WHO clinical criteria–based initiation of antiretroviral therapy: lessons from rural district hospitals in Cameroon with regard to 2009 revised WHO recommendations

Objective To assess the proportion of patients infected with HIV with a CD4 count above 350 cells/mm³ among those classified at WHO clinical stage 3 or 4 who initiated antiretroviral therapy in rural district hospitals in Cameroon to assess the 2009 revised WHO recommendations. Methods Cross‐sectional study in nine rural district hospitals where the treatment initiation is based on the WHO clinical criteria. The proportion of patients who were classified at stage 3 or 4 and who had a CD4 count >350 cells/mm³ was assessed. Results Of 458 patients included in 2006–2008 (women 70.5%; median age 37.0 years), 337 (73.6%) were classified at WHO clinical stage 3 and 121 (26.4%) at stage 4. Overall, 108 patients (23.6%) had a CD4 count >350 cells/mm³. Of them, 94 patients (20.5%) were classified at WHO clinical stage 3, and 14 (3.1%) were classified at WHO clinical stage 4. Conclusion The WHO clinical stages 3 and 4 were poorly correlated with the ‘gold standard’ of CD4 cell count. This study highlights the need to promote CD4 testing for assessing the patient eligibility.     

Usual sleep duration and cognitive function in older adults in Spain

The few studies that have examined the association between usual sleep duration and cognitive function have shown conflicting results. This cross‐sectional study examined the association between sleep duration and cognitive function among 3212 people, representative of the non‐institutionalized population aged 60 years and over in Spain. Sleep duration was self‐reported, and cognitive function was measured with the Mini‐Examen Cognoscitivo (MEC), a version of the Mini‐Mental State Examination that has been validated in Spain. Linear regression, with adjustment for the main confounders, was used to obtain mean differences in the MEC between the categories of sleep duration (≤5, 6, 7, 8, 9, 10, ≥11 h day^?1). The MEC score decreased progressively (became worse) across sleep categories from 7 to ≥11 h (P for linear trend <0.001). People who slept for ≥11 h had a significantly lower MEC score than those who slept for 7 h (mean difference ?1.48; 95% confidence interval ?2.12 to ?0.85). This difference in the MEC was similar to that observed for a 10‐year increase in age. The results did not vary significantly by sex (P for interaction >0.05). No association was observed between short sleep duration (<7 h) and cognitive function. We conclude that long sleep duration is associated with poorer cognitive function in older adults from the general population.     

Diagnosing the ''strange'' child

The diagnosis of children with a spectrum of autistic features, who do not qualify for the diagnosis of classical autism, has increased during the past decade. A case is reported of an 8-year-old child originally diagnosed as learning disabled with attention disorders and hyperactivity, who was later diagnosed as having an autistic spectrum disorder when abnormalities of social interaction and play activity became more obvious. The frequency of learning and attention problems in school-age children may obscure more significant psychiatric pathologies, such as autistic disorders. Improved awareness of disorders of social functioning and play activity in the school-age child and use of screening tools may lead to earlier detection, definitive diagnosis and treatment for these children. In addition, assessments from multiple sources, i.e. the school, the home and the clinic, are needed in the diagnostic process. Periodic re-evaluations of the school-age child with problem behaviour are necessary to insure that more significant pathologies, which were not clear on initial evaluation, are diagnosed at the earliest opportunity.     

Failure of Plasma Atrial Natriuretic Peptide Levels to Increase During Exercise in Patients with Chronic Atrial Fibrillation

It is generally accepted that plasma atrial natriuretic peptide release occurs secondary to atrial stretch. The influence of coordinated atrial contraction (AC) upon this process is not fully appreciated. The aim of the study was to determine the importance of coordinated AC upon peripheral atrial natriuretic peptide levels (α-hANP) during exercise. Peripheral α-hANP levels were measured at rest and during exercise in 12 patients with complete heart block (CHB) and permanent rate responsive pacemakers. Seven patients had coordinated AC and five had chronic atrial fibrillation (AE). Each patient performed three treadmill exercise tests. Maximal inspired oxygen volume (VO₂ max) was determined during test 1. Tests 2 and 3 were performed to 70% VO₂ max, the pacemaker being programmed to either VVI or VVIR mode. Plasma α-hANP was measured using a two-site immunoradiometric assay. At rest there was a small but significant difference between the two patient groups: AF 60.2 pg/mL versus AC 97.6 pg/mL; P = 0.03. During exercise in the AC patients, there was a significant increase in α-hANP levels, in VVIR mode, to 238.4 pg/mL, and in VVI mode, to 207.9 pg/mL, P = 0.002 and 0.003, respectively. In those patients with chronic AF, there was no significant rise or fall in α-hANP levels in either pacing mode, VVIR 65.2 pg/mL, VVI 46.6 pg/mL. Previous workers have suggested that α-hANP release by nonfunctioning atria is normal. We have shown that the presence of coordinated AC is required for the release of α-hANP during exercise in patients with CHB, and that this appears to be independent of ventricular rate.     

Evaluation of a burn prevention program in Israeli schools

The study describes an educational burn injuries preventionprogram for schoolchildren, and its short and long term effectson knowledge, attitudes and the wish to learn more about preventivebehaviors. The data were collected by self-administered questionnairesin two sampled groups of 10–14 year olds: a study groupof children who were exposed to the program, and a similar controlgroup. All children filled out the questionnaire three times.prior to the introduction of the program, at the end of it,and 10 weeks later. The results show an increase in knowledgein both groups. Yet, a significantly higher level of knowledge was achievedin the study group. Six out of ten attitudes studied changedin the expected direction after the program in the study group,and none in the control group. The expressed willingness tolearn more about prevention of injuries increased significantlyonly in the study group. The results indicate that this programachieved its immediate goals, and suggest that burn preventioneducation programs can be successfully implemented among schoolchildren.     

Lithium/Silver Vanadium Oxide Batteries for Implantable Defibrillators

Lithium/silver vanadium oxide (SVO) batteries have been under development in these laboratories since 1980. The system consists of a lithium anode, a liquid organic electrolyte, a cathode composed of conductive additives, a binder, and silver vanadium oxide, a vanadium oxide bronze produced by the thermal decomposition of vanadium oxide and silver nitrate. High rate batteries/or implantable cardiac defibrillators based on this chemistry have been under development since 1984. The first Li/SVO defibrillator battery introduced was the Model 8512 with a theoretical capacity of 5.5 Ah and dimensions of 52 mm × 33 mm × 13.5 mm. Later, the Model 8615 was introduced. This cell has a theoretical capacity of 3.0 Ah and dimensions of 52 mm × 21 mm × 13.5 mm. Two other cells which are proprietary have also been introduced. All of the cells can deliver pulses of up to 2.0 amps from a microampere background. The self-d is charge of the cells has been shown to be less than 2% per year. In addition, the silver vanadium oxide chemistry provides a discharge curve whose voltage decreases with depth of discharge. This feature can be used as a state-of-charge indicator. The cells have been subjected to rigorous environmental and abuse testing and have been found to have characteristics suitable for implantable applications.     

Hypersensitivity to bacteria in eczema

The sera of persons with generalized eczema (Whitfield-type) or with disseminated nummular eczema were examined for complement-activating antibacterial antibodies to test the hypothesis that some eczematous change results from an antibody-mediated cytotoxic reaction. Bacteria dying in the stratum corneum release soluble antigens, some of which diffuse into the stratum Malpighii and become firmly adsorbed to the epidermal cells. Antibacterial antibody and complement diffusing into the epidermis react with the antigens acquired by the cells and may induce vacuolation or lysis. Phenol-extracted and freeze-press-extracted antigens (both containing teichoic aeids) from Staphy-lococcus aureus and a micrococcus (Baird-Parker types Si and Ml respectively) are adsorbed by mono-layers of human skin, embryo or amnion. Cells acquiring the antigen(s) are severely damagedwhen treated with sera containing the appropriate antibacterial antibodies and complement. IgM comple-ment fixing antibody appears to be much more cytotoxic in this test than IgG. The cytotoxic activity of a serum is specific for the acquired bacterial antigen and appears to depend on a sufficient concentration of the effective antibody, and not on the presence of antibodies with special properties. Explants of full thickness skin treated with bacterial antigen extracts were unharmed by the antibodies thatwere cytotoxic for monolayers of skin cells treated with the same antigens. The in vitro cytotoxic test should represent a potential in vivo cytotoxic phenomenon, because skin cell monolayers from two patients adsorbed bacterial antigen prepared from cultures obtained from the same patients, and were damaged by autologous serum containing anti-staphylococcal antibody and complement. It seems probable that this may be an aggravating but not necessarily an initiating factor in many cases of eczema.