Detection of gram-negative bacteraemia in early sepsis by a quantitative chromogenic and kinetic endotoxin assay

A kinetic chromogenic limulus test was carried out in order to investigate the possibility of a sensitive and specific detection of circulating endotoxin during the first 24 h of septic shock or severe sepsis in 76 patients. Two commercial kits, Whittaeker (W) and Chromogenix (C), were used. Blood culture was taken as a reference. At 1 : 10 plasma dilution (a currently used dilution in the end point limulus test) abnormal reaction kinetics were found in 13% and 41% of tests, for C and W respectively ( P  = 0.0008), resulting in unreliable results. Retesting plasma at a greater dilution, until the reaction kinetic was identical to calibration curve control values, gave similar results between the two kits and a better accuracy. Beyond a 0.5 EU mL⁻¹ endotoxin level, the probability of Gram-negative bacteraemia was high (sensitivity = 0.53 and 0.47; specificity = 0.95 and 0.93 for C and W respectively). This kinetic limulus amoebocyte lysate (LAL) test may be useful in therapeutic decisions for treatment of endotoxaemia.     

Operational factors of maternal mortality in Zimbabwe

Most studies on maternal mortality have looked at the directclinical causes and the distribution of actual rates. Much lessattention has been given to prevailing health care systems orcommunity factors associated with such deaths. A case-controlstudy design using incident cases was used to identify the magnitudeof maternal deaths and community and health care operationalfactors in both an urban and a rural setting in Zimbabwe. Thematernal mortality ratio for the rural setting was 168 per 100000 live births and that for the urban setting was 85 per 100000 live births. For the rural setting, the major direct causesof death were haemorrhage (24.8%), abortion complications (15.2%),puerperal sepsis (13.3%), and eclampsia (4.8%). For the urbansetting they were eclampsia (26.2%), abortion complications(23.0%), puerperal sepsis (14.8%) and haemorrhage (9.8%). Whereas rural-urban variations in maternal mortality were observed,inter-rural district variations were also apparent, especiallywith poor medical resources, poor communication and delayedinterventions. Risk factors for maternal mortality were presentat each of the various levels of care. Lack of antenatal care(ANC) had a significant Odds Ratio (OR 10.7 rural and 4.6 urban)contribution to maternal mortality. When abortions and ectopicswere excluded the OR for absent ANC was 4.1 (rural) and 2.6(urban). Lack of timely transport to nearest clinic or hospitaladversely affected pregnancy outcome in both rural and urbansettings. Despite delivery place planning, predisposing healthconditions and some danger signals, few of the women utilizedthe venue originally planned for delivery. Health education, community sensitization and teaching on risksignal awareness as well as health care delivery system strengtheningare recommended for reducing the high maternal mortality rates. ⁴Includes: Dr F Ashworth, Prof Mtimavalye, Dr Chatora, Dr PNhindiri, Dr Chiwora, Sister Nyangani, Sister Mujaji, SisterMakahamadzem, Mr Mandisodza, Mr Mashu, Sister Nyoni, Mr Dauramanzi,Mrs Dengu and the late Dr Chimbira     

Assessment of differences in linear growth among populations in the WHO Multicentre Growth Reference Study

Aim: To assess differences in length/height among populations in the WHO Multicentre Growth Reference Study (MGRS) and to evaluate the appropriateness of pooling data for the purpose of constructing a single international growth standard. Methods: The MGRS collected growth data and related information from 8440 affluent children from widely differing ethnic backgrounds and cultural settings (Brazil, Ghana, India, Norway, Oman and the USA). Eligibility criteria included breastfeeding, no maternal smoking and environments supportive of unconstrained growth. The study combined longitudinal (birth to 24 mo) and cross-sectional (18–71 mo) components. For the longitudinal component, mother–infant pairs were enrolled at delivery and visited 21 times over the next 2 y. Rigorous methods of data collection and standardized procedures were applied across study sites. We evaluate the total variability of length attributable to sites and individuals, differences in length/height among sites, and the impact of excluding single sites on the percentiles of the remaining pooled sample. Results: Proportions of total variability attributable to sites and individuals within sites were 3% and 70%, respectively. Differences in length and height ranged from −0.33 to +0.49 and −0.41 to +0.46 standard deviation units (SDs), respectively, most values being below 0.2 SDs. Differences in length on exclusion of single sites ranged from −0.10 to +0.07, −0.07 to +0.13, and −0.25 to +0.09 SDs, for the 50th, 3rd and 97th percentiles, respectively. Corresponding values for height ranged from −0.09 to +0.08, −0.12 to +0.13, and −0.15 to +0.07 SDs.
Conclusion: The striking similarity in linear growth among children in the six sites justifies pooling the data and constructing a single international standard from birth to 5 y of age.     

Rapid symptom relief in reflux oesophagitis: a comparison of lansoprazole and omeprazole

Background: Lansoprazole, a substituted benzimidazole, is a proton pump inhibitor which is highly effective in the control of 24-h intragastric acidity. The aim of this multicentre, randomized, double-blind study was to compare lansoprazole 30 mg once daily and omeprazole 20 mg once daily in the symptom relief and healing of patients with reflux oesophagitis. Methods: Six hundred and four patients with endoscopically proven oesophagitis and a recent history of heartburn were randomly assigned to receive lansoprazole 30 mg or omeprazole 20 mg daily for 4–8 weeks. Daily assessment of symptoms was made by the patient using a 100-mm Visual Analogue Scale. Clinical symptoms were evaluated at weeks 0, 1, 4 and 8. Endoscopic assessment of healing, defined by normalization of the oesophageal mucosal appearance, was made at weeks 4 and 8. Results: Two hundred and eighty-two patients in the lansoprazole group and 283 patients in the omeprazole group were eligible for inclusion in the per protocol analysis. At 3 days, there was a significant improvement in daytime symptoms of heartburn for patients in the lansoprazole group compared with the omeprazole group (P=0.05). A similar but non-significant trend was seen at 7 days (P=0.18). Clinical assessment at 7 days demonstrated significant improvement in daytime epigastric pain in the lansoprazole group compared with the omeprazole group (P=0.03), with a similar but non-significant trend in night-time epigastric pain (P=0.07). Healing rates of oesophagitis at 4 and 8 weeks were 70 and 87%, respectively, with lansoprazole, and 63 and 82%, respectively, with omeprazole. Logistic regression analysis of the cumulative healing rates, which included baseline factors affecting outcome, resulted in an odds ratio of 1.46 (95% CI=0.87–2.45), suggesting a higher chance of being healed with lansoprazole treatment compared with omeprazole treatment. A total of 615 adverse events were reported by 308 (51%) patients during the study period. The majority of events were mild in nature and the incidence was similar in both treatment groups. The most frequently reported events were headache, diarrhoea and nausea. Conclusion: Lansoprazole provides greater symptom relief compared with omeprazole during the first week of treatment. Both treatments were effective in healing oesophagitis.     

Mortality of patients excluded from the Danish Verapamil Infarction Trial II

The 18 month mortality rate in 2180 patients excluded from theDanish Verapamil Infarction Trial II (DAVIT II) was 25.6%. Innon-consenters (n = 368) this was 15.0% compared with 13.8%in 897 placebo-treated patients (hazard ratio 1.09 [P = 0.60]when adjusting for sex and age). The increased mortality ratein excluded patients is attributed to heart failure (45.8% andother severe diseases (38.9%).     

Treating chronic hepatitis C with pegylated interferon alfa-2a (40 KD) and ribavirin in clinical practice

BACKGROUND: Pegylated interferon alfa-2a (40 KD) plus ribavirin therapy induces sustained virological response rates up to 63% in randomized-controlled trials. AIM: To conduct a prospective open-label programme to examine the efficacy and safety of this therapy in routine clinical practice. Methods: Treatment-naive patients with chronic hepatitis C received, at the discretion of the investigator, pegylated interferon alfa-2a 180 microg/week + ribavirin 800 mg/day for 24 or 48 weeks. In total, 508 patients were enrolled [334 non-cirrhotic; 174 cirrhotic (defined as stage F3 and F4)]. RESULTS: In genotype 1 patients treated for 48 weeks, sustained virological response rates were 41% in non-cirrhotics and 34% in cirrhotics. Sustained virological response rates in genotype 2 or 3 non-cirrhotics were 79% (24 weeks) and 72% (48 weeks). Corresponding values for cirrhotic genotype 2/3 were 66% and 44%. The negative predictive value of an early virological response at week 12 was 94%. Predictive factors for sustained virological response on multivariate analysis were genotype (2/3 vs. 1), low viral load and degree of fibrosis. Rates of serious adverse events (相似文献