Time since last vaccine dose in PCR-positive and PCR-negative children with suspected pertussis to monitor pertussis vaccine effectiveness

We evaluated whether the results of diagnostic polymerase chain reaction (PCR) testing combined with time since last vaccine dose could be used to monitor the effectiveness of acellular pertussis vaccines. In 258 consecutive nasopharyngeal swabs from children and adolescents with typical pertussis symptoms, 80 were positive and 178 were negative in PCR for Bordetella pertussis DNA (IS 481). Time since last vaccine dose was available for 152 patients, of which 120 were fully immunised. Among the fully vaccinated patients, the median age of 41 PCR-positive patients was 8.4 years (range 0.9–12.3) and that of 79 PCR-negative cases was 3.3 years (range 0.4–14.1) (p?<?0.01). The median time since last pertussis vaccine dose was 6.05 years [95 % confidence interval (CI): 0.5–10.9] in PCR-positive cases and 2.22 years (95 % CI: 0.04–9.23) in PCR-negative cases (p?<?0.001). The use of diagnostic PCR results from pertussis cases together with time since last vaccine dose permits estimates of the duration of protection after vaccination with acellular pertussis vaccines that are in keeping with more complex studies.     

Immunological monitoring of extracorporeal photopheresis after heart transplantation

Extracorporeal photopheresis (ECP) has been used as a prophylactic and therapeutic option to avoid and treat rejection after heart transplantation (HTx). Tolerance‐inducing effects of ECP such as up‐regulation of regulatory T cells (T_regs) are known, but specific effects of ECP on regulatory T cell (T_reg) subsets and dendritic cells (DCs) are lacking. We analysed different subsets of T_regs and DCs as well as the immune balance status during ECP treatment after HTx. Blood samples were collected from HTx patients treated with ECP for prophylaxis (n = 9) or from patients with histologically proven acute cellular rejection (ACR) of grade ≥ 1B (n = 9), as well as from control HTx patients without ECP (HTxC; n = 7). Subsets of T_regs and DCs as well as different cytokine levels were analysed. Almost 80% of the HTx patients showed an effect to ECP treatment with an increase of T_regs and plasmacytoid DCs (pDCs). The percentage of pDCs before ECP treatment was significantly higher in patients with no ECP effect (26·3% ± 5·6%) compared to patients who showed an effect to ECP (9·8% ± 10·2%; P = 0·011). Analysis of functional subsets of CD4⁺CD25^highCD127^low T_regs showed that CD62L‐, CD120b‐ and CD147‐positive T_regs did not differ between the groups. CD39‐positive T_regs increased during ECP treatment compared to HTxC. ECP‐treated patients showed higher levels for T helper type 1 (Th1), Th2 and Th17 cytokines. Cytokine levels were higher in HTx patients with rejection before ECP treatment compared to patients with prophylactic ECP treatment. We recommend a monitoring strategy that includes the quantification and analysis of T_regs, pDCs and the immune balance status before and up to 12 months after starting ECP.     

Lower prediagnostic serum 25-hydroxyvitamin D concentration is associated with higher risk of insulin-requiring diabetes: a nested case–control study

Aims/hypothesis

Low serum 25-hydroxyvitamin D [25(OH)D] concentration may increase risk of insulin-requiring diabetes.

Methods

A nested case–control study was performed using serum collected during 2002–2008 from military service members. One thousand subjects subsequently developed insulin-requiring diabetes. A healthy control was individually matched to each case on blood-draw date (±2?days), age (±3?months), length of service (±30?days) and sex. The median elapsed time between serum collection and first diagnosis of diabetes was 1?year (range 1?month to 10?years). Statistical analysis used matched pairs and conditional logistic regression.

Results

ORs for insulin-requiring diabetes by quintile of serum 25(OH)D, from lowest to highest, were 3.5 (95% CI 2.0, 6.0), 2.5 (1.5, 4.2), 0.8 (0.4, 1.4), 1.1 (0.6, 2.8) and 1.0 (reference) (p _trend <0.001). The quintiles (based on fifths using serum 25(OH)D concentration in the controls) of serum 25(OH)D in nmol/l, were <43 (median 28), 43–59 (median 52), 60–77 (median 70), 78–99 (median 88) and ≥100 (median 128).

Conclusions/interpretation

Individuals with lower serum 25(OH)D concentrations had higher risk of insulin-requiring diabetes than those with higher concentrations. A 3.5-fold lower risk was associated with a serum 25(OH)D concentration ≥60?nmol/l.     

Test–retest stability of an experimental measure of human turning behaviour in right-handers,mixed-handers,and left-handers

Animals turn away from the hemisphere with the more active dopamine (DA) system. For humans, a similar relationship has been assumed, albeit that side preferences obtained from different measures are inconsistent. Given the important role of DA on human behaviour and cognition, a stable human turning measure is of significant experimental value. We assessed the stability (test and retest 4 weeks apart) of veering behaviour (lateral deviations during blindfolded straight ahead walking) in 20 healthy right-handers, 20 mixed-handers, and 20 left-handers. Veering behaviour did not differ between groups, and did not reveal any particular side preference in any group. Relationships of side preferences between testing sessions for the different handedness groups was low for right-handers, and showed some minor consistency for the mixed-handed group. Neither handedness nor footedness was significantly related to preferred veering side. These findings, if not related meaningfully to DA-mediated conditions (e.g., clinical populations, pharmacological studies, personality) in the future, suggests that veering behaviour is an inappropriate alternative to the animal turning model. These findings challenge the reliability of human turning measures, and invite more broadly for a critical evaluation of turning measures as an indicator of hemispheric DA asymmetries in human populations.     

Nasotracheal intubation with three indirect laryngoscopes assisted by standard or modified Magill forceps

We assessed the effect of modifying standard Magill forceps on the laryngeal introduction of an Eschmann stylet during nasotracheal intubations with three indirect laryngoscopes (Airtraq?, C‐MAC^® or GlideScope^®) in patients with predicted difficult intubation. We allocated 50 participants to each laryngoscope. The stylet was advanced by one forceps followed by the other (standard or modified), with each sequence allocated to 25/50 for each laryngoscope. There were no differences in rates of failed tracheal intubation with the allocated laryngoscopes: 6/50, 5/50 and 5/50, respectively. An Eschmann stylet was advanced into the trachea less often with the standard forceps (65% vs 93%, p < 0.0001). Mean (SD) time for stylet advancement was longer with the standard forceps, 38 (30) vs 19 (19) s, p < 0.0001. In conclusion, the modified Magill forceps facilitated nasotracheal intubation, independent of the type of indirect laryngoscope.     

Therapiezieländerung und Therapiebegrenzung in der Intensivmedizin

The task of physicians is to maintain life, to protect and re-establish health as well as to alleviate suffering and to accompany the dying until death, under consideration of the self-determination rights of patients. Increasingly more and differentiated options for this are becoming available in intensive care medicine. Within the framework of professional responsibility physicians must decide which of the available treatment options are indicated. This process of decision-making is determined by answering the following question: when and under which circumstances is induction or continuation of intensive care treatment justified? In addition to the indications, the advance directive of the patient is the deciding factor. Medical indications represent a scientifically based estimation that a therapeutic measure is suitable in order to achieve a defined therapy target with a given probability. The ascertainment of the patient directive is achieved in a graded process depending on the state of consciousness of the patient. The present article offers orientation assistance to physicians for these decisions which are an individual responsibility.