National audit on maternal mortality in Guinea-Bissau, West-Africa: A retrospective observational study of 2020.

Guinea-Bissau has particularly alarming indicators of maternal health, with one of the highest maternal mortality (MM) worldwide. According to UNICEF-2014, this ratio (MMR) was 900/100,000 live births, mostly due to preventable and treatable causes. In 2013, the European Union developed an Integrated Programme to reduce Maternal and Infant Mortality (EU/PIMI),** the largest project of this kind, implemented in Guinea-Bissau. This study performed a national audit of MM over 2020, with the aim to analyse its numbers, characteristics, and causes. We used data of local and regional hospitals where EU/PIMI-II was operating. These hospitals showed lower MMR than previous national figures; however, the exclusion of the main obstetrical referral hospitals, and the unknown number of community-based deliveries make it difficult to compare. Guinea-Bissau still faces enormous challenges in reducing MM. Despite the slow progresses, this study gives us hope, as EU/PIMI-IÍs interventions appeared to have a positive impact in MM reduction.

In pursuit of a sensitive EEG functional connectivity outcome measure for clinical trials in Alzheimer's disease.

OBJECTIVE: In clinical trials in Alzheimer's Disease (AD), an improvement of impaired functional connectivity (FC) could provide biological support for the potential efficacy of the drug. Electroencephalography (EEG) analysis of the SAPHIR-trial showed a treatment induced improvement of global relative theta power but not of FC measured by the phase lag index (PLI). We compared the PLI with the amplitude envelope correlation with leakage correction (AEC-c), a presumably more sensitive FC measure. METHODS: Patients with early AD underwent 12 weeks of placebo or treatment with PQ912, a glutaminylcyclase inhibitor. Eyes-closed task free EEG was measured at baseline and follow-up (PQ912 n = 47, placebo n = 56). AEC-c and PLI were measured in multiple frequency bands. Change in FC was compared between treatment groups by using two models of covariates. RESULTS: A significant increase in global AEC-c in the alpha frequency band was found with PQ912 treatment compared to placebo (p = 0.004, Cohen's d = 0.58). The effect remained significant when corrected for sex, country, ApoE ε4 carriage, age, baseline value (model 1; p = 0.006) and change in relative alpha power (model 2; p = 0.004). CONCLUSIONS: Functional connectivity in early AD, measured with AEC-c in the alpha frequency band, improved after PQ912 treatment. SIGNIFICANCE: AEC-c may be a robust and sensitive FC measure for detecting treatment effects.

Morbidity of cardiac arrest in the very elderly.

The objective of this retrospective cohort study was to assess mortality and morbidity after cardiac arrest in hospital inpatients aged 80 years or older, in an Australian tertiary hospital. We studied patients aged 80 years or older who suffered an in-hospital cardiac arrest from 1 January 2000 to 31 December 2016. The main outcome measures were one-year survival and narrative morbidity. Two hundred and eighty-five patients were identified. Absolute one-year survival after cardiac arrest was, at best, 12.6%. Narrative descriptions of morbidity demonstrate high healthcare utilisation, dependency or residential care, and significant impairments of physical and social function. In conclusion, one-year survival after cardiac arrest in the very elderly is poor. In those who survive, significant morbidity is present.

Bullous pemphigoid and epidermolysis bullosa acquisita. Differentiation by fluorescence overlay antigen mapping.

BACKGROUND AND DESIGN: From previous studies, we concluded that the fluorescence overlay antigen mapping (FOAM) technique could be of value to the differential diagnosis of the acquired subepidermal bullous skin disorders, bullous pemphigoid (BP) and epidermolysis bullosa acquisita (EBA). In these diseases, ultrastructural identification of the site of skin-bound IgG deposits at the epidermal basement membrane zone (EBMZ) may be essential to the correct diagnosis. Since ultrastructural studies are more expensive, time-consuming, and less widely available than immunofluorescence, we addressed the question of whether the FOAM technique can reliably identify the site of IgG deposits at the EBMZ, and distinguish BP from EBA. For this purpose, the technique was applied to perilesional skin from seven patients with BP and six with EBA, using computer-aided imaging of red-stained type VII collagen and green-stained IgG, according to previous findings. RESULTS: Digitized multicolor FOAM images of perilesional skin from patients with BP showed nonoverlap band patterns of green-stained lamina lucida IgG deposits (ultrastructurally proven) and red-stained type VII collagen. By contrast, FOAM images of EBA skin typically showed overlap patterns of green-stained sublamina densa IgG deposits and red-stained type VII collagen. These findings were observed also in skin tissue stored in Michel's transport medium or stored frozen for 15 years. CONCLUSIONS: The computer-aided FOAM technique may have great potential in distinguishing between IgG deposits above (BP) and just below (EBA) the lamina densa of the EBMZ in skin tissue. The technique is not as simple as saline-split skin methodology but offers more flexibility, and it certainly is quicker and less expensive than electron microscopy. Furthermore, the use of digitized fluorescence images offers improved possibilities for evaluating the various "linear" patterns of immune reactant deposition at the EBMZ in subepidermal bullous autoimmune skin diseases.

Fluorescence overlay antigen mapping of the epidermal basement membrane zone: III. Topographic staining and effective resolution.

In this third study on the fluorescence overlay antigen mapping (FOAM) technique, we have addressed the question of which differences of antigen distributions close to the resolving power of the light microscope can be distinguished. An answer to this question should provide clues to future applications of the technique aiming at the topographic differentiation of IgG deposits displayed at the epidermal basement membrane zone (EBMZ) in certain bullous skin disorders. For the present purpose we have developed a topographic staining model in human skin, using structural EBMZ antigens as topographic reference markers. The distribution of these markers relative to one another is visualized in FOAM images obtained by selective double immunofluorescence tracing and videomicroscopic overlay imaging. The theoretical resolution limit of the technique is discussed and suggests an effective lower limit of some 60-65 nm. Although this limit is not reached under present conditions, our results show that it is possible to distinguish topographic differences of antigen distributions with an upper resolution limit of 200 +/- 50 nm. Furthermore, our findings indicate that collagen Type VII and beta 4 integrin are the most suitable molecules to serve as topographic reference markers in future applications of the technique aiming at the differentiation of bullous pemphigoid (BP) and epidermolysis bullosa acquisita (EBA). Preliminary results on this topic are most promising indeed.

Fluorescence overlay antigen mapping of the epidermal basement membrane zone: II. Color fidelity.

In this second report on the fluorescence overlay antigen mapping (FOAM) technique, we highlight some of the errors that may influence faithful color rendition of slide preparations using triple antigen immunofluorescence staining. Reliable interpretation of multicolor fluorescence images requires that the observer can unambiguously assign each color in these images to the presence of a specific combination of the labeled antigens. This is possible only when the image fidelity meets certain standards. The present study concentrates on color fidelity which is easily undermined by spectral matching errors, image contrast errors, and exposure time errors. Evaluation of these errors, using the photomicrographic overlay variant of FOAM, showed the potential unreliability of the simultaneous use of multiple fluorophores for immunofluorescence microscopy. The procedures described here may serve as a solid starting point in formulating technical conditions that allow reliable color rendition in multicolor immunofluorescence microscopy. Furthermore, these procedures can be adapted to studies other than the analysis of basement membrane zone antigens, to which they have been first applied.

Fluorescence overlay antigen mapping of the epidermal basement membrane zone: I. Geometric errors.

To identify in tissue sections the relative positions of antigen distributions close to the resolving power of the microscope, we have developed the fluorescence overlay antigen mapping (FOAM) procedure. As this technique makes high demands on the geometric fidelity of the overlay image, it is essential to recognize geometric errors resulting from optical imperfections. This applies in particular to the image shift difference (ISD) that may routinely occur during fluorescence overlay. We describe here procedures for assessment and mechanical correction of the ISD in tissue sections. Furthermore, we describe an alignment verification test to assess the accuracy of the ISD correction procedure, using collagen Type VII as the geometric verification marker. These procedures should enable reliable evaluation of relative antigen distributions in tissue sections using photomicrographic multicolor fluorescence overlay. Further details of the FOAM technique, such as color fidelity and its utility for diagnostic and research purposes, will be published separately.

Comparison of reticulate and elementary body antigens in detection of antibodies against Chlamydia trachomatis by an enzyme-linked immunosorbent assay.

Reticulate bodies from a type C and elementary bodies from a type L2 strain of Chlamydia trachomatis were isolated and used as antigens in an enzyme-linked immunosorbent assay (ELISA). Results obtained for human sera with these two antigens used in the ELISA were compared with each other and with results obtained for the same sera by the micro-immunofluorescence test. Negative control populations included cloistered nuns and children with respiratory infections. Populations at risk for chlamydial infection consisted of 42 men with nongonococcal urethritis attending a sexually transmitted diseases clinic and 42 college women who had contact with men with nongonococcal urethritis. ELISAs done with the two antigens were equivalent to each other and to the micro-immunofluorescence test in the ability to predict the presence or absence of infection. None of the tests had high predictive values for the men with urethritis. However, the negative predictive value of both the micro-immunofluorescence test and the elementary body ELISA was 0.92 for the college women. Such serological tests may be of value in screening selected populations for subclinical infections with C. trachomatis.

Radioimmunoassay for detection of IgG antibodies against enterobacterial antigens.

The rough mutant of Salmonella minnesota (Re 595) contains several broad reacting antigens including a core LPS common to many aerobic gram-negative bacteria without sugars that confer serotype specificity to most gram-negative bacteria. Therefore, antibodies against this organism can be evoked by a large number of gram-negative bacteria. Using radioimmunoassay methods, sera from 59 patients with bacteremia due to enterobacteriaceae had higher concentrations of IgG antibodies against the rough mutant of Salmonella minnesota (Re 595) than control subjects. There was a significant correlation between concentrations of antibodies against Salmonella minnesota and concentrations of antibodies against a single strain of E coli. Sera from patients with bacteremia due to E coli or Klebsiella were tested against one strain of E coli and one strain of Klebsiella. The concentrations of antibodies against the homologous antigen were not higher than the concentrations of antibodies against the heterologous antigen. Sera from patients infected with S aureus or Pseudomonas aeruginosa did not have high concentrations of antibodies against S minnesota. Antibodies against common antigen(s) in Salmonella minnesota (Re 595) are useful in diagnosis of enterobacterial infections.

Parameters affecting the enzyme-linked immunosorbent assay of immunoglobulin G antibody to a rough mutant of Salmonella minnesota.

An enzyme-linked immunosorbent assay was developed to detect rabbit immunoglobulin G antibodies against purified lipopolysaccharide of the rough Re mutant of Salmonella minnesota. The time necessary for each step was investigated, and this resulted in a test that could be completed in 1 working day. Serial dilutions of rabbit sera drawn throughout immunization with the Re mutant revealed an elimination of the prozone effect upon prolonged immunization. We interpret this to demonstrate an increase in immunoglobulin G affinity for the lipopolysaccharide on prolonged immunization. We propose that the enzyme-linked immunosorbent assay prozone effect be investigated for use as a measure of antibody affinity.

Left atrial myxoma infected with Histoplasma capsulatum.

A patient is presented in whom a left atrial myxoma was found to be infected with Histoplasma capsulatum. Histoplasmosis has not been previously associated with this tumor, nor has any fungus without preceding bacterial endocarditis and long-term antibiotic therapy. The clinical course in foru previously reported cases of bacterially infected myxoma is reviewed. There have been 18 prior cases of Histoplasma endocarditis and in two the patients have survived. Their clinical presentation and response to therapy are also reviewed, and pertinent therapeutic conclusions drawn. The role of echocardiography in this patient's evaluation and the ultimate successful therapy are discussed.

Cross-reactive antigens: their potential for immunization-induced immunity to Gram-negative bacteria.

The involvement of multiple species and serologic types in gram-negative bacteremia prompted evaluation of immunization with shared, cross-reactive antigens of gram negative bacilli. Active and passive immunization with Re chemotype mutants of Salmonella minnesota afforded significant protection against heterologous gram-negative bacilli and were considerably more effective than immunization with smooth S. minnesota or its Ra, Rb, Rc, Rd1 and Rd2 mutants. Since the lipopolysaccharide of the Re mutant is composed solely of 2-keto-3-deoxycotonate (KDO) and lipid A, the protective activity of antibody to the Re mutant and lipid A was evaluated. Immunization with Re mutant protected granulocytopenic rabbits against lethal bacteremia and protected mice against lethal challenge with heterologous endotoxins, whereas antibody to lipid A had no protective activity. In concomitant clinical studies, high titers of antibody to the Re mutant at the onset of bacteremia were associated with a significant diminution in the frequency of shock and death, which was independent of any effect of O-specific antibody.

Immunization with R mutants of Salmonella minnesota. II. Comparison of the protective effect of immunization with lipid A and the Re mutant.

The protective effect of active immunization with Salmonella minnesota Re bacilli or lipid A was assessed in the granulocytopenic rabbit model. Animals were immunized with Re bacilli, lipid A, or Pseudomonas aeruginosa as a nonspecific immunogen. After colonization with one of three enterobacterial strains (two Escherichia coli, one Enterobacter aerogenes), the immunized rabbits as well as controls given saline injections were made leukopenic with nitrogen mustard and monitored for fever, bacteremia, and death. Survival rates were significantly greater in Re-immunized animals than in saline controls or P. aeruginosa-immunized animals. Immunization with lipid A afforded no protection. In addition, rabbits immunized with Re mutant bacilli developed bacteremia less frequently than the others, indicating that antibody to Re may inhibit invasion of the intestinal mucosa as well as protect after bacteremia has developed.

Immunization with R mutants of Salmonella minnesota. II. Serological response to lipid A and the lipopolysaccharide of Re mutants.

Rabbits were immunized with Salmonella minnesota Re mutant bacilli or lipid A, and the serological responses were compared. Re lipopolysaccharide and lipid A were found to possess distinct antigenic determinants as measured by hemagglutination, hemolysis, and precipitin techniques. Lipid A preparations from several enterobacterial and non-enterobacterial species were shown to cross-react in agar gel precipitation reactions. In contrast, preparations from bacilli that do not contain glucosamine as an integral part of their lipid A structure did not demonstrate cross-reactivity with enterobacterial lipid A. Antibody to smooth heterologous bacilli present in some antisera prepared against Re bacilli or lipid A was directed specifically against the smooth lipopolysaccharide and not against the Re or lipid A determinants, demonstrating a nonspecific mitogenic response. Precipitation and immunofluorescence tests indicated that the Re determinant was available on smooth bacilli for reactions with specific antisera but that the lipid A determinant was not.

The relation of K-antigen to virulence of Escherichia coli.

The content of K-antigen was determined for 100 strains of Escherichia coli isolated from the blood of patients with bacteremia. 30 strains isolated from urine cultures, and 30 strains isolated from the feces of patients recently admitted to the hospital. The K-antigen content of urinary isolates of E. coli was significantly greater than that of strains isolated from feces, as noted by other workers. In contrast, the amount of K-antigen of blood culture isolates was not significantly greater than that of fecal isolates and was significantly lower than that of urinary E. coli isolates. No correlation could be detected between the K-antigen content of blood culture isolates and the severity and outcome of the bacteremia.