Community-acquired spontaneous bacterial meningitis in adult diabetic patients: an analysis of clinical characteristics and prognostic factors

BACKGROUND

We analyzed the clinical characteristics and prognostic factors of community-acquired spontaneous bacterial meningitis (CASBM) in adult diabetic patients.

PATIENTS AND METHODS

Over a period of 15 years, 47 adult diabetic patients with CASBM were identified. The clinical characteristics, laboratory data and therapeutic outcome of these 47 patients were statistically analyzed.

RESULTS

The 47 patients were 31 men and 16 women, aged 22 to 79 years, and they accounted for 38.5% (47/122) of our adult patients with culture-proven CASBM. The most common causative pathogen was Klebsiella pneumoniae (n = 32), followed by pathogens of the streptococcal species (n = 6). Besides classic manifestations of bacterial meningitis, bacteremia and focal suppuration, especially liver abscess, were common features in this group of patients. Liver cirrhosis and/or alcoholism were the other frequent underlying conditions. 27 patients survived in the course of therapy. The prognostic factors with statistical significance were glucose ratio and cerebrospinal fluid (CSF) white blood cell (WBC) count.

CONCLUSION

This study showed the high incidence of diabetes mellitus (DM) among the adult patients with CASBM in Taiwan. K. pneumoniae was the most frequent causative pathogen. Bacteremia and focal suppuration, especially liver abscess, were common findings. The values of glucose ratio and CSF WBC count had a statistically significant influence on the prognosis of our patients.

Identification of viridans streptococcal species causing bacterial meningitis in adults in Taiwan

In order to determine the species responsible for viridans-group streptococcal meningitis in adults in Taiwan, seven cases of culture-proven meningitis due to these organisms were studied. The cases were all identified at the Chang Gung Memorial Hospital-Kaohsiung over a period of 3 years, and they accounted for 9% (7/78) of all cases of culture-proven bacterial meningitis occurring in adults during this period. Of the seven viridans streptococci isolates recovered, Streptococcus constellatus accounted for four, Streptococcus anginosus for two, and Streptococcus oralis for one. Thus, it appears that streptococci of the milleri group are the most common species causing bacterial meningitis in adults in Taiwan. The tendency for these organisms to cause invasive central nervous system infections in adults should not be overlooked when these species are recovered from cerebrospinal fluid specimens.

Mechanism of bradykinin-induced Ca(2+) mobilization in MG63 human osteosarcoma cells

BACKGROUND

The effect of bradykinin on intracellular free Ca(2+) levels ([Ca(2+)](i)) in MG63 human osteosarcoma cells was explored using fura-2 as a Ca(2+) dye.

METHODS/RESULTS

Bradykinin (0.1 nM-1 microM) increased [Ca(2+)](i) in a concentration-dependent manner with an EC(50) value of 0.5 nM. The [Ca(2+)](i) signal comprised an initial peak and a fast decay which returned to baseline in 2 min. Extracellular Ca(2+) removal inhibited the peak [Ca(2+)](i )signals by 35 +/- 3%. Bradykinin (1 nM) failed to increase [Ca(2+)](i) in the absence of extracellular Ca(2+ )after cells were pretreated with thapsigargin (an endoplasmic reticulum Ca(2+) pump inhibitor; 1 microM). Bradykinin (1 nM)-induced intracellular Ca(2+) release was nearly abolished by inhibiting phospholipase C with 2 microM 1-(6-((17 beta-3-methoxyestra-1,3,5(10)-trien-17-yl)amino)hexyl)-1H-pyrrole-2,5-dione (U73122). The [Ca(2+)](i )increase induced by 1 nM bradykinin in Ca(2+)- free medium was abolished by 1 nM HOE 140 (a B2 bradykinin receptor antagonist) but was not altered by 100 nM Des-Arg-HOE 140 (a B1 bradykinin receptor antagonist). Pretreatment with 1 pM pertussis toxin for 5 h in Ca(2+) medium inhibited 30 +/- 3% of 1 nM bradykinin-induced peak [Ca(2+)](i) increase.

CONCLUSIONS

Together, this study shows that bradykinin induced [Ca(2+)](i) increases in a concentration-dependent manner, by stimulating B2 bradykinin receptors leading to mobilization of Ca(2+) from the thapsigargin-sensitive stores in a manner dependent on inositol-1,4,5-trisphosphate, and also by inducing extracellular Ca(2+) influx. The bradykinin response was partly coupled to a pertussis toxin-sensitive G protein pathway.

Characteristics and potency of an acellular pertussis vaccine composed of pertussis toxin, filamentous hemagglutinin, and pertactin

In an attempt to develop a safer pertussis vaccine, we successfully purified 3 pertussis protective antigens-pertussis toxin, filamentous hemagglutinin, and a 69-kDa outer membrane protein (also named pertactin), from Bordetella pertussis strain ATCC 9340. The toxicity of pertussis toxin could be effectively reduced by the treatment with formaldehyde 0.07% while preserving of a high degree of immunogenicity. By mixing purified pertussis antigens with diphtheria and tetanus toxoids (DT), we have formulated a DT acellular pertussis (DTaP) vaccine. Toxicity studies on body-weight gain in mouse, histamine sensitization, lymphocyte promoting, and Chinese hamster ovary cell clustering tests suggested that this DTaP vaccine is safer than a whole cell vaccine produced in France (DTP[F]). The formulated vaccine elicited high levels of anti-pertussis toxin antibodies in both mice and monkeys. In mice, a 2-fold neutralization of anti-pertussis toxin antibodies was produced by DTaP compared with DTP(F) vaccine and an acellular vaccine manufactured in Japan (DTaP[J]). More importantly, in intracerebral challenge assay in mouse, this vaccine also provided a better protection than DTaP(J).

Adults with meningitis caused by viridans streptococci

BACKGROUND

We analyzed the clinical features and therapeutic outcomes of adults with meningitis caused by viridans streptococci.

PATIENTS AND METHODS

12 adult patients with meningitis caused by viridans streptococci were enrolled in this study. Clinical data were collected over a period of 15 years.

RESULTS

Of the 12 patients, 11 patients had community-acquired meningitis, while one had nosocomially acquired meningitis. 11 contracted the spontaneous form and one contracted the postneurosurgical form. All isolates were susceptible to penicillin. The portals of entry of infection were determined in all 12 patients; five patients had otopharyngeal infections with or without their being spread hematogenously. The infections in six patients were spread hematogenously, but one of them was spread hematogenously with endocarditis. One patient became infected after a craniotomy. The patients infected by viridans streptococci had a high incidence of focal suppuration and cerebral vasculitis but no deaths occurred.

CONCLUSION

Adult bacterial meningitis caused by viridans streptococci is not uncommon and otopharyngeal infection appears to be an important portal of entry. Clinical manifestations varied according to the different underlying conditions. The results of this study also demonstrate the high incidence of intracranial focal suppuration and cerebral vasculitis concomitant with meningitis. Penicillin remains the treatment of choice for patients with meningitis caused by viridans streptococci. Therapeutic outcome is favorable for patients who receive prompt treatment.

The prognostic factors of adult tuberculous meningitis

BACKGROUND

Our aim was to analyze the prognostic factors and therapeutic outcomes of adult tuberculous meningitis (TBM).

PATIENTS AND METHODS

Clinical data of 36 patients with adult TBM were retrospectively identified at our institution over a period of 5 years.

RESULTS

36 adult TBM patients, 23 males and 13 females, aged 16-83 years, were included in this study. The 36 patients were also divided into three groups (stages I, II and III) according to the severity of TBM on admission. Therapeutic outcomes at 3 months were determined using a modified Barthel Index (BI). For the purpose of statistical analysis, the patients were divided into two groups: good outcome (BI > or = 12) and poor outcome (BI < 12). Positive cerebrospinal fluid (CSF) culture was found in 47% (17/36) of patients and isoniazid-resistant strains were found in 18% (3/17) of culture-proven TBM. We statistically compared clinical manifestations, CSF features and therapeutic results of the two patient groups. Significant prognostic factors included severity of TBM at the time of admission, the presence of headache, fever, hydrocephalus, high CSF protein concentration and high CSF lactate concentration. In stepwise logistic regression analysis, only the presence of hydrocephalus and severity of TBM on admission were strongly associated with therapeutic failure even after adjusting for other potentially confounding factors.

CONCLUSION

In Taiwan, TBM is an important public health issue and the emergence of resistant strains of this disease in recent years presents a therapeutic challenge. Because delay in diagnosis is directly related to poor outcome, early diagnosis and early treatment are essential for survival.

Effect of oleamide on Ca(2+) signaling in human bladder cancer cells

The effect of oleamide, a sleep-inducing endogenous lipid in animal models, on intracellular free levels of Ca(2+) ([Ca(2+)](i)) in non-excitable and excitable cells was examined by using fura-2 as a fluorescent dye. [Ca(2+)](i) in pheochromocytoma cells, renal tubular cells, osteoblast-like cells, and bladder cancer cells were increased on stimulation of 50 microM oleamide. The response in human bladder cancer cells (T24) was the greatest and was further explored. Oleamide (10-100 microM) increased [Ca(2+)](i) in a concentration-dependent fashion with an EC(50) of 50 microM. The [Ca(2+)](i) signal comprised an initial rise and a sustained plateau and was reduced by removing extracellular Ca(2+) by 85 +/- 5%. After pre-treatment with 10-100 microM oleamide in Ca(2+)-free medium, addition of 3 mM Ca(2+) increased [Ca(2+)](i) in a manner dependent on the concentration of oleamide. The [Ca(2+)](i) increase induced by 50 microM oleamide was reduced by 100 microM La(3+) by 40%, but was not altered by 10 microM nifedipine, 10 microM verapamil, and 50 microM Ni(2+). In Ca(2+)-free medium, pre-treatment with thapsigargin (1 microM), an endoplasmic reticulum Ca(2+) pump inhibitor, abolished 50 microM oleamide-induced [Ca(2+)](i) increases; conversely, pretreatment with 50 microM oleamide reduced 1 microM thapsigargin-induced [Ca(2+)](i) increases by 50 +/- 3%. Suppression of the activity of phospholipase C with 2 microM U73122 failed to alter 50 microM oleamide-induced Ca(2+) release. Linoleamide (10-100 microM), another sleep-inducing lipid with a structure similar to that of oleamide, also induced an increase in [Ca(2+)](i). Together, it was shown that oleamide induced significant [Ca(2+)](i) increases in cells by a phospholipase C-independent release of Ca(2+) from thapsigargin-sensitive stores and by inducing Ca(2+) entry.

KAI1 metastasis suppressor gene is frequently down-regulated in cervical carcinoma

KAI1 is a metastasis suppressor gene located on human chromosome 11p11.2. It belongs to a structurally distinct family of cell surface glycoproteins. Decreased KAI1 expression has been observed in several common solid epithelial tumors, including prostatic, pancreatic, lung, hepatic, colorectal, ovarian, and esophageal cancers. A recent study also observed frequent loss of KAI1 expression in a number of squamous cell carcinomas of the cervix by immunohistochemical technique. To further confirm whether this gene is altered in this malignancy, we analyzed KAI1 expression in various stages of cervical carcinoma by a molecular method. Total cellular RNA was extracted from 84 primary invasive cervical carcinomas and 6 metastatic or recurrent lesions. cDNA was synthesized and was used for real-time quantitative polymerase chain reaction analysis. The level of KAI1 expression was obtained as the value of threshold cycle (Ct) and was quantitated with a comparative Ct method. In addition, paraffin blocks of the tumors were selected and prepared for immunohistochemical study with an anti-KAI1 polyclonal antibody, C-16. Both the real-time quantitative polymerase chain reaction method and immunohistochemical study revealed a frequent decrease in KAI1 expression in invasive cervical cancers and metastatic or recurrent lesions. However, the reduction in KAI1 was not related to progression of the disease. When tumor cell differentiation was analyzed, poorly differentiated tumors showed a greater decrease in KAI1 expression than well or moderately differentiated tumors (P < 0.001). Histologically, KAI1 loss was observed equally in both squamous cell carcinoma and adeno-/adenosquamous carcinoma. Since down-regulation of KAI1 occurs in both early and late stages of cervical cancer, we suggest that its involvement in the progression of this malignancy is an early event.

Streptococcal meningitis in adults: therapeutic outcomes and prognostic factors

Thirty-eight patients with streptococcal meningitis, aged 17-75 years, have been identified over a period of 13.5 years. Among these 38 patients, 35 had community-acquired infections, and the other three had nosocomial infections. Twelve of the 38 patients were found to have postneurosurgical forms and 26 to have spontaneous forms. These 38 cases of streptococci included Streptococcus (S.) pneumoniae in 19 cases, viridans group streptococci in 13, non-A, non-B, and non-D streptococci in three, Group D streptococci in one, and Group B streptococci (S. agalactiae) in two. Although one case was found to have penicillin-resistant S. pneumoniae PRSP in 1994, multi-antibiotic resistant strains were rare in this study. Therapeutic outcomes varied according to the different species of streptococci. In this study, the overall mortality rate was 34%. In the multiple logistic regression analysis, only initial consciousness level and the presence of seizure were strongly associated with the mortality rate even after other potentially confounding factors were adjusted for. Early diagnosis and the use of appropriate antibiotics are essential for survival.

Protean infectious types and frequent association with neurosurgical procedures in adult Serratia marcescens CNS infections: report of two cases and review of the literature

Serratia marcescens is a rare pathogen of adult central nervous system (CNS) infection. We report on the clinical features and therapeutic outcomes of two adult patients with such infections. The clinical characteristics of 13 other reported adult cases are also included for analysis. The 15 cases were nine males and six females, aged 19-83 years, in whom, underlying post-neurosurgical states and ear operation were noted in 93% (14/15). Fever and conscious disturbance were the most common clinical manifestations of these 15 cases, followed by hydrocephalus, seizures, and wound infections. The manifestation types were protean, including meningitis and focal suppurations such as brain abscess, cranial and spinal epidural abscess, cranial subdural abscess, and infected lumbar pseudomeningocele. One case of S. marcescens CNS infection was diagnosed postmortem; the other 14 were diagnosed by the positive culture from CSF or pus. Antibiotic therapy with or without neurosurgical intervention was the management strategy in 14/15 cases. The therapeutic results showed a high mortality rate.

Staphylococcus aureus meningitis in adults: a clinical comparison of infections caused by methicillin-resistant and methicillin-sensitive strains

BACKGROUND

This study was undertaken to compare the clinical characteristics of adult methicillin-sensitive Staphylococcus aureus (MSSA) meningitis and adult methicillin-resistant S. aureus (MRSA) meningitis.

PATIENTS AND METHODS

The clinical characteristics and therapeutic outcomes of 19 adult patients with S. aureus meningitis, including eight with MSSA infections and 11 with MRSA infections, were analyzed. A comparison was made between the clinical data of the patients with MSSA infections and those with MRSA infections.

RESULTS

Before the end of 1995, MSSA infection was involved in all the adult patients with S. aureus meningitis but thereafter, MRSA infection was involved in 79% of the cases. The clinical characteristics found in patients with MSSA infection included underlying medical disorders (75%), community-acquired infection (75%) and mortality rate (13%). The clinical characteristics found in patients with MRSA infection included post-neurosurgical states (91%), nosocomial infections (100%), men outnumbering women (8:3), hydrocephalus (36%) and mortality rate (56%). Comparative study between the patient groups (hematogenous and post-neurosurgical) showed that only the mode of acquisition of infection had statistical significance.

CONCLUSIONS

This study showed an increase in MRSA infections in adult S. aureus meningitis in recent years. The clinical characteristics of patients with MSSA and MRSA meningitis were different. Community-acquired infection was common in hematogenous S. aureus meningitis, while nosocomial infection was common in post-neurosurgical S. aureus meningitis. Vancomycin should be considered as one of the drugs of choice for initial therapy of adult bacterial meningitis, especially in post-neurosurgical patients.

Streptococcal brain abscess: analysis of clinical features in 20 patients

BACKGROUND

To assess the clinical features and therapeutic outcomes of brain abscess caused by streptococci.

METHODS

Twenty patients, 18 males and 2 females, aged 3 to 76 years, collected over a 14-year period, have been identified at Kaohsiung Chang Gung Memorial Hospital.

RESULTS

Among these 20 patients, 13 had viridans streptococci infection alone, one had non-A, non-B, and non-D streptococci infection alone, and the other 6 had mixed infections each including streptococci. The locations of all of the abscesses were supratentorial. Among these patients, 18 had a single abscess and 2 had multiple abscesses. Underlying conditions were common in our patients, including head trauma, heart disease, otopharyngeal infection, and medical procedures. Nineteen patients were treated surgically and 1 was treated with antibiotics alone. Nineteen survived and 1 died, with an overall mortality rate of 5%.

CONCLUSION

The clinical presentations and underlying conditions varied according to the different streptococcal species. Streptococcal brain abscesses accounted for 17% of our cases with brain abscesses, and 30% of our streptococcal infections had polymicrobial infections. Although streptococcal brain abscesses were commonly associated with otopharyngeal infections or infectious endocarditis, they also appeared to be often related to neurosurgical events or medical procedures in recent years. Based on our study, prognosis is favorable with early diagnosis and prompt treatment.

Molecular subtyping of Shigella flexneri 3a isolates by plasmid profile analysis and pulsed-field gel electrophoresis

Twenty-two clinical isolates of Shigella flexneri 3a that were obtained from stool specimens from seven outbreaks of infection in northern Taiwan were subtyped and compared using plasmid profile analysis and pulsed-field gel electrophoresis (PFGE). Among 32 isolates, three distinct patterns were found by plasmid profile analysis and six by PFGE, with three different restriction enzymes, XbaI, SfiI, or NotI. Seven PFGE patterns were observed in a comparative analysis using a combination of these three enzymes. Isolates collected from the same outbreaks had the same PFGE combination patterns and were distinguishable from those obtained during other outbreaks. These findings suggest that PFGE may be the most powerful method of genotyping S. flexneri 3a in epidemiological studies.

Mechanisms of histamine-induced intracellular Ca 2+ release and extracellular Ca 2+ entry in MG63 human osteosarcoma cells 1 1Abbreviations: [Ca2+]i; Cytosolic free Ca2+ concentration; and IP3, inositol 1,4,5-trisphosphate

The effect of histamine on intracellular free Ca2+ levels ([Ca2+](i)) in MG63 human osteosarcoma cells was explored using fura-2 as a Ca2+ dye. Histamine increased ([Ca2+](i)) in a concentration-dependent fashion with an EC(50) value of 0.5 microM. Extracellular Ca2+ removal inhibited the ([Ca2+](i)) signals. Histamine failed to increase ([Ca2+](i)) in Ca2+-free medium after cells were pretreated with thapsigargin (an endoplasmic reticulum Ca2+ pump inhibitor). Addition of Ca2+ induced concentration-dependent ([Ca2+](i)) increases after preincubation with histamine in Ca2+-free medium. Histamine-induced intracellular Ca2+ release was abolished by inhibiting phospholipase C with 1-(6-((17beta-3-methoxyestra-1,3,5(10)-trien-17-yl)amino)hexyl)-1H-pyrrole-2,5-dione (U73122). The ([Ca2+](i)) increase induced by histamine in Ca2+ medium was abolished by cimetidine, but was not altered by pyrilamine, nifedipine, verapamil, and La(3+). Together, this study shows that histamine increased in ([Ca2+](i)) in osteosarcoma cells by stimulating H2 histamine receptors. The Ca2+ signal was caused by Ca2+ release from the endoplasmic reticulum in a phospholipase C-dependent manner. The Ca2+ release was accompanied by Ca(2+) influx.

Hypertensive caudate hemorrhage prognostic predictor, outcome, and role of external ventricular drainage

BACKGROUND AND PURPOSE

The purpose of the present study was to analyze the outcome and outcome predictors of caudate hemorrhage and role of external ventricular drainage in acute hydrocephalus.

METHODS

Clinical data from 36 consecutive patients with hypertensive caudate hemorrhage was used in the present study. Age, gender, volume of parenchymal hematoma, hematoma in the internal capsule, initial Glasgow Coma Scale (GCS), hydrocephalus, severity of intraventricular hemorrhage, and hemorrhagic dilatation of the fourth ventricle were analyzed for effect on outcome. Effect of external ventricle drainage for hydrocephalus was evaluated by comparing preoperative and postoperative GCS scores.

RESULTS

By univariate analyses, poor outcome was associated with a poor initial GCS score (P=0.016), hydrocephalus (P<0.001), intraventricular hemorrhage severity (P<0.01), and hemorrhagic dilatation of the fourth ventricle (P=0.02). By multivariate analysis, stepwise logistic regression revealed that hydrocephalus was the only independent prognostic factor for poor outcome (P<0.001). Postoperative 48-hour GCS score was better than the preoperative score by use of paired-sample t test (P<0.001).

CONCLUSIONS

Hydrocephalus is the most important predictor of poor outcome. External ventricular drainage response for hydrocephalus was good in the present study, whereas an early decision should be made regarding preoperative neurological condition.

Cerebral infarction in chronic meningitis: a comparison of tuberculous meningitis and cryptococcal meningitis

Twenty-eight patients with cerebral infarction secondary to chronic meningitis were retrospectively identified at our institution over a period of 5 years. They accounted for 47% (17/36) of tuberculous meningitis (TBM) and 32% (11/34) of cryptococcal meningitis cases. Single infarctions were found in 15 patients and multiple infarctions in 13. The distribution of single infarctions was: basal ganglia 7; internal capsule 3; thalamus 1; cerebellum 1; and cortical infarct 3. Therapeutic outcomes at 3 months were determined using a modified Barthel INDEX: At follow-up of 3 months or more, 10 had good outcomes while the other 18 had poor outcomes. The 18 with poor outcomes included six who died, and 12 who had severe neurological sequelae. TBM and cryptococcal meningitis shared similar clinical features, both being frequently associated with other neurological complications, including hydrocephalus, cranial nerve palsy, and seizures in our patients. However, extracranial involvement, such as spinal and pulmonary involvement, was more commonly found in TBM patients. Cerebral infarction can occur in both the acute stage and later stages of treatment. Mortality and morbidity are high, and early diagnosis and appropriate antimicrobial treatment are essential. If hydrocephalus is demonstrated, early ventricular decompression is needed to prevent further cerebral ischaemia.

Intraluminal meconium calcification without distal obstruction

Intraluminal meconium calcification of unknown mechanism is reported in three neonates who did not have distal intestinal obstruction. The condition was benign in all three cases and did not require surgical intervention. This new form of intra-abdominal calcification should be differentiated from other forms that invariably are due to surgical disorders.

Early prediction of aphasia outcome in left basal ganglia hemorrhage

OBJECTIVES

The independent predictors of aphasia outcome for patients with left basal ganglia hemorrhage were evaluated.

PATIENTS AND METHODS

We included 140 patients of 1,036 patients with spontaneous intracerebral hemorrhage admitted to our hospital from January 1993 through December 1997. Aphasia was assessed using the aphasia scale of the Scandinavian stroke scale. Univariate and step-wise logistic regression analyses were performed to assess the relationships between the initial aphasia score, age, gender, blood volume, locations of hematoma and aphasia outcome.

RESULTS

Step-wise logistic regression analysis revealed that the following two factors were independently associated with the final aphasia outcome: initial aphasia score (P < 0.0001) and location of hematoma involving the posterior limb of the internal capsule (P = 0.004).

CONCLUSIONS

A particularly high likelihood of poor aphasia outcomes of patients with left basal ganglia hemorrhage are predicted in those who have poor initial aphasia score and whose brain computed tomography shows the hematoma involves the posterior limb of the internal capsule.

Klebsiella brain abscess in adults

BACKGROUND

We analyzed the clinical manifestations and therapeutic outcomes of Klebsiella brain abscesses.

PATIENTS AND METHODS

The clinical data of 15 patients with Klebsiella brain abscesses, retrospectively collected over a 14-year period, were studied.

RESULTS

The 15 patients included 13 cases of Klebsiella pneumoniae infection and two cases of Klebsiella oxytoca. All but one case were community-acquired infections. Locations of all of these abscesses were supratentorial. 12 cases involved a single abscess, and three involved multiple abscesses. Gas formation was also found in two cases (13%). Common predisposing factors included metastatic spread, chronic otitis media and neurosurgical procedures. Among these 15 patients, 11 were treated surgically and four received antibiotics alone. In total, 11 patients survived and four died, with an overall mortality rate of 26.7%.

CONCLUSION

The clinical presentations and therapeutic outcomes varied according to the different Klebsiella species. While debilitating diseases were common in K. pneumoniae infections, they were not common in K. oxytoca infection. And while metastatic septic abscess is a well-known, devastating complication of K. pneumoniae septicemia, usually seen as a brain abscess with a gas-forming appearance, all of these K. oxytoca infections had both otogenic infections and more favorable outcomes.

Adult Enterobacter meningitis: a high incidence of coinfection with other pathogens and frequent association with neurosurgical procedures

BACKGROUND

The clinical characteristics of Enterobacter infection in adult bacterial meningitis were defined.

PATIENTS AND METHODS

The clinical manifestations and therapeutic outcomes of ten adult patients with Enterobacter infections in acute bacterial meningitis were analyzed.

RESULTS

Enterobacter infection was found in 4.5% (10/223) of our adult patients with culture-proven bacterial meningitis. The ten patients comprised seven men and three women aged between 16-69 years (mean 47 years). Coinfections with other pathogens were found in 50% of the cases, the most common pathogen being Klebsiella pneumoniae. Nine of the ten patients had a history of neurosurgery, and seven patients contracted the infection nosocomially. Multiple antibiotic-resistant strains, including resistance to third-generation cephalosporins, were found in three patients with polymicrobial infections. These three patients received iv imipenem/cilastin therapy. The therapeutic results showed that two of the ten patients died; five of the eight surviving patients had neurological sequelae.

CONCLUSION

The predominant coinfection with Enterobacteriaceae in adult Enterobacter meningitis may reflect the fact that most of the cases of polymicrobial Enterobacter infections have a potential gastrointestinal source. A postneurosurgical state was the most important predisposing factor for the development of Enterobacter infection in adult bacterial meningitis in our patients. The strains of the Enterobacter species in adult polymicrobial Enterobacter meningitis were commonly resistant to multiple antibiotics, including third-generation cephalosporins. In light of the high incidence of multiple antibiotic-resistant Enterobacter strains in adult polymicrobial Enterobacter meningitis, the choice of initial empiric antibiotics may include carbapenem (imipenem/cilastin or meropenem). Although the mortality rate was not high in this group of patients, most survivors suffered neurological sequelae.

Influence of irrelevant information on human performance: effects of S-R association strength and relative timing

Six experiments examined effects of stimulus-response (S-R) association strength and relative timing on the magnitude of consistency effects for irrelevant information in Stroop-like tasks. Keypresses were made to two-dimensional stimuli (a colour or location word surrounded by a coloured rectangle or arrow), with the irrelevant information presented simultaneously with or prior to the relevant information. With simultaneous presentation, irrelevant information affected performance regardless of whether its S-R association was weak or strong, if the relevant S-R association was weak (e.g., colour word to keypress). However, a weak irrelevant S-R association (location word to keypress) had little effect when paired with a strong relevant S-R association (arrow direction to keypress), except when the stimulus onset asynchrony (SOA) between the irrelevant and relevant information was 300 ms. When the relevant information was colour, the effect of an irrelevant colour word persisted at a 500-ms SOA but that of an irrelevant physical colour did not, reflecting different decay functions for irrelevant verbal and non-verbal information. The persisting effect of an irrelevant colour word was reduced by articulatory suppression and eliminated at extended SOAs of 3 s. The results indicate that whether the consistency effect patterns are symmetric or asymmetric is determined by the relative strengths of the relevant and irrelevant S-R associations, as specified by the criteria of conceptual and mode similarity. The magnitude of the consistency effect is also a function of the temporal overlap of the resulting response activation, which is determined primarily by mode similarity.

Adult bacterial meningitis in Southern Taiwan: epidemiologic trend and prognostic factors

In two investigative phases over a 13.5-year study period (January 1986-June 1999), 202 adult patients with culture-proven bacterial meningitis were enrolled in this study. In order to determine the epidemiologic trend, prognostic factors and therapeutic results for this disease. Klebsiella pneumoniae (K. pneumoniae), Pseudomonas aeruginosa, and Streptococcus pneumoniae were the three most commonly revealed pathogens, accounting for about 48% of the episodes. Although there was a change in relative frequency for the pathogens, K. pneumoniae remained the most prevalent during the two periods studied (January 1986-December 1992 and January 1993-June 1999). Multiantibiotic resistant strains have been in evidence since their appearance in 1994, with most of our patients acquiring their infection nosocomially. The overall mortality rates during the two periods were 40% and 34%, respectively. In stepwise logistic regression analysis, only initial conscious level, appropriate antibiotic therapy and septic shock were independently associated with mortality, after adjustment for other potentially confounding factors. Initial empirical antibiotics with both third-generation cephalosporin and penicillin G, should be considered for the majority of meningitis cases resulting from infection with Gram-negative bacilli and streptococcal species. Besides the evolution of newer pathogens, there has been increasing incidence for nosocomially acquired bacterial meningitis for patients postneurosurgery, with the emergence of resistant strains presenting a therapeutic challenge in recent years. Vancomycin and imipenem/cilastatin should be considered as the initial empirical antibiotics of choice for the treatment of this special group of patients.

Conserved overlapping and reciprocal expression of msh/Msx1 and apterous/Lhx2 in Drosophila and mice

Here we describe and compare the expression patterns of the murine genes Lhx2 and Msx1 and their Drosophila orthologues apterous (ap) and muscle-segment homeobox (msh). We find that Lhx2 and Msx1 show complementary patterns of expression in most tissues including the neural and cranial epithelium, pituitary gland, olfactory organs, and neural tube; in contrast, Lhx2 and Msx1 are coexpressed in the developing limbs. Strikingly, the spatial relationship between ap and msh expression in Drosophila is very reminiscent of the expression of their murine orthologues. ap and msh show complementary expression in the leg and antennal imaginal discs, brain and ventral ganglion of the central nervous system (CNS), but both are coexpressed in the wing imaginal disc. These observations suggest conservation in the regulation of these genes between Drosophila and mice.

Predictive factors for residual disease in subsequent hysterectomy following conization for CIN III

OBJECTIVE

The aim of this study was to determine predictive factors for post-cone residual disease in subsequent hysterectomy for CIN III.

METHODS

From June 1994 to June 1999, 120 patients with CIN III who received hysterectomy within 6 months of conization regardless of marginal status were identified from 1450 conization cases. The demographic features and pathologic parameters were analyzed for the predictive rate of post-cone residual disease.

RESULTS

Age >==50 years and parity >==5 were significant factors associated with residual disease. The incidence of residual disease was 56.5 and 29. 3% in patients >==50 and <50 years, respectively, and 61.8 and 36.0% in patients with parity >==5 and <5. Post-cone endocervical curettage (ECC) and multiple-quadrant disease were the only pathologic predictive factors identified. The incidence of residual disease was 64.6 and 29.2% in patients with positive ECC and negative ECC, respectively, and 48.4 and 25.9% in patient with multiple-quadrant disease and one- or two-quadrant disease. Other pathologic parameters, including endocervical margins, ectocervical margins, endocervical gland involvement, and depth of conization, were not predictive of residual disease. When ECC was combined individually with age, endocervical margins, or multiple-quadrant disease, there was no increase of positive predictive rate.

CONCLUSIONS

(1) Age 50 years or more and parity >==5 were two demographic features that predicted post-cone residual disease. (2) ECC and multiple-quadrant disease were the only pathologic parameters that predicted post-cone residual disease. (3) With the appropriate application of the predictive factors, post-cone hysterectomy may be further decreased.

Community-acquired Acinetobacter meningitis in adults

Community-acquired Acinetobacter meningitis in adults is an extremely rare infection of the central nervous system (CNS). Here we report one adult case of this rare CNS infection and review the clinical data of another seven cases reported in the English language literature. In total, eight patients (six men and two women) aged between 19 and 63 years were studied. The causative pathogen in our patient was Acinetobacter baumannii; in the other reported cases they were most likely Acinetobacter Iwoffii, Acinetobacter johnsonii, Acinetobacter junii, a genomic species 3 or 6. No underlying disease was found in seven of the eight cases and six of the eight patients acquired the infections before the age of 30 years. Fever and consciousness disturbance were the most common clinical manifestations. Waterhouse-Friderichsen syndrome (WFS) was found in two cases. Unlike the Acinetobacter strains found in nosocomial infections, the strain of Acinetobacter meningitis in the community-acquired case did not show multiple antibiotic resistance. Most adult patients with community-acquired Acinetobacter meningitis can be saved by timely therapy with appropriate antibiotics before deterioration of the systemic condition and impairment of consciousness.