The therapeutic effects of bacteriophage (phage) KPP12 in Pseudomonas aeruginosa keratitis were investigated in mice. Morphological analysis showed that phage KPP12 is a member of the family Myoviridae, morphotype A1, and DNA sequence analysis revealed that phage KPP12 is similar to PB1-like viruses. Analysis of the phage KPP12 genome did not identify any genes related to drug resistance, pathogenicity or lysogenicity, and so phage KPP12 may be a good candidate for therapeutic. KPP12 showed a broad host range for P. aeruginosa strains isolated from clinical ophthalmic infections. Inoculation of the scarified cornea with P. aeruginosa caused severe keratitis and eventual corneal perforation. Subsequent single-dose administration of KPP12 eye-drops significantly improved disease outcome, and preserved the structural integrity and transparency of the infected cornea. KPP12 treatment resulted in the suppression of neutrophil infiltration and greatly enhanced bacterial clearance in the infected cornea. These results indicate that bacteriophage eye-drops may be a novel adjunctive or alternative therapeutic agent for the treatment of infectious keratitis secondary to antibiotic-resistant bacteria.
The aim of this study was to assess clinical and pulmonary thin-section CT findings in patients with acute Pseudomonas aeruginosa (PA) pulmonary infection.
We retrospectively identified 44 patients with acute PA pneumonia who had undergone chest thin-section CT examinations between January 2004 and December 2010. We excluded nine patients with concurrent infections. The final study group comprised 35 patients (21 males, 14 females; age range 30–89 years, mean age 66.9 years) with PA pneumonia. The patients' clinical findings were assessed. Parenchymal abnormalities, enlarged lymph nodes and pleural effusion were evaluated on thin-section CT.
Underlying diseases included malignancy (n=13), a smoking habit (n=11) and cardiac disease (n=8). CT scans of all patients revealed abnormal findings, including ground-glass opacity (n=34), bronchial wall thickening (n=31), consolidation (n=23) and cavities (n=5). Pleural effusion was found in 15 patients.
PA pulmonary infection was observed in patients with underlying diseases such as malignancy or a smoking habit. The CT findings in patients with PA consisted mainly of ground-glass attenuation and bronchial wall thickening.
Advances in knowledge
The CT findings consisted mainly of ground-glass attenuation, bronchial wall thickening and cavities. These findings in patients with an underlying disease such as malignancy or a smoking habit may be suggestive of pneumonia caused by PA infection.
The aim of this study was to compare the pulmonary thin-section CT findings of patients with acute Streptococcus pneumoniae pneumonia with and without concurrent infection.
The study group comprised 86 patients with acute S. pneumoniae pneumonia, 36 patients with S. pneumoniae pneumonia combined with Haemophilus influenzae infection, 26 patients with S. pneumoniae pneumonia combined with Pseudomonas aeruginosa infection and 22 patients with S. pneumoniae pneumonia combined with methicillin-susceptible Staphylococcus aureus (MSSA) infection. We compared the thin-section CT findings among the groups.
Centrilobular nodules and bronchial wall thickening were significantly more frequent in patients with pneumonia caused by concurrent infection (H. influenzae: p<0.001 and p<0.001, P. aeruginosa: p<0.001 and p<0.001, MSSA: p<0.001 and p<0.001, respectively) than in those infected with S. pneumoniae alone. Cavity and bilateral pleural effusions were significantly more frequent in cases of S. pneumoniae pneumonia with concurrent P. aeruginosa infection than in cases of S. pneumoniae pneumonia alone (p<0.001 and p<0.001, respectively) or with concurrent H. influenzae (p<0.05 and p<0.001, respectively) or MSSA infection (p<0.05 and p<0.05, respectively).
When a patient with S. pneumoniae pneumonia has centrilobular nodules, bronchial wall thickening, cavity or bilateral pleural effusions on CT images, concurrent infection should be considered.
Moraxella catarrhalis is an important pathogen in the exacerbation of chronic obstructive pulmonary disease. The aim of this study was to assess the clinical and pulmonary thin-section CT findings in patients with acute M. catarrhalis pulmonary infection.
Thin-section CT scans obtained between January 2004 and March 2009 from 292 patients with acute M. catarrhalis pulmonary infection were retrospectively evaluated. Clinical and pulmonary CT findings in the patients were assessed. Patients with concurrent infection including Streptococcus pneumoniae (n = 72), Haemophilus influenzae (n = 61) or multiple pathogens were excluded from this study.
The study group comprised 109 patients (66 male, 43 female; age range 28–102 years; mean age 74.9 years). Among the 109 patients, 34 had community-acquired and 75 had nosocomial infections. Underlying diseases included pulmonary emphysema (n = 74), cardiovascular disease (n = 44) or malignant disease (n = 41). Abnormal findings were seen on CT scans in all patients and included ground-glass opacity (n = 99), bronchial wall thickening (n = 85) and centrilobular nodules (n = 79). These abnormalities were predominantly seen in the peripheral lung parenchyma (n = 99). Pleural effusion was found in eight patients. No patients had mediastinal and/or hilar lymph node enlargement.
M. catarrhalis pulmonary infection was observed in elderly patients, often in combination with pulmonary emphysema. CT manifestations of infection were mainly ground-glass opacity, bronchial wall thickening and centilobular nodules.
The purpose of this study was to compare the clinical and thin-section CT findings in patients with meticillin-resistant Staphylococcus aureus (MRSA) and meticillin-susceptible S. aureus (MSSA).
We retrospectively identified 201 patients with acute MRSA pneumonia and 164 patients with acute MSSA pneumonia who had undergone chest thin-section CT examinations between January 2004 and March 2009. Patients with concurrent infectious disease were excluded from our study. Consequently, our study group comprised 68 patients with MRSA pneumonia (37 male, 31 female) and 83 patients with MSSA pneumonia (32 male, 51 female). Clinical findings in the patients were assessed. Parenchymal abnormalities, lymph node enlargement and pleural effusion were assessed.
Underlying diseases such as cardiovascular were significantly more frequent in the patients with MRSA pneumonia than in those with MSSA pneumonia. CT findings of centrilobular nodules, centrilobular nodules with a tree-in-bud pattern, and bronchial wall thickening were significantly more frequent in the patients with MSSA pneumonia than those with MRSA pneumonia (p=0.038, p=0.007 and p=0.039, respectively). In the group with MRSA, parenchymal abnormalities were observed to be mainly peripherally distributed and the frequency was significantly higher than in the MSSA group (p=0.028). Pleural effusion was significantly more frequent in the patients with MRSA pneumonia than those with MSSA pneumonia (p=0.002).
Findings from the evaluation of thin-section CT manifestations of pneumonia may be useful to distinguish between patients with acute MRSA pneumonia and those with MSSA pneumonia.
The aim of this study was to assess pulmonary thin-section CT findings in patients with acute Haemophilus influenzae pulmonary infection.
Thin-section CT scans obtained between January 2004 and March 2009 from 434 patients with acute H. influenzae pulmonary infection were retrospectively evaluated. Patients with concurrent infection diseases, including Streptococcus pneumoniae (n=76), Staphylococcus aureus (n=58) or multiple pathogens (n=89) were excluded from this study. Thus, our study group comprised 211 patients (106 men, 105 women; age range, 16–91 years, mean, 63.9 years). Underlying diseases included cardiac disease (n=35), pulmonary emphysema (n=23), post-operative status for malignancy (n=20) and bronchial asthma (n=15). Frequencies of CT patterns and disease distribution of parenchymal abnormalities, lymph node enlargement and pleural effusion were assessed by thin-section CT.
The CT findings in patients with H. influenzae pulmonary infection consisted mainly of ground-glass opacity (n=185), bronchial wall thickening (n=181), centrilobular nodules (n=137) and consolidation (n=112). These abnormalities were predominantly seen in the peripheral lung parenchyma (n=108). Pleural effusion was found in 22 patients. Two patients had mediastinal lymph node enlargement.
These findings in elderly patients with smoking habits or cardiac disease may be characteristic CT findings of H. influenzae pulmonary infection.
We examined the memory cytotoxic T-lymphocytic (CTL) responses of peripheral blood mononuclear cells (PBMC) obtained from patients in Thailand 12 months after natural symptomatic secondary dengue virus infection. In all four patients analyzed, CTLs were detected in bulk culture PBMC against nonstructural dengue virus proteins. Numerous CD4+ and CD8+ CTL lines were generated from the bulk cultures of two patients, KPP94-037 and KPP94-024, which were specific for NS1.2a (NS1 and NS2a collectively) and NS3 proteins, respectively. All CTL lines derived from both patients were cross-reactive with other serotypes of dengue virus. The CD8+ NS1.2a-specific lines from patient KPP94-037 were HLA B57 restricted, and the CD8+ NS3-specific lines from patient KPP94-024 were HLA B7 restricted. The CD4+ CTL lines from patient KPP94-037 were HLA DR7 restricted. A majority of the CD8+ CTLs isolated from patient KPP94-024 were found to recognize amino acids 221 to 232 on NS3. These results demonstrate that in Thai patients after symptomatic secondary natural dengue infections, CTLs are mainly directed against nonstructural proteins and are broadly cross-reactive.
Kpp95, isolated on Klebsiella pneumoniae, is a bacteriophage with the morphology of T4-type phages and is capable of rapid lysis of host cells. Its double-stranded genomic DNA (ca. 175 kb, estimated by pulsed-field gel electrophoresis) can be cut only by restriction endonucleases with a cleavage site flanked either by A and T or by T, as tested, suggesting that it contains the modified derivative(s) of G and/or C. Over 26 protein bands were visualized upon sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the virion proteins. N-terminal sequencing indicated that the most abundant band (46 kDa) is the major coat protein (gp23) which has been cleaved from a signal peptide likely with a length similar to that of T4. Phylogenetic analyses based on the sequences of the central region (263 amino acid residues) of gp23 and the full length of gp18 and gp19 placed Kpp95 among the pseudo-T-even subgroup, most closely related to the coliphage JS98. In addition to being able to lyse many extended-spectrum β-lactamase strains of K. pneumoniae, Kpp95 can lyse Klebsiella oxytoca, Enterobacter agglomerans, and Serratia marcescens cells. Thus, Kpp95 deserves further studies for development as a component of a therapeutic cocktail, owing to its high efficiencies of host lysis plus extended host range.
Rubinstein et al. [Hearing Res. 127, 108–118 (1999)] suggested that the representation of electric stimulus waveforms in the temporal discharge patterns of auditory-nerve fiber (ANF) might be improved by introducing an ongoing, high-rate, desynchronizing pulse train (DPT). To test this hypothesis, activity of ANFs was studied in acutely deafened, anesthetized cats in response to 10-min-long, 5-kpps electric pulse trains that were sinusoidally modulated for 400 ms every second. Two classes of responses to sinusoidal modulations of the DPT were observed. Fibers that only responded transiently to the unmodulated DPT showed hyper synchronization and narrow dynamic ranges to sinusoidal modulators, much as responses to electric sinusoids presented without a DPT. In contrast, fibers that exhibited sustained responses to the DPT were sensitive to modulation depths as low as 0.25% for a modulation frequency of 417 Hz. Over a 20-dB range of modulation depths, responses of these fibers resembled responses to tones in a healthy ear in both discharge rate and synchronization index. This range is much wider than the dynamic range typically found with electrical stimulation without a DPT, and comparable to the dynamic range for acoustic stimulation. These results suggest that a stimulation strategy that uses small signals superimposed upon a large DPT to encode sounds may evoke temporal discharge patterns in some ANFs that resemble responses to sound in a healthy ear.
Thyrotoxic hypokalemic periodic paralysis (TPP) is characterized by acute attacks of weakness, hypokalemia, and thyrotoxicosis of various etiologies. These transient attacks resemble those of patients with familial hypokalemic periodic paralysis (hypoKPP) and resolve with treatment of the underlying hyperthyroidism. Because of the phenotypic similarity of these conditions, we hypothesized that TPP might also be a channelopathy. While sequencing candidate genes, we identified a previously unreported gene (not present in human sequence databases) that encodes an inwardly rectifying potassium (Kir) channel, Kir2.6. This channel, nearly identical to Kir2.2, is expressed in skeletal muscle and is transcriptionally regulated by thyroid hormone. Expression of Kir2.6 in mammalian cells revealed normal Kir currents in whole-cell and single-channel recordings. Kir2.6 mutations were present in up to 33% of the unrelated TPP patients in our collection. Some of these mutations clearly alter a variety of Kir2.6 properties, all altering muscle membrane excitability leading to paralysis.
In patients with hyperkalemic periodic paralysis (HyperKPP), attacks of muscle weakness or paralysis are triggered by K+ ingestion or rest after exercise. Force can be restored by muscle work or treatment with β2-adrenoceptor agonists. A missense substitution corresponding to a mutation in the skeletal muscle voltage-gated Na+ channel (Nav1.4, Met1592Val) causing human HyperKPP was targeted into the mouse SCN4A gene (mutants). In soleus muscles prepared from these mutant mice, twitch, tetanic force, and endurance were markedly reduced compared with soleus from wild type (WT), reflecting impaired excitability. In mutant soleus, contractility was considerably more sensitive than WT soleus to inhibition by elevated [K+]o. In resting mutant soleus, tetrodotoxin (TTX)-suppressible 22Na uptake and [Na+]i were increased by 470 and 58%, respectively, and membrane potential was depolarized (by 16 mV, P < 0.0001) and repolarized by TTX. Na+,K+ pump–mediated 86Rb uptake was 83% larger than in WT. Salbutamol stimulated 86Rb uptake and reduced [Na+]i both in mutant and WT soleus. Stimulating Na+,K+ pumps with salbutamol restored force in mutant soleus and extensor digitorum longus (EDL). Increasing [Na+]i with monensin also restored force in soleus. In soleus, EDL, and tibialis anterior muscles of mutant mice, the content of Na+,K+ pumps was 28, 62, and 33% higher than in WT, respectively, possibly reflecting the stimulating effect of elevated [Na+]i on the synthesis of Na+,K+ pumps. The results confirm that the functional disorders of skeletal muscles in HyperKPP are secondary to increased Na+ influx and show that contractility can be restored by acute stimulation of the Na+,K+ pumps. Calcitonin gene-related peptide (CGRP) restored force in mutant soleus but caused no detectable increase in 86Rb uptake. Repeated excitation and capsaicin also restored contractility, possibly because of the release of endogenous CGRP from nerve endings in the isolated muscles. These observations may explain how mild exercise helps locally to prevent severe weakness during an attack of HyperKPP.
Our objective was to assess the clinical factors that would reliably distinguish methicillin-resistant S. aureus (MRSA) from methicillin-susceptible S. aureus (MSSA) endocarditis. A retrospective cohort study of clinical features and mortality in patients with MRSA and MSSA endocarditis between March 1986 and March 2004 was performed in a 750-bed, tertiary care teaching hospital. A total of 32 patients (10 MRSA [31.3%] vs 22 MSSA [68.7%]) were evaluated. Their mean age and sex ratio (male/female) were as follows: 30.8 ± 16.0 vs 24.4±19.6 years old and 6/4 vs 13/9, for MRSA and MSSA infective endocarditis (IE), respectively. Univariate and multivariate analyses revealed that persistent bacteremia was significantly more prevalent in MRSA IE (OR, 10.0 [1.480-67.552]; p, 0.018). There was a higher mortality trend for MRSA IE (50.0%) than for MSSA IE (9.1%) (p=0.019). However, persistent bacteremia was not associated with higher mortality (p>0.05). These results indicate that if persistent bacteremia is documented, the likelihood of MRSA endocarditis should be viewed as high, and the patient's antistaphylococcal therapy should be prolonged and/or changed to a more "potent" regimen.
Staphylococcus aureus; bacteremia; endocarditis
of this study was to describe findings on sequential high resolution
computed tomographic (CT) scans of nine patients with non-specific
CT scans of nine patients with pathologically proven non-specific
interstitial pneumonia were evaluated retrospectively. All patients
underwent sequential CT scanning (mean follow up 3.1 years (range
predominant finding on the initial CT scans in seven patients was
patchy areas of ground glass opacity in both the central and peripheral
lung, with (n = 5) or without (n = 2) irregular areas of consolidation.
In another two patients areas of consolidation in both the central and
peripheral lung were seen as the predominant abnormality. The initial
parenchymal abnormalities had resolved completely in four patients with
predominant ground glass opacity without bronchiolectasis. Some of the
bronchiectasis and bronchiolectasis resolved. In two patients
bronchiectasis and bronchiolectasis occurred at one year and two years
of follow up, respectively. In two patients with predominant
consolidation the consolidation decreased but persisted, and in one
patient the consolidation evolved into honeycombing. In the other
patient bronchiectasis progressed over the course of seven years,
forming varicoid bronchiectasis.
with non-specific interstitial pneumonia may recover completely after
treatment with corticosteroids, but as many as half of these patients
will have persistent pulmonary abnormalities on CT scans including
bronchiectasis and honeycomb lung.
Methicillin resistant Staphylococcus aureus (MRSA) has been considered for many years a typical nosocomial pathogen. Recently MRSA has emerged as a frequent cause of infections in the community. More commonly, community-acquired (CA)-MRSA is a cause of infections of the skin and soft-tissues, but life-threatening infections such as necrotizing pneumonia and sepsis can occasionally occur.
This report describes an uncommon presentation of invasive CA-MRSA infection in an adolescent without known risk factors. The presentation was typical for bacterial meningitis, but the clinical findings also revealed necrotizing pneumonia. Following the development of deep venous thrombosis, the presence of an inherited trombophilic defect (factor V Leiden) was detected. The patient was successfully treated with an antibiotic combination including linezolid and with anticoagulant therapy. CA-MRSA was isolated from both cerebrospinal fluid and blood. The isolates were resistant to oxacillin and other beta-lactam antibiotics and susceptible to the other antibiotics tested including erythromycin. Molecular typing revealed that the strains contained the Panton-Valentine leukocidin genes and type IV SCCmec, and were ST8, spa type t008, and agr type 1. This genetic background is identical to that of the USA300 clone.
This report highlights that meningitis can be a new serious presentation of CA-MRSA infection. CA-MRSA strains with the genetic background of the USA300 clone are circulating in Italy and are able to cause severe infections.
Abdominal surgery carries significant morbidity and mortality, which is in turn associated with an enormous use of healthcare resources. We describe the clinical course of 30 Intensive Care Unit (ICU) patients who underwent abdominal surgery and showed severe infections caused by Klebsiella pneumoniae sequence type (ST) 258 producing K. pneumoniae carbapenemase (KPC-Kp). The aim was to evaluate risk factors for mortality and the impact of a combination therapy of colistin plus recommended regimen or higher dosage of tigecycline.
A prospective assessment of severe monomicrobial KPC-Kp infections occurring after open abdominal surgery carried out from August 2011 to August 2012 in the same hospital by different surgical teams is presented. Clinical and surgical characteristics, microbiological and surveillance data, factors associated with mortality and treatment regimens were analyzed. A combination regimen of colistin with tigecycline was used. A high dose of tigecycline was administered according to intra-abdominal abscess severity and MICs for tigecycline.
The mean age of the patients was 56.6 ± 15 and their APACHE score on admission averaged 22.72. Twenty out of 30 patients came from the surgical emergency unit. Fifteen patients showed intra-abdominal abscess, eight anastomotic leakage, four surgical site infection (SSI) and three peritonitis. The overall crude ICU mortality rate was 40% (12 out of 30 patients). Twelve of the 30 patients were started on a combination treatment of high-dose tigecycline and intravenous colistin. A significantly lower mortality rate was observed among those patients compared to patients treated with approved dose of tigecycline plus colistin. No adverse events were reported with high doses of tigecycline.
Critically-ill surgical patients are prone to severe post-surgical infectious complications caused by KPC-Kp. Timely microbiological diagnosis and optimizing antibiotic dosing regimens are essential to prevent worse outcomes. Further studies and well-controlled clinical trials are needed to define the optimal treatment of infections by KPC-Kp and, more generally, carbapenem-resistant bacteria.
Klebsiella pneumoniae; Carbapenemase; Abdominal surgery
In the phytopathogenic fungus Ustilago maydis, pheromone-mediated cell fusion is a prerequisite for the generation of the infectious dikaryon. The pheromone signal elevates transcription of the pheromone genes and elicits formation of conjugation hyphae. Cyclic AMP and mitogen-activated protein kinase (MAPK) signaling are involved in this process. The MAPK cascade is presumed to be composed of Ubc4 (MAPK kinase kinase), Fuz7 (MAPK kinase), and Ubc3/Kpp2 (MAPK). We isolated the kpp4 gene and found it to be allelic to ubc4. Epistasis analyses with constitutively active alleles of kpp4 and fuz7 substantiate that Kpp4, Fuz7, and Kpp2/Ubc3 are components of the same module. Moreover, we demonstrate that Fuz7 activates Kpp2 and shows interactions in vitro. Signaling via this cascade regulates expression of pheromone-responsive genes, presumably through acting on the transcription factor Prf1. Interestingly, the same cascade is needed for conjugation tube formation, and this process does not involve Prf1. In addition, fuz7 as well as kpp4 deletion strains are nonpathogenic, while kpp2 deletion mutants are only attenuated in pathogenesis. Here we show that strains expressing the unphosphorylatable allele kpp2T182A/Y184F are severely affected in tumor induction and display defects in early infection-related differentiation.
When using electronic medical record (EMR) data to study drug use, hospitalizations are markers of severe outcomes. To identify events within a specified time window, it is important to validate hospitalization diagnoses and dates. Our objective was to validate pneumonia hospitalizations and their dates identified using hospitalization codes in The Health Improvement Network (THIN), a UK primary care EMR.
This cross-sectional study used a cohort of THIN adult visits for acute nonspecific respiratory infections from 6/1985-8/2006. Pneumonia hospitalizations within 14 days after the visit were identified using THIN diagnosis and hospitalization codes; 60 were randomly selected for validation. Patients' general practitioners (GPs) returned deidentifed hospital summaries and consultants' letters regarding overnight hospitalizations within a 180-day window around the THIN hospitalization. Positive predictive value (PPV) was the number of GP-validated hospitalizations divided by THIN documented hospitalizations.
GPs returned 59/60 patient records; 52 had confirmed hospitalizations. PPV of THIN hospitalization documentation was 88% (95% c.i.77–95). One admission was not for pneumonia; PPV of THIN-documented pneumonia admission was 86% (75–94). Of 52 valid THIN hospitalizations, 50 were actually admitted within 14 days of the documented THIN date (range −2 to +18). The absolute median difference between THIN and validated admission dates was +0.5 days; absolute mean difference was +3.1 days. In 16 of 52 admitted patients, the THIN admission date was the actual discharge date.
THIN hospitalization codes performed well in identifying acute pneumonia hospitalizations and their timing. Admission date validity might be better for conditions associated with shorter vs. longer hospitalizations.
pneumonia; health services research; validation studies; electronic medical records; drug safety; treatment outcomes
The literature contains variable reports on the causative organisms of osteomyelitis and septic arthritis in patients with injecting drug abuse and on the rate of oxacillin-resistant S aureus. It is important to have a clear notion of the organisms to initiate empiric antimicrobial therapy.
We therefore determined the spectrum of organisms in bone and joint infections in patients who were injecting drug users.
We retrospectively reviewed the medical records of 215 patients (154 male, 61 female) with a history of injecting drug abuse and concurrent bone and/or joint infection from 1998 to 2005. The mean age was 43 years (range, 23–83 years). Osteomyelitis was present in 127 of the 215 patients (59%), septic arthritis in 53 (25%), and both in 35 (16%). The lower extremity was most commonly involved (141 cases, 66%), with osteomyelitis of the tibia present in 70 patients (33%) and septic knee arthritis in 30 patients (14%).
Cultures yielded predominately Gram-positive bacteria: Staphylococcus aureus in 52% and coagulase-negative Staphylococcus in 20%. The proportion of oxacillin-resistant S aureus among S aureus infections increased from 21% in 1998 to 73% in 2005. Gram-negative organisms were present in 19% of infections and anaerobes in 13%. Patients with osteomyelitis had a higher prevalence of polymicrobial infections (46% versus 15%), infections due to Gram-negative organisms (24% versus 9%), and anaerobic infections (19% versus 6%) compared to patients with septic arthritis.
These findings suggest broad-spectrum empiric antibiotic therapy, including vancomycin, should be considered for bone and joint infections in patients with injecting drug abuse.
Level of Evidence
Level IV, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
Anaesthesia and surgical procedures lead to a
reduction of intestinal motility, and opioids may
produce a postoperative ileus, that might delay
postoperative feeding. The aim of this prospective
randomised study is to test whether or not different
kinds of epidural analgesia (Group A: morphine 0.00
17 mg/kg/h and bupivacaine 0.125% – 0.058 mg/kg/h;
Group B: morphine alone 0.035mg/kg/12h in the
postoperative period) allow earlier postoperative
enteral feeding, enhance intestinal motility a passage
of flatus and help avoid complications, such
as nausea, vomiting, ileus, diarrhoea, pneumonia or
other infective diseases. We included in the study 60
patients (28 males and 32 females) with a mean age
of 61.2 years (range 50–70) and with an ASA score of
2 or 3. All patients had hepato–biliary-pancreatic
neoplasm and were candidates for major surgery.
We compared two different pharmacological approaches,
i.e., morphine plus bupivacaine (30 patients,
Group A)versus morphine alone (30 patients,
Group B). Each medication was administered by
means of a thoracic epidural catheter for the control
of postoperative pain. In the postoperative course
we recorded every 6 hours peristaltic activity. We
also noted morbidity (pneumonia, wound sepsis)
and mortality. Effective peristalsis was present in
all patients in Group A within the first six postoperative
hours; in Group B, after 30 hours. Six
patients in Group A had bowel motions in the first
postoperative day, 11 in the second day, 10 in the
third day and 3 in fourth day, while in Group B none
in the first day, two in the second, 7 in the third, 15
in the fourth, and 6 in the fifth: the difference
between the two groups was significant (P<0.05
in 1st, 2nd, 4th and 5th days). Pneumonia occurred
in 2 patients of Group A, and in 10 of Group B
We conclude that epidural analgesia with morphine
plus bupivacaine allowed a move rapid return
to normal gut activity and early enteral nutrition compared
with epidural analgesia with morphine alone.
Acute osteomyelitis comprised 78 (29.3%) of the 266 major skeletal complications seen in 207 patients with sickle cell disease in a five and a half year period. Forty eight (61.5%) of the 78 patients were under the age of 15 years, and the mean age at onset was 12 years (range 9 months to 50 years). Osteomyelitis was often multifocal (in 42% of the cases) and associated with some life threatening disorders. Salmonella accounted for 50% of the 36 organisms isolated from 32 patients with bacteriologically confirmed diagnosis. The 'best guess' antibiotic was a combination of chloramphenicol and cloxacillin. Medical treatment alone proved adequate in most cases. No deaths resulted, but 55% of the patients developed serious complications due partly to the severity of the disease and also to infection involving the epiphyses and joints.
Benign recurrent hematuria usually indicates a good prognosis. This condition is associated with abnormally thin glomerular basement membranes. Of 680 renal biopsy cases in which lower urinary tract disease had been excluded by careful study, 25 cases from seven children and eighteen adults met the criteria for thin glomerular basement membrane disease, placing the incidence of the disease at 3.7%. The mean patient age was 32.4 years and the male to female ratio was 1 to 5.3. The primary finding was microscopic hematuria in eighteen patients and gross hematuria in five patients. Among eighteen patients who had microscopic hematuria, one patient also exhibited proteinuria and one patient suffered from acute renal failure due to acute drug-induced interstitial nephritis. Proteinuria was only found in one patient. All of the patients had normal renal function, with the exception of one who suffered from acute renal failure. The duration of hematuria from the time of detection to the date of biopsy ranged from 3 months to 30 years with a mean interval of 56.6 months. No apparent evidence of familial hematuria in any patient was noted. Under light microscopy most glomeruli were normal. However, five cases showed focal global sclerosis. Under immunofluorescence microscopy seventeen cases were negative for all immunoglobulins, for complement, and for fibrinogen. Eight cases showed nonspecific mesangial deposition of fibrinogen and/or IgM. Ultrastructurally, extensive diffuse thinning of the GBM was a constant finding. The mean thickness of the GBM was 203.2 +/- 28.3 nm (n = 25); the thickness in adult (201.4 +/- 27.5 nm; n = 18) did not differ from that in children (208.1 +/- 32.0 nm; n = 7).
Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring in a patient after intubation with an endotracheal tube or tracheostomy tube lasting for 48 hours or more. We describe a case of 75-year-old male who initially presented with pneumonia of the right basis with accompanying plevritis. The patient was intubated and his condition was complicated with a VAP infection while he developed a lung abscess. The antibiotic therapy was based on susceptibility bronchial secretions isolated acinetobacter baumannii and klebsiella pneumoniae; these pathogens were also isolated from the drained abscess. The patient was discharged in good health. The interest of this case is recommended in the existence of two responsible pathogens, the paucity of the development of lung abscess in a patient with VAP, and the successful treatment of the patient with the combination of controlled drainage of the abscess and appropriate antibiotic therapy.
Ventilator-associated pneumonia; Acinetobacter baumannii; Klebsiella pneumoniae; Lung; Abscess
This study aimed to compare thin-section CT images from sarcoidosis patients who had either normal or elevated serum KL-6 levels.
101 patients with sarcoidosis who underwent thin-section CT examinations of the chest and serum KL-6 measurements between December 2003 and November 2008 were retrospectively identified. The study group comprised 75 sarcoidosis patients (23 male, 52 female; aged 19–82 years, mean 54.1 years) with normal KL-6 levels (152–499 U ml–1, mean 305.7 U ml–1) and 26 sarcoidosis patients (7 male, 19 female; aged 19–75 years, mean 54.3 years) with elevated KL-6 levels (541–2940 U ml–1, mean 802.4 U ml–1). Two chest radiologists, unaware of KL-6 levels, retrospectively and independently interpreted CT images for parenchymal abnormalities, enlarged lymph nodes and pleural effusion.
CT findings in sarcoidosis patients consisted mainly of lymph node enlargement (70/75 with normal KL-6 levels and 21/26 with elevated KL-6 levels), followed by nodules (50 and 25 with normal and elevated levels, respectively) and bronchial wall thickening (25 and 21 with normal and elevated levels, respectively). Ground-glass opacity, nodules, interlobular septal thickening, traction bronchiectasis, architectural distortion and bronchial wall thickening were significantly more frequent in patients with elevated KL-6 levels than those with normal levels (p<0.001, p<0.005, p<0.001, p<0.001, p<0.001 and p<0.001, respectively). By comparison, there was no significant difference in frequency of lymph node enlargement between the two groups.
These results suggest that serum KL-6 levels may be a useful marker for indicating the severity of parenchymal sarcoidosis.
Klebsiella pneumoniae is one of the organisms most commonly isolated from pyogenic liver abscesses in Asian populations. We compared CT findings in liver abscesses caused by K. pneumoniae with those caused by other bacterial pathogens.
Of 214 patients with liver abscesses examined over a 5 year period, 129 patients with positive blood or aspirate cultures were enrolled. The patients were divided into two groups: the K. pneumoniae monomicrobial liver abscess (KLA) group (n = 59) and the non-K. pneumoniae monomicrobial or polymicrobial liver abscess (non-KLA) group (n = 70). Two radiologists blinded to the culture results evaluated the CT images, recording the number, size, location and configuration of abscesses, the thickness of the abscess wall, the pattern of rim enhancement, septal enhancement, the double target sign, internal necrotic debris, internal gas bubbles and underlying biliary disease. The presence of diabetes and metastatic infection was also compared between groups. Statistical analyses were performed using univariate (Student's t-test and χ2 test) and multivariate analyses.
Multivariate analysis showed that a thin wall, necrotic debris, metastatic infection and the absence of underlying biliary disease were the most significant predictors of KLA. When three of the four criteria were used in combination, a specificity of 98.6% was achieved for the diagnosis of KLA.
A thin-walled abscess, internal necrotic debris, the presence of metastatic infection and the absence of underlying biliary disease may be useful CT findings in the early diagnosis of K. pneumoniae liver abscesses.
The impact of dizziness on Quality of Life (QoL) can be assessed by the Dizziness Handicap Inventory (DHI), which is used as a discriminative
and evaluative tool. Although the DHI is available in several languages, an equivalent version for the Italian population is not yet
available. Aim of this study was to translate the DHI into the Italian language (DHI-I), assess its correlation to the Italian version of the
Short Form-36 Health Survey and to investigate its reliability in evaluating the QoL of patients with acute dizziness. The study population
consisted of 50 patients (76% females and 24% males), mean age 51.6 years, range 25-85 years (SD = 14.5). A cross-sectional design was
used to examine the internal consistency (Cronbach’s α) and concurrent validity (Pearson’s product moment correlation r). The application
followed the stages of translation from English to Italian and linguistic adaptation, grammatical and idiomatic equivalence review. To
confirm the external validity of DHI-I, the Pearson correlation test between the total score and single subscales of DHI-I and the 8 scales
of the Short Form Health Survey (SF-36) was performed. The Cronbach α coefficients for internal consistency were 0.92 for the DHI-I and
0.82, 0.84 and 0.75 for the sub-scale functional, emotional and physical, respectively. The frequency distribution of no one item showed
a percentage higher than 75% in a single possible answer (0, 2, 4), excluding a ceiling or floor effect. Correlations with the total score of
DHI-I were consistent and the correlation between total score of DHI-I and total score on SF-36 was -0.593. Of the single subscales, the
emotional scale showed a closer correlation with almost all scales of the SF-36. The correlation between the total score of SF-36 and the
single sub-scale of DHI-I (functional, emotional, physical) were respectively -0.599, -0.563, -0.398. The DHI was culturally and linguistically
adapted for its application in the Italian population. The DHI-I demonstrated a good reliability and is recommended as a measure of
disability in patients with dizziness and unsteadiness. According to the DHI-I, patients with acute dizziness and with a clinical diagnosis of
vestibular syndrome presented a decreased QoL; the physical aspects were the most compromised.
Dizziness Handicap Inventory (DHI); Health-related Quality of Life (QoL); SF-36 Health Survey; Validity; Disability