Nosocomial bloodstream infections with Burkholderia stabilis

Burkholderia stabilis was grown from blood cultures of seven patients presenting with signs and symptoms of septicaemia in the intensive care unit at Mersin University Hospital, Mersin, Turkey between July and October 2002. Four patients had one B. stabilis-positive blood culture, two patients had two, and one patient had four. Isolates from six of seven patients had the same resistotype and random amplified polymorphic DNA analysis type. Despite treatment with ciprofloxacin and imipenem, to which the strains were susceptible, all patients died one to eight days after isolation of B. stabilis from their blood. B. stabilis should be regarded as an opportunistic pathogen that may cause nosocomial bloodstream infections.

The significance of local cellular immune response of women 50 years of age and younger with endometrial carcinoma

OBJECTIVE

Local cellular immune response and traditional histopathologic parameters in endometrial carcinoma patients 50 years old and younger were compared with those of patients older than 50 years of age.

MATERIALS AND METHODS

We retrospectively compared the clinicopathologic factors and outcomes of 24 younger and 82 older women who were operated on for endometrioid type endometrial carcinoma at our institution.

RESULTS

No significant difference was determined in survival with respect to age and menopausal status in patients with endometrial carcinoma. Younger and older age groups had a similar distribution of most pathologic features including myometrial invasion, cervical involvement, lymph node metastasis, vascular invasion, perivascular lymphocytic infiltrates and tumor infiltrating lymphocytes. While older women had higher-grade tumors, younger women had more frequent ovarian metastasis. Tumor infilrating lymphocytes were seen more frequently in the postmenopausal group than those of the premenopausal group.

CONCLUSION

The distribution of local cellular immune response, most histopathologic parameters and survival were the same for younger and older women.

DNA interaction and cytotoxicity of a new series of indolo[2,3-b]quinoxaline and pyridopyrazino[2,3-b]indole derivatives

Absorption, melting temperature and linear dichroism measurements were performed to investigate the interaction with DNA of a series of 16 tricyclic and tetracyclic compounds related to the antiviral agent B-220. The relative DNA affinity of the test compounds containing an indolo[2,3-b]quinoxaline, pyridopyrazino[2,3-b]indoles or pyrazino[2,3-b]indole planar chromophore varies significantly depending on the nature of the side chain grafted onto the indole nitrogen. Compounds with a dimethylaminoethyl chain strongly bind to DNA and exhibit a preference for GC-rich DNA sequences, as revealed by DNase I footprinting. Weaker DNA interactions were detected with those bearing a morpholinoethyl side chain. The incorporation of a 2,3-dihydroxypropyl side chain does not reinforce the DNA interaction compared with the unsubstituted analogues. Both the DNA relaxation assay and cytotoxicity study using two human leukemia cell lines sensitive (HL-60) or resistant (HL-60/MX2) to the antitumor drug mitoxantrone, indicate that topoisomerase II is not a privileged target for the test compounds which only weakly interfere with the catalytic activity of the DNA cleaving enzyme. Cytometry studies showed that the most cytotoxic compounds induce a massive accumulation of cells in the G2/M phase of the cell cycle. Collectively, the data show a relationship between DNA binding and cytotoxicity in the indolo[2,3-b]quinoxaline series.

Apoptosis induced by the homocamptothecin anticancer drug BN80915 in HL-60 cells

The homocamptothecin (hCPT) derivative BN80915 containing a seven-membered lactone ring represents one of the most potent topoisomerase I inhibitors described. This anticancer agent, currently undergoing phase I clinical trials, has been shown to produce a greater number of DNA strand breaks than conventional camptothecins with a six-membered lactone ring. To shed light on the mechanism of action of hCPT at the cellular level, we compared the effects of BN80915 and the classic camptothecin SN-38, the active metabolite of irinotecan, on HL-60 human promyelocytic cancer cells. A variety of biochemical events, at both the mitochondrial and the nuclear levels, were characterized to determine how and to what extent the hCPT derivative can induce apoptotic cell death. The use of cytometry, Western blot analysis, confocal microscopy, and different colorimetric assays enabled us to demonstrate that BN80915 is a potent inducer of apoptosis in HL-60 cells. This induction of apoptosis is associated with cell cycle changes, a marked decrease of intracellular pH, activation of caspase-3 and -8, DNA fragmentation, and externalization of phosphatidylserine lipids but no significant changes of the mitochondrial membrane potential or the expression of Bcl-2. The interconnections between these different events are discussed. Collectively, the results indicate that the superior activity expressed at the topoisomerase I level leads to a more pronounced induction of apoptosis by BN80915 compared with SN-38. The study identifies and delineates signaling factors involved in BN80915-induced apoptosis in HL-60 cells.

Comparative in vitro activities of five quinolone antibiotics, including gemifloxacin, against clinical isolates

The in vitro activities of ciprofloxacin, ofloxacin, norfloxacin, levofloxacin and gemifloxacin against 343 clinical isolates were compared. Gemifloxacin showed the greatest activity, with MIC90 values as low as 0.03-0.25 mg/L against Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, methicillin-susceptible Staphylococcus aureus and Klebsiella pneumoniae, while methicillin-resistant Staphylococcus aureus, Enterococcus spp., Pseudomonas spp., Acinetobacter spp., Escherichia coli and Enterobacter spp. strains exhibited low rates of susceptibility to all five fluoroquinolones.

Renal function and structure in subacute hepatic failure

BACKGROUND AND AIMS

Subacute hepatic failure (SHF) is a fatal complicaton of acute viral hepatitis. Renal failure has been implicated as the main cause of death in this disease. However, renal functional and structural evaluation in such patients have not been performed. The present prospective study evaluated the renal functional and structural abnormalities in patients with subacute hepatic failure.

METHODS

Fourteen consecutive patients with SHF, 11 with acute liver failure (ALF) and 15 with cirrhosis of the liver (Child's B or C) were included in the present study. All 40 patients had liver disease caused by hepatitis viruses. The glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) estimations were measured in all patients by the use of technetium-99m diethylenetriaminepentaacetic acid and [131I]-labeled ortho-iodohippuric acid, respectively. Ante-mortem or post-mortem liver biopsies were performed in all patients. In three patients with SHF, post-mortem kidney biopsies were also performed.

RESULTS

Thirty six percent (5/14) of patients with SHF, 18% (2/11) of patients with ALF and 20% (3/15) of patients with cirrhosis had renal failure. Seven patients with SHF, seven with ALF and nine with cirrhosis died. All the patients with renal failure in each of the three groups were among the deceased patients. Glomerular function was markedly affected among patients with SHF, which was shown by significantly higher (P < 0.05) proteinuria levels (0.367 +/- 0.38 g/24 h) compared to levels in patients with ALF (0.178 +/- 0.11 g/24 h) and cirrhosis (0.212 +/- 0.133 g/24 h). The GFR in SHF (56 +/- 27 mL/min per 1.73 m2) and cirrhotic patients (58 +/- 36 mL/min per 1.73 m2) was significantly lower compared to those in ALF patients (102 +/- 51 mL/min per 1.73 m2; P < 0.05). A significantly higher proportion (P < 0.05) of patients with SHF and cirrhosis (64 and 73%, respectively) had a GFR below 80 mL/min per 1.73 m2 compared to patients with ALF (18%). The GFR value among the deceased SHF patients (46 +/- 26 mL/min per 1.73 m2) was significantly lower (P < 0.05) than those SHF patients who survived (65 +/- 25 mL/min per 1.73 m2). However, similar features could not be documented among patients with ALF or cirrhosis. Subtle structural changes in the glomerulus were also noted in patients with SHF. These included mesangial proliferation and thickening, basal membrane thickening and increased cellularity with interstitial edema. The ERPF was markedly reduced (P = 0.058) among patients with SHF (347 +/- 131 mL/min per 1.73 m2) and cirrhosis (395 +/- 137 mL/min per 1.73 m2) in comparison to ERPF documented among patients with ALF (436 +/- 217 mL/min per 1.73 m2). Such a reduction in renal tubular blood flow, along with histologic documentation of hyaline presence, bile and grannular cast in the tubule, indicated a possible tubular dysfunction in patients with SHF.

CONCLUSION

It is concluded that glomerular and tubular dysfunction with subtle structural abnormalities does occur in patients with SHF. These are similar to renal changes in cirrhosis and may have similar pathogenetic mechanisms that require further evaluation.

In vivo regulation of von willebrand factor synthesis: von Willebrand factor production in endothelial cells after lung transplantation between normal pigs and von Willebrand factor-deficient pigs

To evaluate the regulation of plasma von Willebrand factor (vWF) and its in situ production by endothelial cells (ECs), 12 swine leukocyte antigen (SLA)-compatible left lung transplantations were performed. Normal lungs were transplanted into 10 pigs homozygous for von Willebrand disease and into 2 normal pigs. Additionally, 1 normal pig underwent pneumonectomy, and 1 SLA-incompatible lung transplantation between normal pigs was performed. None of the transplanted animals received immunosuppressive therapy. Plasma vWF level was evaluated by ELISA and multimeric pattern. EC vWF content was assessed by immunohistochemistry. Global hemostasis was assessed by standardized ear bleeding time. Six of 12 SLA-compatible lung transplantations and the incompatible transplantation were successful and were used for the study. The functions and the viability of ECs, reflected by their ability to produce vWF and normal multimeric plasma vWF pattern, were preserved in SLA-compatible and -incompatible lung transplantations. vWF production was preserved in ECs that initially synthesized it. EC constitutive and storage pathways are modulated differently according to transplantation compatibility and severity of rejection. In SLA-compatible lung transplantations without histological evidence of rejection, the production of vWF was preserved, whereas constitutive vWF secretion appeared to be altered in cases with minor histological signs of rejection. In pigs with von Willebrand disease that were transplanted with normal lungs without sign of rejection, plasma vWF was significantly increased in an amount expected from the estimated production of a normal lung. In the transplanted normal lung, there was no vWF overexpression by the ECs and no recruitment of ECs that initially did not express vWF. In SLA-incompatible transplantation, ECs were morphologically normal with increased and blurred vWF labeling, whereas plasma vWF levels remained normal, reflecting that EC activation is associated with an increased vWF production with probable diversion to storage pathway. This model depicts the changes of EC regulation of vWF secretion in pig lung transplants. However, this model cannot be directly extrapolated to human organ transplantation because animals did not receive any immunosuppressive therapy, which may be toxic to ECs.

Increasing antimicrobial resistance in STDs and the need for surveillance: Neisseria gonorrhoeae as a model

Neisseria gonorrhoeae has a rising trend of resistance against antimicrobials. Today, third generation cephalosporins are the only antibiotics for treatment of gonorrhea against which there is no resistance in gonococci. On the other hand, decreased susceptibility against this group, including ceftriaxone, has already been observed. This historically famous pathogen deserves current attention and is reviewed here with respect to its resistance mechanisms and patterns, and the problems concerning standardization of its susceptibility testing are discussed.

Lansoprazole and secnidazole with clarithromycin, amoxycillin or pefloxacin in the eradication of Helicobacter pylori in a developing country

BACKGROUND

A number of triple drug regimens using proton pump inhibitors and two antibiotics have been evaluated in the West and reported to achieve Helicobacter pylori eradication rates of over 90%. In developing countries however, these combinations have neither been well evaluated, nor the optimum treatment for H. pylori infection well defined.

AIM

To compare the combination of a proton pump inhibitor with a nitroimidazole and another antibiotic in eradicating H. pylori infection and healing duodenal ulcer.

METHODS

Sixty consecutive patients with active duodenal ulcer who were positive for H. pylori (by rapid urease test and 14C-urea breath test) were randomized into three treatments groups: (1) LAS (n=21): lansoprazole 30 mg o.m., amoxycillin 500 mg q.d.s. and secnidazole 2 g on alternate days for 2 weeks; (2) LCS (n=18): lansoprazole 30 mg o.m., clarithromycin 500 mg b.d. and secnidazole 2 g on alternate days for 1 week; (3) LPS (n=21): lansoprazole 30 mg o.m., pefloxacin 400 mg o.m. and secnidazole 2 g on alternate days for 2 weeks. Urease and breath tests were performed at 0, 6 and 12 weeks to check for H. pylori eradication.

RESULTS

Intention-to-treat eradication rates were as follows: LAS 86%, LCS 83%, LPS 71%; the overall ulcer healing rate was 90% at 6 weeks.

CONCLUSIONS

High H. pylori eradication rates were achieved using the amoxycillin- and clarithromycin-based therapies. Fewer side-effects, better compliance and low cost favoured the amoxycillin-based therapy.

Description of Nocardiopsis synnemataformans sp. nov., elevation of Nocardiopsis alba subsp. prasina to Nocardiopsis prasina comb. nov., and designation of Nocardiopsis antarctica and Nocardiopsis alborubida as later subjective synonyms of Nocardiopsis dassonvillei

Data from chemotaxonomic and 16S ribosomal DNA sequence analyses of an isolate obtained from the sputum of a kidney transplant patient identified the isolate as a member of the genus Nocardiopsis. DNA-DNA hybridization data, as well as physiological characteristics, indicated that the isolate represents a new species of the genus Nocardiopsis, designated Nocardiopsis synnemataformans; the type strain is strain IMMIB D-1215 (= DSM 44143). In addition, DNA-DNA hybridization data, as well as the results of biochemical tests, indicated that Nocardiopsis alborubida DSM 40465T, Nocardiopsis antarctica DSM 43884T, and Nocardiopsis dassonvillei DSM 43111T represent a single species designated N. dassonvillei. We also found that Nocardiopsis alba subsp. alba DSM 43377T and N. alba subsp. prasina DSM 43845T are genetically different and therefore propose that N. alba subsp. prasina be elevated to species status as Nocardiopsis prasina comb. nov., whose type strain is strain DSM 43845.

Management of glioblastoma multiforme: with special reference to recurrence

Between 1985 and 1995, 46 patients underwent craniotomy for glioblastoma multiforme. The mean age was 47, varying from 9 to 71 years. The influence of such prognostic factors as age, preoperative Karnofsky score, extent of resection, tumour site, tumour size, radiotherapy, reoperation as well as initial symptoms upon survival were studied. Of these, gross complete removal, radiotherapy, preoperative Karnofsky score, and reoperation were shown to be statistically significant to the survival time according to logrank and univariate tests. However, age, preoperative Karnofsky score, tumour size and temporal localisation remained as significant factors in multivariate analysis. The overall median survival was 53 weeks, with no patients surviving more than 3 years. Of the patients, 41% survived over a year and 8.6% lived over two years. Twenty-six patients developed a recurrent mass after an interval of 32 weeks. The median interval time from operation to recurrence was longer in those patients who underwent gross removal than in those who had a subtotal resection, 28.2 against 20 weeks (P < 0.05). Of patients who had a recurrent mass, 16 were reoperated on, with a subsequent median survival time of 26.5 weeks. Our experience suggests that the survival of patients with glioblastoma depends on many factors, including radical surgery as an initial step. In addition, the gross total removal of the tumour also delays the development of recurrence.

Prospective randomized clinical trial to evaluate the optimal dose of 131 I for remnant ablation in patients with differentiated thyroid carcinoma

BACKGROUND

Radioiodine has been used for more than a half-century to ablate thyroid remnants following thyroid surgery, but a single optimal dose has not been established. We designed a prospective randomized trial to determine the optimal dose of 131 I for remnant ablation.

METHODS

Using a simple randomization technique, 149 patients with remnant thyroid were incorporated into 4 treatment groups. Twenty-seven of these patients were administered 25 to 34 millicurie (mCi) of 131 I (30 +/- 1.5), 54 received 35 to 64 mCi (50.6 +/- 5.4), 38 received 65 to 119 mCi (88.6 +/- 14) and 30 patients received 120 to 200 mCi (155 +/- 28.7). Six months to 1 year after treatment, all subjects were reassessed after withdrawing L-thyroxine for 4 to 6 weeks. A successful ablation was defined as the absence of thyroid bed activity in 5 mCi 131 I neck scan at 48 hours along with 2 adjunctive criteria which were the neck uptake of <0.2% of the administered activity and the thyroglobulin (Tg) value of <10 ng/mL.

RESULTS

Applying the above criteria, we observed complete ablation of 17 of 27 thyroid gland remnants (63%) in the 30 mCi group, 42 of 54 (77.8%) in the 50 mCi group, 28 of 38 (73.7%) in the 90 mCi group and 23 of 30 (76.7%) in the 155 mCi group. When the radiation-absorbed dose was calculated, a 30 mCi dose delivered approximately 20,000 centigray (cGy), a 50 mCi dose about 30,000 cGy, a 90 mCi dose about 50,000 cGy, and a 155 mCi dose about 130,000 cGy.

CONCLUSIONS

Increasing the empirical 131 I initial dose to more than 50 mCi results in plateauing of the dose-response curve and thus, conventional high dose remnant ablation needs critical evaluation. Based on dosimetry results, one should aim to deliver about 30,000 cGy to the thyroid remnant, as higher doses do not appear to yield a higher ablation rate.

Characterization of beta-lactamase gene blaPER-2, which encodes an extended-spectrum class A beta-lactamase

Plasmidic extended-spectrum beta-lactamases of Ambler class A are mostly inactive against ceftibuten. Salmonella typhimurium JMC isolated in Argentina harbors a bla gene located on a plasmid (pMVP-5) which confers transferable resistance to oxyiminocephalosporins, aztreonam, and ceftibuten. The beta-lactamase PER-2 (formerly ceftibutenase-1; CTI-1) is highly susceptible to inhibition by clavulanate and is located at a pI of 5.4 after isoelectric focusing. The blaPER-2 gene was cloned and sequenced. The nucleotide sequence of a 2.2-kb insert in vector pBluescript includes an open reading frame of 927 bp. Comparison of the deduced amino acid sequence of PER-2 with those of other beta-lactamases indicates that PER-2 is not closely related to TEM or SHV enzymes (25 to 26% homology). PER-2 is most closely related to PER-1 (86.4% homology), an Ambler class A enzyme first detected in Pseudomonas aeruginosa. An enzyme with an amino acid sequence identical to that of PER-1, meanwhile, was found in various members of the family Enterobacteriaceae isolated from patients in Turkey. Our data indicate that PER-2 and PER-1 represent a new group of Ambler class A extended-spectrum beta-lactamases. PER-2 so far has been detected only in pathogens (S. typhimurium, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis) isolated from patients in South America, while the incidence of PER-1-producing strains so far has been restricted to Turkey, where it occurs both in members of the family Enterobacteriaceae and in P. aeruginosa.

Effect of endoscopic variceal sclerotherapy on esophageal motor functions and gastroesophageal reflux

Sclerotherapy results in significant local complications, both immediate and delayed. This study was designed to examine the esophageal pathophysiology underlying these complications.

METHODS

We prospectively evaluated esophageal transit, motility abnormalities and gastroesophageal reflux (GER) with barium studies and esophageal functional scintigraphy in 24 patients (20 men, 4 women; mean age 33 +/- 12.4 yr) before sclerotherapy (Phase I), after two sessions (Phase II), following variceal eradication (Phase III) and 4 wk later (Phase IV).

RESULTS

Varices were obliterated after 5.6 +/- 1.9 sessions of intravariceal sclerotherapy performed weekly with 1% polidocanol (17.3 ml per session). There was no baseline Phase I dysmotility or reflux. Phase II studies recorded a marked delay of esophageal global and segmental (mid and distal) transit time in 98.2% of patients by scintigraphy and 90% by barium studies. Incoordinate contractions and aperistalsis were observed in 0, 66.7%, 58.3% and 33.8% of patients from Phases I-IV studies, respectively. Barium studies revealed tertiary waves and reverse peristalsis in 0, 50%, and 75% of patients from Phases I-III; strictures were observed in 0, 1, and 3 patients during Phases I-III. GER was detected scintigraphically in 0, 58.3%, 25% and 16.6% during Phases I-IV sequentially. In contrast, barium studies grossly underestimated GER (0, 5% and 15% at phases I-III).

CONCLUSION

There was strong concordance between esophageal symptoms, transit, motility abnormalities and GER (p < 0.05). Variceal eradication (Phases III and IV) was associated with a gradual recovery of esophageal symptoms, ulcers and all abnormal scintigraphic parameters. Sclerosant-induced chemical esophagitis in association with peptic esophagitis due to gross reflux following sclerotherapy possibly can explain the symptoms in most patients.

Technetium-99m-HMPAO SPECT cerebral blood flow study in children with craniosynostosis

Premature closure of cranial sutures (primary craniosynostosis) in children leads to characteristic skull deformities and prevents the constricted brain from growing normally. Although the cause remains unknown, several etiological factors have been cited. Recently, hypovascularity has been reported as a possible cause of craniosynostosis.

METHODS

In a prospective study regional cerebral blood flow studies were carried out with 99mTc-HMPAO SPECT in seven children with craniosynostoses. Five preoperative and six postoperative studies were conducted and the results correlated with radiological and surgical findings.

RESULTS

Preoperative studies revealed regional hypovascularity in the underlying cerebral hemisphere, corresponding to the fused sutures. Postoperative studies revealed disappearance of these perfusion defects in most cases, indicating normalization of perfusion following surgical decompression.

CONCLUSION

This study establishes the presence of cerebral hypovascularity in craniosynostoses and suggests that early surgery and release of craniostenosis is essential to achieve optimum perfusion and brain development.

"Insular" carcinoma of thyroid. A subset of anaplastic thyroid malignancy with a less aggressive clinical course

Insular carcinoma of the thyroid appears to represent an entity situated morphologically and biologically in an intermediate position between the well-differentiated and undifferentiated (anaplastic) tumors. The retention of I-131 concentrating ability by this variant, unlike anaplastic, is very encouraging and amenable to detection and therapy by radioiodine after initial aggressive surgery. A 46-year-old man with a histologic label of anaplastic thyroid carcinoma has had an unusually prolonged disease-free survival and histopathologic review confirmed insular carcinoma. Postoperative radioiodine evaluation revealed avid concentration of tracer in the thyroid bed. Thus, it is possible to ablate with radioiodine. The insular carcinoma should be considered as a distinct clinicopathologic entity and widespread awareness of this variant of tumor may help pathologists, surgeons, and nuclear medicine practitioners to aggressively treat the condition after initial diagnosis.

The therapeutic efficacy of oral cholecystographic agent (iopanoic acid) in the management of hyperthyroidism

Five randomly chosen patients with thyrotoxicosis were administered 1 gm of the oral cholecystographic agent iopanoic acid daily for 21 days. There was a marked fall in T3 levels by 75% of the pretherapy value by 96 hr; values remained normal over the 21-day period. T4 values fell significantly by seven days of therapy, and the decreased values were sustained. FT3 and FT4I also showed corresponding decreases in value. All subjects showed clinical improvement by both subjective and objective criteria. During therapy, escape from the effect of iopanoic acid was not encountered. However, after stopping the drug for 2-4 wk, the patients' iodine-131 uptake become as high as the pretherapy level, enabling them to undergo radioiodine treatment for thyrotoxicosis. The treatment strategy can be aimed at achieving quick euthyroidism and in planning radioiodine treatment as early as possible in high risk patients. This treatment may also be useful in preoperative control of thyrotoxicosis.