis, ventriculitis and concomitant brain abscess. Non-central nervous system infections are rare. The present case illustrates that neonatal osteomyelitis caused by unusual organisms can present to pediatricians in an inner-city setting, and can respond favorably to surgical and medical management.

Impaired phagocyte oxidative capacity in human immunodeficiency virus-infected children.

Children infected with the human immunodeficiency virus (HIV) have T helper cell deficiency, but frequent bacterial infections suggest phagocyte dysfunction. Whole blood chemiluminescence (CL) assays were used to measure the respiratory burst capacity of phagocytes from HIV-infected children, perinatally HIV-exposed but uninfected children, and normal healthy children. Phagocytes were stimulated by zymosan opsonized with human complement with and without priming by platelet-activating factor (PAF) or FMLP. Activities of enzymes involved in the respiratory burst, oxidase and myeloperoxidase, were examined after opsonin receptor-independent stimulation with PMA. Unprimed CL responses to opsonized zymosan were decreased for HIV-infected children with severe CD4 lymphocyte suppression compared with healthy children (P=.03), and PAF-primed CL responses to opsonized zymosan were decreased in HIV-infected children with both moderate and severe CD4 lymphocyte suppression (P=.02 and P=.01, respectively), despite normal or increased activities of the respiratory burst enzymes. These impairments may contribute to secondary bacterial infections.

Citrobacter sedlakii meningitis and brain abscess in a premature infant.

Citrobacter sedlakii was isolated from blood and cerebrospinal fluid cultures of a 5-day-old premature infant with sepsis, meningitis, and brain abscess. This newly described organism was difficult to identify due to discrepancies between the Vitek and API 20E identification systems. To our knowledge, this is the first report of the isolation of C. sedlakii from cerebrospinal fluid.

Evidence for long-term memory of the mucosal immune system: milk secretory immunoglobulin A against Shigella lipopolysaccharides.

Although the common mucosal immune system has generally been considered to have only short-term memory, recent data suggest that long-term memory exists for Shigella virulence plasmid antigens. Because such antigens might cross-react with environmental antigens, we investigated milk for the persistence of antibodies to the specific Shigella lipopolysaccharide (LPS) antigens. Enzyme-linked immunosorbent assays to detect secretory immunoglobulin A (sIgA) against Shigella flexneri and Shigella sonnei LPS in milk samples were developed; 15 random milk samples tested on different days correlated from one day to the next (P = 0.0001). Of 18 Mexican mothers, 18 (100%) had one or more milk samples positive for anti-S. flexneri LPS, 14 (78%) had one or more milk samples positive for anti-S. sonnei LPS, and 14 (78%) had one or more milk samples positive for both. Of 27 Houston mothers, 16 (59%) had one or more milk samples positive for anti-S. flexneri LPS, 7 (26%) had one or more milk samples positive for anti-S. sonnei LPS, and 5 (19%) had one or more milk samples positive for both. Mexican mothers were significantly more likely than Houston mothers to have at least one sample with a positive titer for anti-S. flexneri LPS (P less than 0.02) and at least one sample with a positive titer for anti-S. sonnei LPS (P less than 0.002). Although the Houston women had a lower rate of titer positivity for both Shigella species, the rate was too high to be consistent with short-lived mucosal immunity. It is unlikely that 18 of the 27 Houston women had shigellosis during or just prior to lactation. The data suggest that there exists a long-term hormonally driven memory in the secretory immune system for Shigella spp.

Concentration of milk secretory immunoglobulin A against Shigella virulence plasmid-associated antigens as a predictor of symptom status in Shigella-infected breast-fed infants.

We conducted a prospective, community-based study of healthy breast-fed Mexican infants to determine the protective effects of anti-Shigella secretory IgA antibodies in milk. Milk samples were collected monthly, and stool culture specimens were obtained weekly and at the time of episodes of diarrhea. Nineteen breast-fed infants were found to have Shigella flexneri, Shigella boydii, or Shigella sonnei in stool samples. Ages of the 10 infants with symptomatic infection and the nine with asymptomatic infection did not differ significantly. Milk samples collected up to 12 weeks before infection were evaluated by enzyme-linked immunosorbent assay for secretory IgA antibodies against lipopolysaccharides of S. flexneri, S. boydii serotype 2, S. sonnei, and virulence plasmid-associated antigens. The geometric mean titers of anti-Shigella antibodies to virulence plasmid-associated antigens in milk received before infection were eightfold higher in infants who remained well than in those in whom diarrhea developed. The significance of milk secretory IgA directed against lipopolysaccharide was less clear. We conclude that human milk protects infants against symptomatic shigella infection when it contains high concentrations of secretory IgA against virulence plasmid-associated antigens.

Pharmacokinetics of once-daily dosing of gentamicin in neonates.

In a prospective, randomized trial of once-daily versus twice-daily intravenous or intramuscular dosing with gentamicin, 11 neonates received 5.0 mg/kg once daily and 15 received 2.5 mg/kg twice daily for 2 ro 3 days. The once-daily intravenous dosing group and the twice-daily intravenous or intramuscular dosing group, respectively, had mean steady-state gentamicin peak concentrations of 10.7 versus 6.6 micrograms/ml (p < 0.05), 6-hour postdosing concentrations of 4.7 versus 2.8 micrograms/ml (p < 0.05), trough concentrations of 1.7 versus 1.7 micrograms/ml, elimination half-life of 8.8 versus 5.4 hours (p < 0.05), and volume of distribution at steady state of 0.67 versus 0.46 L/kg. No nephrotoxic effects were identified in any group. Once-daily gentamicin therapy with 5.0 mg/kg in neonates achieves peak serum levels that are more suitable for optimal bacterial killing than those which traditional regimens achieve. Similar trough levels suggest that even larger doses and longer dosing intervals may be ideal in term neonates.