A Bundle of Services Increased Ascertainment of Tuberculosis among HIV-Infected Individuals Enrolled in a HIV Cohort in Rural Sub-Saharan Africa.

OBJECTIVES To report on trends of tuberculosis ascertainment among HIV patients in a rural HIV cohort in Tanzania, and assessing the impact of a bundle of services implemented in December 2012, consisting of three components:(i)integration of HIV and tuberculosis services; (ii)GeneXpert for tuberculosis diagnosis; and (iii)electronic data collection. DESIGN Retrospective cohort study of patients enrolled in the Kilombero Ulanga Antiretroviral Cohort (KIULARCO), Tanzania.). METHODS HIV patients without prior history of tuberculosis enrolled in the KIULARCO cohort between 2005 and 2013 were included.Cox proportional hazard models were used to estimate rates and predictors of tuberculosis ascertainment. RESULTS Of 7114 HIV positive patients enrolled, 5123(72%) had no history of tuberculosis. Of these, 66% were female, median age was 38 years, median baseline CD4+ cell count was 243 cells/µl, and 43% had WHO clinical stage 3 or 4. During follow-up, 421 incident tuberculosis cases were notified with an estimated incidence of 3.6 per 100 person-years(p-y)[95% confidence interval(CI)3.26-3.97]. The incidence rate varied over time and increased significantly from 2.96 to 43.98 cases per 100 p-y after the introduction of the bundle of services in December 2012. Four independent predictors of tuberculosis ascertainment were identified:poor clinical condition at baseline (Hazard Ratio (HR) 3.89, 95% CI 2.87-5.28), WHO clinical stage 3 or 4 (HR 2.48, 95% CI 1.88-3.26), being antiretroviralnaïve (HR 2.97, 95% CI 2.25-3.94), and registration in 2013(HR 6.07, 95% CI 4.39-8.38). CONCLUSION The integration of tuberculosis and HIV services together with comprehensive electronic data collection and use of GeneXpert increased dramatically the ascertainment of tuberculosis in this rural African HIV cohort.

The first batteryless, solar-powered cardiac pacemaker

BACKGROUND: Contemporary pacemakers (PMs) are powered by primary batteries with a limited energy-storing capacity. PM replacements because of battery depletion are common and unpleasant and bear the risk of complications. Batteryless PMs that harvest energy inside the body may overcome these limitations. OBJECTIVE: The goal of this study was to develop a batteryless PM powered by a solar module that converts transcutaneous light into electrical energy. METHODS: Ex vivo measurements were performed with solar modules placed under pig skin flaps exposed to different irradiation scenarios (direct sunlight, shade outdoors, and indoors). Subsequently, 2 sunlight-powered PMs featuring a 4.6-cm2 solar module were implanted in vivo in a pig. One prototype, equipped with an energy buffer, was run in darkness for several weeks to simulate a worst-case scenario. RESULTS: Ex vivo, median output power of the solar module was 1963 μW/cm2 (interquartile range [IQR] 1940-2107 μW/cm2) under direct sunlight exposure outdoors, 206 μW/cm2 (IQR 194-233 μW/cm2) in shade outdoors, and 4 μW/cm2 (IQR 3.6-4.3 μW/cm2) indoors (current PMs use approximately 10-20 μW). Median skin flap thickness was 4.8 mm. In vivo, prolonged SOO pacing was performed even with short irradiation periods. Our PM was able to pace continuously at a rate of 125 bpm (3.7 V at 0.6 ms) for 1½ months in darkness. CONCLUSION: Tomorrow's PMs might be batteryless and powered by sunlight. Because of the good skin penetrance of infrared light, a significant amount of energy can be harvested by a subcutaneous solar module even indoors. The use of an energy buffer allows periods of darkness to be overcome.

Cryptococcal Antigenemia in Immunocompromised Human Immunodeficiency Virus Patients in Rural Tanzania: A Preventable Cause of Early Mortality

Background.  Cryptococcal meningitis is a leading cause of death in people living with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome. The World Health Organizations recommends pre-antiretroviral treatment (ART) cryptococcal antigen (CRAG) screening in persons with CD4 below 100 cells/µL. We assessed the prevalence and outcome of cryptococcal antigenemia in rural southern Tanzania. Methods.  We conducted a retrospective study including all ART-naive adults with CD4 <150 cells/µL prospectively enrolled in the Kilombero and Ulanga Antiretroviral Cohort between 2008 and 2012. Cryptococcal antigen was assessed in cryopreserved pre-ART plasma. Cox regression estimated the composite outcome of death or loss to follow-up (LFU) by CRAG status and fluconazole use. Results.  Of 750 ART-naive adults, 28 (3.7%) were CRAG-positive, corresponding to a prevalence of 4.4% (23 of 520) in CD4 <100 and 2.2% (5 of 230) in CD4 100-150 cells/µL. Within 1 year, 75% (21 of 28) of CRAG-positive and 42% (302 of 722) of CRAG-negative patients were dead or LFU (P<.001), with no differences across CD4 strata. Cryptococcal antigen positivity was an independent predictor of death or LFU after adjusting for relevant confounders (hazard ratio [HR], 2.50; 95% confidence interval [CI], 1.29-4.83; P = .006). Cryptococcal meningitis occurred in 39% (11 of 28) of CRAG-positive patients, with similar retention-in-care regardless of meningitis diagnosis (P = .8). Cryptococcal antigen titer >1:160 was associated with meningitis development (odds ratio, 4.83; 95% CI, 1.24-8.41; P = .008). Fluconazole receipt decreased death or LFU in CRAG-positive patients (HR, 0.18; 95% CI, .04-.78; P = .022). Conclusions.  Cryptococcal antigenemia predicted mortality or LFU among ART-naive HIV-infected persons with CD4 <150 cells/µL, and fluconazole increased survival or retention-in-care, suggesting that targeted pre-ART CRAG screening may decrease early mortality or LFU. A CRAG screening threshold of CD4 <100 cells/µL missed 18% of CRAG-positive patients, suggesting guidelines should consider a higher threshold.

The Neuropsychological Assessment of Cognitive Deficits Considering Measures of Performance Variability

Neuropsychologists often face interpretational difficulties when assessing cognitive deficits, particularly in cases of unclear cerebral etiology. How can we be sure whether a single test score below the population average is indicative of a pathological brain condition or normal? In the past few years, the topic of intra-individual performance variability has gained great interest. On the basis of a large normative sample, two measures of performance variability and their importance for neuropsychological interpretation will be presented in this paper: the number of low scores and the level of dispersion.We conclude that low scores are common in healthy individuals. On the other hand, the level of dispersion is relatively small. Here, base rate information about abnormally low scores and abnormally high dispersion across cognitive abilities are providedto improve the awareness of normal variability and to serve clinicians as additional interpretive measures in the diagnostic process.

Burden of serious fungal infections in Tanzania.

The incidence and prevalence of fungal infections in Tanzania remains unknown. We assessed the annual burden in the general population and among populations at risk. Data were extracted from 2012 reports of the Tanzanian AIDS program, WHO, reports, Tanzanian census, and from a comprehensive PubMed search. We used modelling and HIV data to estimate the burdens of Pneumocystis jirovecii pneumonia (PCP), cryptococcal meningitis (CM) and candidiasis. Asthma, chronic obstructive pulmonary disease and tuberculosis data were used to estimate the burden of allergic bronchopulmonary aspergillosis (ABPA) and chronic pulmonary aspergillosis (CPA). Burdens of candidaemia and Candida peritonitis were derived from critical care and/or cancer patients' data. In 2012, Tanzania's population was 43.6 million (mainland) with 1 500 000 people reported to be HIV-infected. Estimated burden of fungal infections was: 4412 CM, 9600 PCP, 81 051 and 88 509 oral and oesophageal candidiasis cases respectively. There were 10 437 estimated posttuberculosis CPA cases, whereas candidaemia and Candida peritonitis cases were 2181 and 327 respectively. No reliable data exist on blastomycosis, mucormycosis or fungal keratitis. Over 3% of Tanzanians suffer from serious fungal infections annually, mostly related to HIV. Cryptococcosis and PCP are major causes of mycoses-related deaths. National surveillance of fungal infections is urgently needed.

Chlorophyll Breakdown in Senescent Arabidopsis Leaves. Characterization of Chlorophyll Catabolites and of Chlorophyll Catabolic Enzymes Involved in the Degreening Reaction

During senescence, chlorophyll (chl) is metabolized to colorless nonfluorescent chl catabolites (NCCs). A central reaction of the breakdown pathway is the ring cleavage of pheophorbide (pheide) a to a primary fluorescent chl catabolite. Two enzymes catalyze this reaction, pheide a oxygenase (PAO) and red chl catabolite reductase. Five NCCs and three fluorescent chl catabolites (FCCs) accumulated during dark-induced chl breakdown in Arabidopsis (Arabidopsis thaliana). Three of these NCCs and one FCC (primary fluorescent chl catabolite-1) were identical to known catabolites from canola (Brassica napus). The presence in Arabidopsis of two modified FCCs supports the hypothesis that modifications, as present in NCCs, occur at the level of FCC. Chl degradation in Arabidopsis correlated with the accumulation of FCCs and NCCs, as well as with an increase in PAO activity. This increase was due to an up-regulation of Pao gene expression. In contrast, red chl catabolite reductase is not regulated during leaf development and senescence. A pao1 knockout mutant was identified and analyzed. The mutant showed an age- and light-dependent cell death phenotype on leaves and in flowers caused by the accumulation of photoreactive pheide a. In the dark, pao1 exhibited a stay-green phenotype. The key role of PAO in chl breakdown is discussed.

Chlorophyll breakdown: Pheophorbide a oxygenase is a Rieske-type iron-sulfur protein, encoded by the accelerated cell death 1 gene

Chlorophyll (chl) breakdown during senescence is an integral part of plant development and leads to the accumulation of colorless catabolites. The loss of green pigment is due to an oxygenolytic opening of the porphyrin macrocycle of pheophorbide (pheide) a followed by a reduction to yield a fluorescent chl catabolite. This step is comprised of the interaction of two enzymes, pheide a oxygenase (PaO) and red chl catabolite reductase. PaO activity is found only during senescence, hence PaO seems to be a key regulator of chl catabolism. Whereas red chl catabolite reductase has been cloned, the nature of PaO has remained elusive. Here we report on the identification of the PaO gene of Arabidopsis thaliana (AtPaO). AtPaO is a Rieske-type iron–sulfur cluster-containing enzyme that is identical to Arabidopsis accelerated cell death 1 and homologous to lethal leaf spot 1 (LLS1) of maize. Biochemical properties of recombinant AtPaO were identical to PaO isolated from a natural source. Production of fluorescent chl catabolite-1 required ferredoxin as an electron source and both substrates, pheide a and molecular oxygen. By using a maize lls1 mutant, the in vivo function of PaO, i.e., degradation of pheide a during senescence, could be confirmed. Thus, lls1 leaves stayed green during dark incubation and accumulated pheide a that caused a light-dependent lesion mimic phenotype. Whereas proteins were degraded similarly in wild type and lls1, a chl-binding protein was selectively retained in the mutant. PaO expression correlated positively with senescence, but the enzyme appeared to be post-translationally regulated as well.

Failure Rate and Conductor Externalization of the Biotronik Linox / Sorin Vigila Implantable Cardioverter Defibrillator Lead

BACKGROUND We observed a case of conductor externalization in a Biotronik Linox lead. OBJECTIVE To investigate lead performance of the Linox and identical Sorin Vigila lead and prevalence of conductor externalization. METHODS We compared lead performance of all Linox and Vigila leads implanted at our center (BL group; n=93) with all Boston Scientific Endotak Reliance leads (ER group; n=190) and Medtronic Sprint Quattro leads (SQ group; n=202) implanted during the same period. We screened all BL group patients for conductor externalization. RESULTS We identified 8 cases of lead failures in the BL group (index case of conductor externalization; 6 cases of non-physiological high rate sensing; one case of high voltage conductor fracture). Prospective, fluoroscopic screening of 98% of all active BL group cases revealed one additional case of conductor externalization. Median follow-up was 41, 27 and 29 months for the BL group, ER group and SQ group, respectively, lead survival 94.9%, 99.2% and 100% at 3 years, and 88%, 97.5% and 100% at 5 years (p=0.038 for BL group vs. ER group, and p=0.007 for BL group vs. SQ group by the log-rank test). Younger age at implant was an independent predictor for lead failure in the BL group (adjusted HR 0.85 [95% confidence interval 0.77-0.94]; p=0.001). CONCLUSION At our center, survival of the Linox lead is 88% at five years and significantly worse than its comparators. Conductor externalization is present in a minority of failed Linox leads. Younger age at implant is an independent predictor of Linox lead failure.

A 22,000 14C year BP sediment and pollen record of climate change from Laguna Miscanti (23°S), northern Chile

Lake sediments and pollen, spores and algae from the high-elevation endorheic Laguna Miscanti (22°45′S, 67°45′W, 4140 m a.s.l., 13.5 km2 water surface, 10 m deep) in the Atacama Desert of northern Chile provide information about abrupt and high amplitude changes in effective moisture. Although the lack of terrestrial organic macrofossils and the presence of a significant 14C reservoir effect make radiocarbon dating of lake sediments very difficult, we propose the following palaeoenvironmental history. An initial shallow freshwater lake (ca. 22,000 14C years BP) disappeared during the extremely dry conditions of the Last Glacial Maximum (LGM; 18,000 14C years BP). That section is devoid of pollen. The late-glacial lake transgression started around 12,000 14C years BP, peaked in two phases between ca. 11,000 and <9000 14C years BP, and terminated around 8000 14C years BP. Effective moisture increased more than three times compared to modern conditions (∼200 mm precipitation), and a relatively dense terrestrial vegetation was established. Very shallow hypersaline lacustrine conditions prevailed during the mid-Holocene until ca. 3600 14C years BP. However, numerous drying and wetting cycles suggest frequent changes in moisture, maybe even individual storms during the mid-Holocene. After several humid spells, modern conditions were reached at ca. 3000 14C years BP. Comparison between limnogeological data and pollen of terrestrial plants suggest century-scale response lags. Relatively constant concentrations of long-distance transported pollen from lowlands east of the Andes suggest similar atmospheric circulation patterns (mainly tropical summer rainfall) throughout the entire period of time. These findings compare favorably with other regional paleoenvironmental data.

Electrocardiographic characteristics of patients with funnel chest before and after surgical correction using pectus bar: A new association with precordial J wave pattern.

OBJECTIVE Abnormal ECG findings suggestive of cardiac disease are frequent in patients with funnel chest, although structural heart disease is rare. Electrocardiographic characteristics and changes following new surgical treatments in young adults are not described so far. The aim of the study was to analyze electrocardiographic characteristics of patients with funnel chest before and after minimally invasive funnel chest correction by the Nuss procedure. METHODS Twenty-six patients with surgical correction of funnel chest using pectus bar were included. Twelve-lead ECGs before and later than one year after surgery were analyzed. RESULTS In postoperative ECGs, amplitude of P wave in lead II and negative terminal amplitude of P wave in lead V1 decreased from 0.13 to 0.10mV (p=0.03), and from 0.10 to 0.04mV (p<0.001), respectively. Mean QRS duration decreased from 108ms to 98ms (p=0.003) after correction. A pathological left and right Sokolow-Lyon index was observed in 35% and 23% of patients before, versus 8% (p=0.04) and 0% (p=0.01) after correction, respectively. In contrast, the rate of patients with J wave pattern in precordial leads V4-V6 increased from 8% before to 42% after surgery (p=0.004). CONCLUSIONS ECG abnormalities in patients with funnel chest are frequent, and can normalize after surgical correction by the Nuss procedure. De novo J wave pattern in precordial leads V4-V6 is a frequent finding after surgical funnel chest correction using pectus bar.

Katheterablation von Vorhofflimmern. Den richtigen Takt finden

Mit der steigenden Lebenserwartung steigt auch die Zahl der Herzerkrankungen, insbesondere des Vorhofflimmerns. Die Disharmonie von Vorhöfen und Herzkammern führt häufig zu Hospitalisationen und zu gefährlichen Komplikationen wie Schlaganfällen. Neben der medikamentösen Therapie steht heute die Katheterablation zur Verfügung. Ist sie eine echte Alternative?