Effect of Vagus Nerve Stimulation in an Adult Patient with Dravet Syndrome: Contribution to Sudden Unexpected Death in Epilepsy Risk Reduction?.

We report on a patient who developed, from 5 months of age, multiple seizure types, including myoclonic, associated with severe psychomotor delay, leading to the diagnosis of Dravet syndrome. Over the years, he developed refractory epilepsy and was implanted with a vagus nerve stimulator at the age of 19. After 3 months, he experienced a progressive improvement of partial and generalized seizures, with a >90% reduction, and better alertness. This meaningful clinical improvement is discussed in the light of the sudden unexpected death in epilepsy risk, which is high in this setting, and seems remarkably diminished in our patient in view of the reduction of generalized convulsions.

Time of ruin in a risk model with generalized Erlang (n) interclaim times and a constant dividend barrier

In this paper we analyze the time of ruin in a risk process with the interclaim times being Erlang(n) distributed and a constant dividend barrier. We obtain an integro-differential equation for the Laplace Transform of the time of ruin. Explicit solutions for the moments of the time of ruin are presented when the individual claim amounts have a distribution with rational Laplace transform. Finally, some numerical results and a compare son with the classical risk model, with interclaim times following an exponential distribution, are given.

Caspofungin for prevention of intra-abdominal candidiasis in high-risk surgical patients.

PURPOSE: Thirty to forty percent of patients with recurrent gastrointestinal perforation/anastomotic leakage or acute necrotizing pancreatitis develop intra-abdominal invasive candidiasis (IC). A corrected Candida colonization index (CCI) > or =0.4 is a powerful predictor of IC. Fluconazole prevents intra-abdominal IC in this setting, but azole-resistant Candida species are emerging. The aim of this study was to explore the efficacy and safety of caspofungin for prevention of intra-abdominal IC in high-risk surgical patients. METHODS: Prospective non-comparative single-center study in consecutive adult surgical patients with recurrent gastrointestinal perforation/anastomotic leakage or acute necrotizing pancreatitis. Preventive caspofungin therapy (70 mg, then 50 mg/day) was given until resolution of the surgical condition. Candida colonization index and CCI, occurrence of intra-abdominal IC and adverse events were monitored. RESULTS: Nineteen patients were studied: 16 (84%) had recurrent gastrointestinal perforation/anastomotic leakage and 3 (16%) acute necrotizing pancreatitis. The median duration of preventive caspofungin therapy was 16 days (range 4-46). The colonization index decreased significantly during study therapy, and the CCI remained <0.4 in all patients. Caspofungin was successful for prevention of intra-abdominal IC in 18/19 patients (95%, 1 breakthrough IC 5 days after inclusion). No drug-related adverse event requiring caspofungin discontinuation occurred. CONCLUSION: Caspofungin may be efficacious and safe for prevention of intra-abdominal candidiasis in high-risk surgical patients. This needs to be further investigated in randomized trials.

Cell-mediated immunity to predict cytomegalovirus disease in high-risk solid organ transplant recipients.

Late-onset cytomegalovirus (CMV) disease commonly occurs after discontinuation of antiviral prophylaxis. We determined the utility of testing CD8+ T-cell response against CMV as a predictor of late-onset CMV disease after a standard course of antiviral prophylaxis. Transplant patients at high-risk for CMV disease were enrolled. CD8+ T-cell-mediated immunity (CMI) was tested using the QuantiFERON-CMV assay at baseline, 1, 2 and 3 months posttransplant by measurement of interferon-gamma response to whole blood stimulation with a 21-peptide pool. The primary outcome was the ability of CMI testing to predict CMV disease in the first 6 months posttransplant. There were 108 evaluable patients (D+/R+ n = 39; D-/R+ n = 34; D+/R- n = 35) of whom 18 (16.7%) developed symptomatic CMV disease. At the end of prophylaxis, CMI was detectable in 38/108 (35.2%) patients (cutoff 0.1 IU/mL interferon-gamma). CMV disease occurred in 2/38 (5.3%) patients with a detectable interferon-gamma response versus 16/70 (22.9%) patients with a negative response; p = 0.038. In the subgroup of D+/R- patients, CMV disease occurred in 1/10 (10.0%) patients with a detectable interferon-gamma response (cutoff 0.1 IU/mL) versus 10/25 (40.0%) patients with a negative CMI, p = 0.12. Monitoring of CMI may be useful for predicting late-onset CMV disease.

Lack of extended venous thromboembolism prophylaxis in high-risk patients undergoing major orthopaedic or major cancer surgery. Electronic Assessment of VTE Prophylaxis in High-Risk Surgical Patients at Discharge from Swiss Hospitals (ESSENTIAL).

Extended pharmacological venous thromboembolism (VTE) prophylaxis beyond discharge is recommended for patients undergoing high-risk surgery. We prospectively investigated prophylaxis in 1,046 consecutive patients undergoing major orthopaedic (70%) or major cancer surgery (30%) in 14 Swiss hospitals. Appropriate in-hospital prophylaxis was used in 1,003 (96%) patients. At discharge, 638 (61%) patients received prescription for extended pharmacological prophylaxis: 564 (77%) after orthopaedic surgery, and 74 (23%) after cancer surgery (p < 0.001). Patients with knee replacement (94%), hip replacement (81%), major trauma (80%), and curative arthroscopy (73%) had the highest prescription rates for extended VTE prophylaxis; the lowest rates were found in patients undergoing major surgery for thoracic (7%), gastrointestinal (19%), and hepatobiliary (33%) cancer. The median duration of prescribed extended prophylaxis was longer in patients with orthopaedic surgery (32 days, interquartile range 14-40 days) than in patients with cancer surgery (23 days, interquartile range 11-30 days; p<0.001). Among the 278 patients with an extended prophylaxis order after hip replacement, knee replacement, or hip fracture surgery, 120 (43%) received a prescription for at least 35 days, and among the 74 patients with an extended prophylaxis order after major cancer surgery, 20 (27%) received a prescription for at least 28 days. In conclusion, approximately one quarter of the patients with major orthopaedic surgery and more than three quarters of the patients with major cancer surgery did not receive prescription for extended VTE prophylaxis. Future effort should focus on the improvement of extended VTE prophylaxis, particularly in patients undergoing major cancer surgery.

Intergenerational differences in cardiovascular risk factor levels in Switzerland

Background: There is little information regarding cardiovascular risk factor (CV RF) trends in Switzerland. We aimed at assessing generation differences in CV RFs by comparing CV RFs levels within selected age groups separated by a 20 year time lag. Design: Two population-based surveys. Methods: Data from the Monica (1984-1986) and Colaus (2004-2006) surveys were used. Analyses were stratified by sex and age groups (35-44, 45-54, 55-64 and 65-75 years). Results: No changes were found for BMI levels and status between surveys: in men, 26}3, 26}3, 27}4 and 27}4 kg/m2 for age groups 35-44, 45-54, 55-64 and 65-74, respectively, in MONICA, vs. 26}4, 26}4, 27}4 and 28}4 kg/m2 in COLAUS, p=NS, in women: 24}4, 26}4, 26}4 and 26}5 kg/m2 in MONICA, vs. 24}5, 25}5, 26}5 and 26}5 kg/m2 in COLAUS, p=NS. Similar results were found after adjusting for education. Smoking prevalence increased in men: 28, 30, 22 and 15% for age groups 35-44, 45-54, 55-64 and 65-74, respectively, in MONICA, vs. 35, 29, 28 and 21% in COLAUS. In women, changes differed according to age: 39, 26, 16 and 18%, in MONICA vs. 28, 30, 22 and 15% in COLAUS. Blood pressure decreased in the younger age groups and remained constant in the older ones: in men, systolic blood pressure was 129}15, 133}16, 138}18 and 143}21 mm Hg in MONICA, vs. 125}12, 129}15, 137}16 and 144}19 mm Hg in COLAUS, p<0.01. Similar findings were obtained after adjusting for education. Prevalence of hypertension increased, due to an increase in the prevalence of treated subjects, in men : 4, 8, 16 and 19% for age groups 35-44, 45-54, 55-64 and 65-74, respectively, in MONICA, vs. 5, 14, 31 and 46% in COLAUS, p<0.05; in women: 2, 10, 16, and 24% in MONICA, vs. 4, 12, 24, and 34% in COLAUS, p<0.05. This increase was stronger in men: 14, 17, 23 and 31% for age groups 35-44, 45-54, 55-64 and 65-74, respectively, in MONICA vs. 10, 21, 41 and 55% in COLAUS, p<0.01 and smaller in women: 6, 15, 24 and 44% in MONICA vs. 6, 16, 30 and 42% in COLAUS, p=NS. Similar findings were obtained after adjusting for education. Conclusion: With the exception of BMI, the newer Swiss generations appear to have a worse CV profile than the older generations. This is especially true regarding smoking and hypertension.

Changes in the risk of death after HIV seroconversion compared with mortality in the general population.

CONTEXT: Mortality among human immunodeficiency virus (HIV)-infected individuals has decreased dramatically in countries with good access to treatment and may now be close to mortality in the general uninfected population. OBJECTIVE: To evaluate changes in the mortality gap between HIV-infected individuals and the general uninfected population. DESIGN, SETTING, AND POPULATION: Mortality following HIV seroconversion in a large multinational collaboration of HIV seroconverter cohorts (CASCADE) was compared with expected mortality, calculated by applying general population death rates matched on demographic factors. A Poisson-based model adjusted for duration of infection was constructed to assess changes over calendar time in the excess mortality among HIV-infected individuals. Data pooled in September 2007 were analyzed in March 2008, covering years at risk 1981-2006. MAIN OUTCOME MEASURE: Excess mortality among HIV-infected individuals compared with that of the general uninfected population. RESULTS: Of 16,534 individuals with median duration of follow-up of 6.3 years (range, 1 day to 23.8 years), 2571 died, compared with 235 deaths expected in an equivalent general population cohort. The excess mortality rate (per 1000 person-years) decreased from 40.8 (95% confidence interval [CI], 38.5-43.0; 1275.9 excess deaths in 31,302 person-years) before the introduction of highly active antiretroviral therapy (pre-1996) to 6.1 (95% CI, 4.8-7.4; 89.6 excess deaths in 14,703 person-years) in 2004-2006 (adjusted excess hazard ratio, 0.05 [95% CI, 0.03-0.09] for 2004-2006 vs pre-1996). By 2004-2006, no excess mortality was observed in the first 5 years following HIV seroconversion among those infected sexually, though a cumulative excess probability of death remained over the longer term (4.8% [95% CI, 2.5%-8.6%] in the first 10 years among those aged 15-24 years). CONCLUSIONS: Mortality rates for HIV-infected persons have become much closer to general mortality rates since the introduction of highly active antiretroviral therapy. In industrialized countries, persons infected sexually with HIV now appear to experience mortality rates similar to those of the general population in the first 5 years following infection, though a mortality excess remains as duration of HIV infection lengthens.

Assessment of cytomegalovirus-specific cell-mediated immunity for the prediction of cytomegalovirus disease in high-risk solid-organ transplant recipients: a multicenter cohort study.

BACKGROUND: Cytomegalovirus (CMV) disease remains an important problem in solid-organ transplant recipients, with the greatest risk among donor CMV-seropositive, recipient-seronegative (D(+)/R(-)) patients. CMV-specific cell-mediated immunity may be able to predict which patients will develop CMV disease. METHODS: We prospectively included D(+)/R(-) patients who received antiviral prophylaxis. We used the Quantiferon-CMV assay to measure interferon-γ levels following in vitro stimulation with CMV antigens. The test was performed at the end of prophylaxis and 1 and 2 months later. The primary outcome was the incidence of CMV disease at 12 months after transplant. We calculated positive and negative predictive values of the assay for protection from CMV disease. RESULTS: Overall, 28 of 127 (22%) patients developed CMV disease. Of 124 evaluable patients, 31 (25%) had a positive result, 81 (65.3%) had a negative result, and 12 (9.7%) had an indeterminate result (negative mitogen and CMV antigen) with the Quantiferon-CMV assay. At 12 months, patients with a positive result had a subsequent lower incidence of CMV disease than patients with a negative and an indeterminate result (6.4% vs 22.2% vs 58.3%, respectively; P < .001). Positive and negative predictive values of the assay for protection from CMV disease were 0.90 (95% confidence interval [CI], .74-.98) and 0.27 (95% CI, .18-.37), respectively. CONCLUSIONS: This assay may be useful to predict if patients are at low, intermediate, or high risk for the development of subsequent CMV disease after prophylaxis. CLINICAL TRIALS REGISTRATION: NCT00817908.

Disparities in work, risk and health between immigrants and native-born Spaniards

We analyse the impact of working and contractual conditions, particularly exposure to job risks, on the probability of acquiring a permanent disability, controlling for other personal and firm characteristics. We postulate a model in which this impact is mediated by the choice of occupation, with a level of risk associated with it. We assume this choice is endogenous, and that it depends on preferences and opportunities in the labour market, both of which may differ between immigrants and natives. To test this hypothesis we apply a bivariate probit model to data for 2006 from the Continuous Sample of Working Lives provided by the Spanish Social Security system, containing records for over a million workers. We find that risk exposure increases the probability of permanent disability arising from any cause - by almost 5%.

Trends in cardiovascular risk factors (1984-1993) in a Swiss region: results of three population surveys.

BACKGROUND: This study attempted to assess the time trends in lifestyle and cardiovascular risk factors in the Swiss region of Vaud-Fribourg (population 784,000). METHODS: Three surveys (1984/1985, 1988/1989, and 1992/1993), based on independent representative samples (n = 3,300) of the population ages 25 to 74, were conducted within the framework of the international WHO-MONICA Project. RESULTS: The most favorable changes were observed in reported behaviors: increased physical activity in leisure time, healthier dietary habits (switch from unskimmed milk, butter, and meat to skimmed milk, margarine, and fish, with no change for fruits and vegetables), and lower prevalence of regular smoking among men (from 32 to 28%). Body mass index did not vary significantly, apart from an increase in the prevalence of obesity among men (from 11 to 15%). Total cholesterol varied only slightly, while the HDL cholesterol levels decreased steadily (from 1.37 to 1.19 mmol/L among men; from 1.59 to 1.51 among women). Average systolic blood pressure regressed among women (from 127.2 to 124.4 mm Hg), while the prevalence of untreated hypertension increased among older men. CONCLUSION: The self-reported changes in lifestyle were only partially reflected by favorable trends in objective measurements. Physical activity, even at moderate intensity, and consumption of fruits, vegetables, and fiber in general should be promoted.

Russian transition in the early 21st century

Tässä tutkimuksessa käsitellään Venäjän talouden kehitystä uudella vuosituhannella. Kylmän sodan aikaan Neuvostoliitto oli suurvalta, jonka asema perustui sotilasmahtiin. Sotateollisuuden konversio palvelemaan nykytarpeita ei ole ollut helppo tehtävä. Vuoden 1998 talouskriisin jälkeen elintaso on toipunut verraten nopeasti, mikä on nähtävissä tarkastellessa kotitalouksien kulutusrakenteita, joita käsitellään tarkemmin luvussa 2. Siirtymätalouksissa vaihtotaseen vajeet ovat yleisiä, mutta luonnonrikkauksiensa ansiosta Venäjän vaihtotaseet ovat olleet huomattavan ylijäämäisiä, mitä pohditaan luvussa 3. Vaihtotaseen ylijäämien heijatusvaikutus on ollut Venäjän rooli pääomien nettoviejänä. Venäjän investointikertymä onedelleen erittäin vaatimaton suhteutettuna maan kehitysvaiheeseen. Jokaisessa menestyksekkäässä taloudessa investoinnit ovat pitkän aikavälintaloudellisen menestyksen avaintekijä. Venäjän erityispiirteitä tähän liittyen on kuvattu luvussa 4. Raportti päättyy talouden nykytilanteen analyysiin (luvut 5 ja 6).