Community-acquired urinary tract infection in adults: a hospital viewpoint

The clinical and epidemiologic spectrum of 175 cases of community-acquired urinary tract infection (UTI) were evaluated at a university hospital. Patients were grouped in five different categories of which complicated UTI was the most common (39%). Bacteraemia was detected in eight patients (18%) of this group and in five (12%) with acute uncomplicated pyelonephritis. A single organism was isolated in 166 cases (95%). The rate of Escherichia coli bacteriuria ranged from 60% (asymptomatic bacteriuria) to 94% (uncomplicated cystitis). Of the 184 isolates, 92% were susceptible to ciprofloxacin and significantly high rates of resistance were found for ampicillin, cefazolin, cefuroxime, and co-trimoxazole. Isolates causing uncomplicated UTI had significantly high rates of resistance to ampicillin, amoxycillin-clavulanate and co-trimoxazole and those causing complicated UTI, had significantly high rates of resistance to most oral antibiotics tested, except quinolones and nitrofurantoine. Community-acquired UTI requiring hospital evaluation occurs in a complex group of patients, and current patterns of antibiotic resistance make it difficult to suggest empiric oral treatments in this setting.

Novel segment polarity gene interactions during embryonic head development in Drosophila

In the trunk of the Drosophila embryo, the segment polarity genes are initially activated by the pair-rule genes, and later maintain each other's expression through a complex network of cross-regulatory interactions. These interactions, which are critical to cell fate specification, are similar in each of the trunk segments. To determine whether segment polarity gene expression is established differently outside the trunk, we studied the regulation of the genes hedgehog (hh), wingless (wg), and engrailed (en) in each of the segments of the developing head. We show that the cross-regulatory relationships among these genes, as well as their initial mode of activation, in the anterior head are significantly different from those in the trunk. In addition, each head segment exhibits a unique network of segment polarity gene interactions. We propose that these segment-specific interactions evolved to specify the high degree of structural diversity required for head morphogenesis.

Establishing primordia in the Drosophila eye-antennal imaginal disc: the roles of decapentaplegic, wingless and hedgehog

The eye-antennal imaginal discs of Drosophila melanogaster form the head capsule of the adult fly. Unlike the limb primordia, each eye-antennal disc gives rise to morphologically and functionally distinct structures. As a result, these discs provide an excellent model system for determining how the fates of primordia are specified during development. In this study, we investigated how the adjacent primordia of the compound eye and dorsal head vertex are specified. We show that the genes wingless (wg) and orthodenticle (otd) are expressed throughout the entire second instar eye-antennal disc, conferring a default fate of dorsal vertex cuticle. Activation of decapentaplegic (dpp) expression in the posterior eye disc eliminates wg and otd expression, thereby permitting eye differentiation. We also demonstrate that otd is activated by wg in the vertex primordium. Finally, we show that early activation of dpp depends on hedgehog (hh) expression in the eye anlage prior to morphogenetic furrow formation.

Severe minocycline-induced eosinophilic pneumonia: extrapulmonary manifestations and the use of in vitro immunoassays

OBJECTIVE

To report a severe and unusual reaction to minocycline and the use of in vitro immunologic assays.

CASE SUMMARY

A 46-year-old white man developed severe respiratory distress with pulmonary infiltrates on chest X-ray and eosinophilia in blood, bronchoalveolar lavage fluid, and biopsied lung tissue during exposure to minocycline. Additional manifestations included pleuropericardial effusion, liver function abnormality, and bone marrow eosinophilia. Macrophage inhibition factor and mast cell degranulation assays were positive to minocycline.

DISCUSSION

The patient's manifestations were compatible with the diagnosis of eosinophilic pneumonia. After excluding other possible etiologies, minocycline was identified as the offending agent. Generalized damage was suggested by the presence of a combination of extrapulmonary manifestations previously not reported. Results of the in vitro immunologic assays supported the hypersensitivity nature of the disease and confirmed the diagnosis.

CONCLUSIONS

Minocycline-induced eosinophilic pneumonia may involve extrapulmonary sites. It is suggested that in vitro immunoassays be used for confirmation of the diagnosis rather than rechallenge or invasive procedures.

Pulmonary infiltrates and skin lesions

Images

[Acute fungal endocarditis due to Trichosporon beigelli]

We report a 59-year-old woman with acute fungal endocarditis of a prosthetic valve caused by the endogenic organism, Trichosporon beigelli. This slowly developing disease mainly effects drug addicts who use intravenous narcotics. In nonaddicts it is rare, with mortality as high as 50%. There are only sporadic reports of T. beigelli as a complication long after open heart surgery. The ongoing infection is undetected for even years after the primary infection, due to its prolonged latent phase. We present the difficulties of diagnosis, and of treating the disease with a combination of surgery and of long-term chemotherapy.

Detection of expiratory flow limitation during exercise in COPD patients

The negative expiratory pressure (NEP) method was used to detect expiratory flow limitation at rest and at different exercise levels in 4 normal subjects and 14 patients with chronic obstructive pulmonary disease (COPD). This method does not require performance of forced expirations, nor does it require use of body plethysmography. It consists in applying negative pressure (-5 cmH2O) at the mouth during early expiration and comparing the flow-volume curve of the ensuing expiration with that of the preceding control breath. Subjects in whom application of NEP does not elicit an increase in flow during part or all of the tidal expiration are considered flow limited. The four normal subjects were not flow limited up to 90% of maximal exercise power output (Wmax). Five COPD patients were flow limited at rest, 9 were flow limited at one-third Wmax, and 12 were flow limited at two-thirds Wmax. Whereas in all patients who were flow limited at rest the maximal O2 uptake was below the normal limits, this was not the case in most of the other patients. In conclusion, NEP provides a rapid and reliable method to detect expiratory flow limitation at rest and during exercise.

Surveillance of the use of antibiotic prophylaxis in surgery

In 1991, updated recommendations for the administration of antimicrobial prophylaxis in surgery were made extensively available to all surgical wards of our hospital. Two years later we surveyed the implementation of these recommendations in our institution. Inpatients undergoing surgical procedures during a 6 month period were prospectively evaluated for the indication, type, timing and duration of antibiotic prophylaxis. On each day of the study, data of patients who underwent surgery in the previous 24-48 h were obtained and monitoring was continued for up to 5 days. Of the 215 evaluated patients 193 (90%) received prophylaxis. This rate was similar for elective and emergency surgeries. The rate of prophylaxis in surgeries for which its use is recommended was significantly higher than in surgeries where compelling data for its use are not available (96 vs. 74%, P = 0.000006). However, many and important deviations of basic principles of antimicrobial prophylaxis in surgery were found. Prophylaxis was administered systematically in some types of surgery lacking compelling data for its use. In almost 50% of the surgical procedures the first dose of antimicrobial prophylaxis was not administered at the optimal timing; prophylaxis was continued for more than 24 h in 21% of the cases, and the use of unstandardized regimens was common. Despite the availability of local guidelines, the implementation of a hospital program with regard to antibiotic prophylaxis in surgery may be difficult. Further measures should be applied to achieve this goal.

Sarcoidosis mimicking toxoplasmosis with severe hypercalcaemia and normal 1,25-dihydroxy vitamin D

We report a case of a female patient with sarcoidosis who presented with a generalized lymphadenopathy and a strong IgG serological test of toxoplasmosis. Progressive lymphadenopathy with a rising plasma calcium (up to 15 mg dL-1) with a normal plasma 1,25-dihydroxy vitamin D concentration occurred later. Corticosteroid therapy resulted in prompt clinical and biochemical responses with normalization of plasma calcium and a significant reduction in 1,25-dihydroxy vitamin D concentration. This is an exceptional presentation of sarcoidosis with severe hypercalcaemia and normal vitamin D metabolites.

Failure of cefonicid prophylaxis for infectious complications related to endoscopic retrograde cholangiopancreatography

We performed a controlled study to evaluate the role of cefonicid in preventing infectious complications related to retrograde cholangiopancreatography (ERCP). Consecutive patients were randomized to receive prophylaxis with cefonicid (1 g intravenously) 1 hour before the procedure or to be untreated controls. During a 26-month period, 179 ERCPs, including 93 therapeutic procedures, were performed on 164 patients. Prophylaxis was administered before 88 procedures (49%). The rate of bacteremia among treated patients was similar to that among controls (3% vs. 2%, respectively; P = .4). The rate of cholangitis was also similar among both groups (8% vs. 2%, respectively; P = .07). There were no episodes of sepsis, and none of the patients died. The rate of bacteremia was also similar among patients undergoing diagnostic procedures and patients undergoing therapeutic procedures, but all cases of cholangitis occurred in the latter group (0 vs. 10%, respectively; P = .002). Nevertheless, the rate of cholangitis was not significantly changed by the use of prophylaxis (14% among treated patients vs. 5% among controls, P = .12). Therefore, infectious complications could not be prevented by cefonicid prophylaxis.

Brain abscesses: the lung connection

Pulmonary arteriovenous fistulas are uncommon abnormalities of capillary development which cause right to left shunting and, if not treated, may lead to severe neurological complications, including meningitis and brain abscess. Pulmonary arteriovenous fistulas are commonly a result of hereditary haemorrhagic telangiectasia (Rendu-Osler-Weber disease) and both conditions may be readily diagnosed by careful history taking and physical examination. Two cases of brain abscess associated with hereditary haemorrhagic telangiectasia, which remained unrecognized for many years, are reported. These cases emphasize the importance of early diagnosis and treatment of pulmonary arteriovenous fistula in preventing central nervous system infections.

hedgehog, wingless and orthodenticle specify adult head development in Drosophila

The adult head capsule of Drosophila forms primarily from the eye-antennal imaginal discs. Here, we demonstrate that the head primordium is patterned differently from the discs which give rise to the appendages. We show that the segment polarity genes hedgehog and wingless specify the identities of specific regions of the head capsule. During eye-antennal disc development, hedgehog and wingless expression initially overlap, but subsequently segregate. This regional segregation is critical to head specification and is regulated by the orthodenticle homeobox gene. We also show that orthodenticle is a candidate hedgehog target gene during early eye-antennal disc development.

Orthodenticle regulation during embryonic head development in Drosophila

The homeobox gene orthodenticle (otd) specifies anterior head development in the Drosophila embryo, otd-related genes are also found in vertebrates, with expression patterns suggesting that they are important for the development of anterior regions of the head and brain. Here, we analyze the molecular mechanisms by which otd expression is activated within its normal domain in the head and repressed outside this region. We demonstrate that, contrary to early models of embryonic pattern formation, high levels of the bicoid morphogen are not required for otd activation or for the establishment of anterior head structures. We also show that the terminal system contributes to otd activation in the head primordium. Finally, we identify a novel pathway mediated by the gap gene huckebein through which three maternal systems cooperate to repress otd expression at the anterior terminus of the embryo.

Alveolar inflammation and its relation to emphysema in smokers

The prevalent theory in the pathogenesis of emphysema proposes that increased numbers of activated neutrophils and/or alveolar macrophages produce large amounts of proteases, an activity that cannot be regulated by alpha 1-antiproteases, resulting in lung destruction. However, the cells in the lung parenchyma of smokers have not been properly identified. We characterized and quantitated the inflammatory cell load in the lungs of smokers and correlated these findings with the degree of lung destruction. Twenty-one patients, six nonsmokers and 15 smokers, undergoing lung resection were studied. Lungs or lobes were fixed and stained for light microscopy and neutrophil identification and immunohistochemically stained for identification of lymphocytes and macrophages. By point counting, we determined the extent of emphysema by the volume density of the lung parenchyma (Vvalv), and the different cell numbers per cubic millimeter in all lungs. In nonsmokers Vvalv was greater than in smokers. The number of neutrophils/mm3 of lung correlated directly with the Vvalv, (r = 0.71, p < 0.01), whereas the number of alveolar macrophages (r = -0.70) and T-lymphocytes (r = -0.78) correlated negatively with the Vvalv. The number of T-lymphocytes correlated negatively with the number of neutrophils (r = -0.58) and positively with the numbers of alveolar macrophages (r = 0.77). Our data suggest that as long as the inflammatory reaction is predominantly of neutrophils there is no destruction of the lung. However, the extent of lung destruction becomes evident, and its extent is directly related to the number of alveolar macrophages and T-lymphocytes/mm3. We conclude that the T-lymphocyte might be importantly implicated in the pathogenesis of emphysema in smokers.

Pattern formation in Drosophila head development: the role of the orthodenticle homeobox gene

Significant progress has been made towards understanding how pattern formation occurs in the imaginal discs that give rise to the limbs of Drosophila melanogaster. Here, we examine the process of regional specification that occurs in the eye-antennal discs, which form the head of the adult fruitfly. We demonstrate genetically that there is a graded requirement for the activity of the orthodenticle homeobox gene in forming specific structures of the developing head. Consistent with this result, we show that OTD protein is expressed in a graded fashion across the disc primordia of these structures and that different threshold levels of OTD are required for the formation of specific subdomains of the head. Finally, we provide evidence suggesting that otd acts through the segment polarity gene engrailed to specify medial head development.

Morphometry of small airways in smokers and its relationship to emphysema type and hyperresponsiveness

Based on our previous finding, of increased small airways disease in centrilobular emphysema (CLE) when compared with panlobular emphysema (PLE), we hypothesized that smokers who develop CLE would have increased airway responsiveness associated with airway inflammation and exaggerated airway narrowing, but not smokers with PLE. We compared preoperative methacholine challenge with the morphologic and cellular inflammatory characteristics of the airways in the lungs of six nonsmokers, 10 smokers with CLE, and five smokers with PLE. The airways of the CLE group were narrower than those of the nonsmokers (KS < 0.05) and the PLE group (KS < 0.05), but perimeters were not different. A greater percentage of airways in the CLE group showed infolding of the epithelium and lumen deformity than in the PLE group and nonsmokers (p < 0.05). Airway inner wall thickening (WI) was increased in the CLE group when compared with the PLE group and nonsmokers (p < 0.05), and WI correlated significantly with PC20 in the CLE group (r = -0.64, p < 0.01) but not in the PLE group and nonsmokers. The number of T lymphocytes in the airway walls correlated with PC20 in the CLE group (r = -0.50, p < 0.05) but not in the PLE group. In conclusion, despite similar age, smoking history, and range of airflow limitation, there was a clear difference in the methacholine responsiveness between the emphysema groups, suggesting that responsiveness is not just a reaction to smoking but either a reaction developing in some smokers or an abnormality initially present in some smokers which, in combination with exposure to cigarettes, determines the development of a type of lung disease: CLE.

Rhabdomyolysis complicating acute Epstein-Barr virus infection

Infection with Epstein-Barr virus (EBV) is common and induces a broad spectrum of illness. In the majority of cases the disease manifests with typical signs of heterophile-positive infectious mononucleosis in which myalgia may be seen in up to 20% of cases. In this study, a case of rhabdomyolysis is reported occurring during the clinical course of an 18-year-old patient with infectious mononucleosis. This severe form of muscle involvement has been rarely associated with EBV infections. Five similar cases previously published in the English literature are also reviewed. The clinical implications of rhabdomyolysis and infectious mononucleosis are discussed.

Epidemiology and clinical spectrum of pneumococcal infections: an Israeli viewpoint

We performed a prospective study of consecutive pneumococcal infections documented during a six-month period in our clinical microbiology laboratory. A total of 59 cultures obtained from clinically significant specimens of 58 patients were positive for Streptococcus pneumoniae. Relative penicillin resistance occurred in 14 strains (24%) and only one (1.7%) was highly resistant to penicillin (minimum inhibitory concentration = 2.0 micrograms ml-1). Resistance to common alternative drugs was not found. Serotypes were of a wide variety, however types 1, 7 and 14 predominated (60% of all blood culture isolates). Twenty-three patients with community-acquired infection required hospitalization. Nosocomial pneumonia developed in three additional cases (14%). Invasive disease was diagnosed in 24 patients with pneumonia representing the most common infection (22 patients). Pneumonia was characterized by a high incidence of serious underlying diseases (82%) and associated bacteraemia (68%). Compared with controls, patients with penicillin-resistant pneumococcal pneumonia had a significantly higher incidence of previous hospitalizations and use of antibiotics (57 vs. 7%, P = 0.02). The overall case fatality rate was high (36%) and did not differ significantly between patients with pneumonia due to resistant and susceptible strains. The epidemiology and clinical spectrum of serious pneumococcal infections in Israel is similar to those described in many parts of the world, but high level resistance to penicillin and to other alternative drugs is still rare.

Expression of two zebrafish orthodenticle-related genes in the embryonic brain

To analyze the molecular mechanism of pattern formation in the anteriormost regions of the zebrafish embryo, we isolated two zebrafish sequences, zOtx1 and zOtx2, related to the Drosophila orthodenticle (otd) and two murine Otx genes. zOtx1 and zOtx2 encode predicted gene products which are 82% and 94% identical to the corresponding mouse proteins. Transcripts of both zebrafish genes appear abruptly at high levels in a triangular patch at the animal pole of the mid-gastrula, a region which contains cells fated to become midbrain and forebrain. Between 9 and 14 h of development, zOtx transcripts disappear from forebrain regions in a manner characteristic for each gene, and from 14 to 24 h, particular regions of the forebrain and midbrain express one or both genes. The posterior limit of expression of both genes in 10-30-h embryos forms a sharp boundary at the posterior border of the midbrain. As in the mouse, the early expression patterns of the zOtx genes are consistent with a role in defining midbrain and forebrain territories. However, there are a number of interesting differences between the forebrain and midbrain regions which express the genes in the two species.

Jejunobronchial fistula: case report and brief discussion of the literature

Enterobronchial fistulas are extremely rare. Herein we describe a 69-year-old man who had previously undergone resection of a gastric adenocarcinoma. He was hospitalized because of a fever, cough that produced brown sputum, dyspnea at rest, and an 18-kg weight loss during the previous year. A jejunobronchial fistula was diagnosed when methylene blue, which had been added to an enteric feeding, was detected in a bronchus during bronchoscopy. In addition to the current case, we include a brief review of the literature.

From fly head to mammalian forebrain: the story of otd and Otx

Many of the genes responsible for axial patterning have been conserved throughout evolution. Recent studies of invertebrates and vertebrates are extending our understanding of this molecular conservation into the anterior region of the animal embryo, including the developing brain. These studies suggest that this domain is specified according to a genetic paradigm that is different from that governing trunk development, and are also beginning to provide insights into the structures that underlie the rostral brain.

Morphological and cellular basis for airflow limitation in smokers

Airflow limitation has two well-defined components, increased resistance, which is found predominantly in the small airways, and loss of elastic recoil. Small airways contribute to the increased resistance to flow by the narrowing of the airway lumen. Morphometric studies have shown that smokers have increased epithelial abnormalities, cellular inflammatory infiltrates in the airway wall, increased muscle and fibrosis, when compared with nonsmokers. Along with these anatomical changes, an increased percentage of airways < 400 microns in diameter is found. In addition to the measured changes, other nonmeasurable, dynamic events occur in the airways of smokers, which further decrease lumen diameter. There is ample evidence to show that the airways of smokers react to nonspecific stimuli by constricting, which results in increased resistance and decreased forced expiratory volume in one second (FEV1). The pathological changes found in smokers, that could be responsible for active muscle constriction and airway narrowing include: 1) airway epithelial damage, resulting in increased permeability and impairment of other epithelial function; 2) chronic airway inflammation; 3) structural changes in the airway wall; and 4) loss of alveolar attachments. However, not all smokers develop the abovementioned airway abnormalities. We describe how smokers could develop either centrilobular emphysema (CLE), or panlobular emphysema (PLE). We have found that smokers with CLE have more abnormal and narrower small airways, and flow limitation is correlated with the small airway abnormalities and not with loss of recoil. In contrast, smokers with PLE have much less severe airway abnormalities, diffuse emphysema that can be detected microscopically at a stage when FEV1 might be only mildly abnormal, and early changes in elastic recoil as evidenced by the changes in the pressure-volume curve of the lung. Furthermore, in PLE, airflow limitation is correlated with loss of recoil but not with abnormalities in the small airways. We believe that the mechanisms involved in the pathogenesis of the two types of emphysema in smokers are different; an airborne mechanism for CLE, possibly related to airway hyperresponsiveness, and a bloodborne mechanism for PLE, which may be related to dysfunction of alpha 1-antiproteases. We conclude that the separation of smokers based on their emphysema type is essential if we are to understand the pathogenesis of chronic obstructive pulmonary disease (COPD) in these subjects.

Fibromyalgia in familial Mediterranean fever

OBJECTIVE

To determine whether chronic lower body pain in a subpopulation of patients with familial Mediterranean fever (FMF) is due directly to the musculoskeletal manifestations of FMF or whether they are connected to mechanical problems in the low back and leg/foot or to other factors operative in fibromyalgia (FM).

METHODS

In 93 consecutive patients with FMF a point count of 14 tender points (TP) was conducted by thumb palpation. Tenderness thresholds were assessed in some of the TP and of control point sites by Chatillon dolorimeter.

RESULTS

In female patients with FMF dolorimeter thresholds of fibrositic and control point sites were significantly lower than in male patients with FMF (p < 0.004). Also patients with FMF with back pain and foot/leg pain are more tender than patients with FMF without this characteristic (p < 0.001).

CONCLUSION

The detection of FM and definition of tenderness thresholds is relevant to this disease, since musculoskeletal complaints are common in this group of patients but not always explained by objective findings.

[Left-sided group A streptococcal endocarditis and mitral valve prolapse]

Group A beta-hemolytic streptococcus is an infrequent cause of endocarditis. Left-sided endocarditis in intravenous drug abuse is likewise uncommon; it carries a poor prognosis. A case of left-sided group A beta-hemolytic streptococcal endocarditis in a 20-year-old male drug addict with mitral valve prolapse is presented. This association has not been reported previously.

Outbreak of Candida tropicalis fungemia in a neonatal intensive care unit

OBJECTIVE

To describe an outbreak of Candida tropicalis fungemia in a neonatal intensive care unit (NICU), to evaluate the risk factors associated with this infection and the possible mode of nosocomial transmission.

DESIGN

Descriptive and case-control study.

PATIENTS AND METHODS

Surveillance cultures were taken from hospitalized patients, personnel, and inanimate objects in the NICU. Six patients with C tropicalis fungemia (cases) were compared with C tropicalis culture-negative patients matched for duration of exposure to the NICU (controls).

RESULTS

During a five-month period, C tropicalis was isolated from 29 blood cultures of six premature infants. The same organism also was isolated from fingernail samples taken from the ward housekeeper, who had a mild onychomycosis, and an asymptomatic nurse. Other potential reservoirs of C tropicalis were not identified among all the other infants or in the hospital environment. The six patients with C tropicalis fungemia were more likely to have received a larger number of antibiotics (4.0 versus 1.8, P < 0.001) and to have been subjected to a longer duration of total parenteral nutrition (TPN) therapy (8.5 versus 2.67 days, P = 0.004) than the controls.

CONCLUSIONS

The risk of fungemia in this outbreak can be attributed to a larger number of antibiotics and a longer period of TPN administered to the patients. Analysis of events suggests that the outbreak may have been the result of cross-infection between staff and patients.

Colonization of the respiratory tract with Legionella species

Pneumonia is the most important manifestation of disease caused by Legionella species. However, it is still not known for certain how these organisms actually enter the lungs. During a 5-month period 318 hospitalized patients without clinical or radiologic features of pneumonia were enrolled in a survey of sputum colonization with Legionella. Diagnostic tests included cultures, direct fluorescent antibody test (DFA) and DNA probe assay of sputum. Colonization was considered to occur when at least one of these tests was positive. According to our definitions, 1.2-10% of of these patients could have been colonized by Legionella spp. However, all cultures were negative and in all but one of these patients the DFA was the only positive test. A case-control study comparing test-positive and test-negative patients failed to identify any different features of disease or epidemiologic characteristics. These findings suggest that a high rate of false-positive DFA results occurred in our study rather than any new evidence of colonization of the respiratory tract with Legionella.

Diagnostic efficacy of a DNA probe in pneumonia caused by Legionella species

A commercial DNA probe kit (Gen-probe) for the detection of rRNA from legionellae was evaluated for its accuracy in diagnosing Legionnaires' disease in 167 patients with pneumonia. The test was performed on freshly obtained clinical respiratory tract samples. Cultures and direct immunofluorescence antibody (DFA) staining of the samples and serological tests were performed simultaneously for all patients. The probe assay result was positive in six patients; five of them had other laboratory evidence of disease (positive cultures or positive serological results or both). Depending on the diagnostic criteria, the probe test had a sensitivity of 31-67%, a specificity of 99% and positive predictive values of 67-83%. The diagnostic performance of the DNA probe assay in this study was superior to that of the DFA test. The results indicate that the examination of respiratory tract secretions by the Gen-probe kit is a suitable screening test for the diagnosis of Legionnaires' disease.

Anaerobic osteomyelitis in patients with Gaucher's disease

Bone involvement in patients with Gaucher's disease is common, and some of its clinical manifestations may resemble acute osteomyelitis. In addition, many studies have emphasized the high risk of secondary infection when surgical procedures are performed at the site of the involved bone. Nevertheless, these infections have never been well documented in the literature. Presentation of a patient with Gaucher's disease and osteomyelitis due to Prevotella (Bacteroides) melaninogenica provided us the opportunity to review 10 other similar case reports documented in the literature since 1966. This review suggests that acute hematogenic osteomyelitis is an uncommon complication of Gaucher's disease, but it is of interest that in most cases it is due to unusual organisms, particularly anaerobes.

orthodenticle activity is required for the development of medial structures in the larval and adult epidermis of Drosophila

Lethal alleles of orthodenticle (= otd) cause abnormalities in the embryonic head that reflect an early role in anterior pattern formation. In addition, otd activity is required for the development of the larval and adult epidermis. Clonal analysis of both viable and lethal alleles shows that the adult requirement for otd is restricted to medial regions of certain discs. When otd activity is reduced or removed, some medial precursor cells produce bristles and cuticle characteristic of more lateral structures. Similar medial defects are observed in the larval epidermis of embryos homozygous for lethal otd alleles. Antibodies to otd recognize a nuclear protein found at high levels in the medial region of the eye antennal discs, the leg discs, the genital discs and along the ventral midline of the ventral epidermis of the embryo. These results suggest that the otd gene product is required to specify medial cell fates in both the larval and adult epidermis.

The orthodenticle gene encodes a novel homeo domain protein involved in the development of the Drosophila nervous system and ocellar visual structures

The orthodenticle (otd) locus of Drosophila is required for embryonic development, and null mutations of otd cause defects in head development and segmental patterning. We show here that otd is necessary for the formation of the embryonic central nervous system (CNS). otd mutations result in the formation of an abnormal neuropil and in the disappearance of identified neurons associated with the midline of the CNS. In addition, otd is allelic to ocelliless (oc), a mutation that causes the deletion of the ocelli of the adult fly. We have identified a transcription unit corresponding to the otd locus and find that it is expressed early in a stripe near the anterior pole of the cellular blastoderm and later in the region of the CNS from which these neurons normally arise. The predicted otd protein contains a well-conserved homeo domain and is therefore likely to be a transcriptional regulator involved in specifying cell fate both in the embryonic CNS and in the ocelli.

Hepatic intraarterial antibiotic therapy for resistant hepatic abscesses

Liver abscesses present a severe problematic medical entity. The traditional treatment modality consists of surgical drainage, which cannot be accomplished in all circumstances. Other modes of therapy include systemic antibiotics or percutaneous catheter drainage under ultrasonography or computerized tomography. Despite new treatment regimes liver abscesses, to date, are a potentially lethal disease, with a mortality rate of about 50%. We report an innovative approach of high dosage intrahepatic arterial antibiotic infusion for the therapy of hepatic abscesses, which are resistant to conventional treatments. A patient who underwent mastectomy for breast carcinoma, developed liver metastases one year later. She was prescribed systemic chemotherapy for one year, but no antitumor response was evident. Since ther was no evidence for extra-hepatic metastases, intraarterial hepatic chemotherapy was instituted, using an Infusaid (Mi-400) implantable pump. Marked regression of liver metastases was observed. Therapy was withheld after 19 months because of biliary sclerosis development. At this stage, the patient developed liver abscesses, which were resistant to systemic antibiotic therapy. Intraarterial antibiotic therapy, using the implantable pump, was initiated. Following the treatment, a marked improvement in the patients' clinical condition was recorded and shrinkage of the abscesses was evident by ultrasonography. The patient was free of symptoms for three months, when she was readmitted with evidence of terminal metastatic disease and sepsis. It is suggested that intrahepatic arterial antibiotic therapy is an additional mode of treatment for patients with persistent liver abscesses which fail to respond to conventional treatment.

The emergence of methicillin-resistant Staphylococcus aureus infections in an Israeli hospital

Between July 1984 and August 1985, 200 cases of methicillin-resistant Staphylococcus aureus (MRSA) occurred in a large, tertiary care, medical school-affiliated hospital. During this period, a limited outbreak, causing serious infections, was identified in the Intensive Care Unit and was contained by appropriate infection control measures. Bacteriophage typing and surveillance cultures failed to identify a common or single source of dissemination of these strains. It appears that MRSA strains have emerged in Israel as endemic pathogens in hospitals, capable of causing serious nosocomial outbreaks.

Bone and joint infections due to Pseudomonas aeruginosa: clinical aspects and treatment

The occurrence of nine cases of Pseudomonas septic arthritis and osteomyelitis within a 12-month period may be considered an uncommon experience even in a large, tertiary referral center. These cases are reported here and the various clinical patterns and therapeutic implications associated with Pseudomonas bone infections are discussed. Epidemiologic serotyping of the isolated strains indicated that they do not represent a single nosocomial outbreak.

[Nontropical pyomyositis]

Pyomyositis of the pectoralis major was diagnosed in a 79-year-old man and Staphylococcus aureus was grown from pus drained from the infected muscle. Bacteremia and overwhelming sepsis accompanied the infection, and the patient died despite early diagnosis, combined chemotherapy and surgical drainage. The incidence of pyomyositis has been increasing lately in temperate climates. To our knowledge, this is the first report of nontropical pyomyositis in Israel.

Drosophila P-element transcripts are incorrectly processed in tobacco

A gene encoding the Drosophila P-element transposase was expressed in transgenic tobacco plants under transcriptional control of the Drosophila HSP70 promoter. Polyadenylated transcripts were produced, but the major transcript was about 1 kb shorter than expected and the two introns were not removed. The 3' end of the most abundant transcript occurred within the transposase coding sequence downstream of the acceptor site of the second intron within a region of high A+T content. These results provide an additional example in which RNA processing enzymes of plants utilize different mRNA processing signals than animals.

Waterborne typhoid fever in Haifa, Israel: clinical, microbiologic, and therapeutic aspects of a major outbreak

A major outbreak of waterborne typhoid fever involving 77 verified cases occurred in 1985 in a large suburban area of Haifa, Israel. The authors summarize the clinical, microbiologic, and therapeutic aspects of these patients. Fever, usually higher than 39 degrees C, was the hallmark of the disease. Other manifestations of typhoid, although relatively frequent, are presented as part of a mild nonspecific symptom complex, often found only in the prodromal period. An elevated level of serum glutamic-oxaloacetic transaminase (mean, 81 IU/ml) was the most characteristic laboratory abnormality, occurring in 94% of the patients. Blood cultures were positive in 46 of the 50 patients (92%), and were not affected by prior outpatient antibiotic therapy. The first blood culture was diagnostic in 93% of the cases. Although fever tended to disappear more rapidly among patients receiving ampicillin than among those treated with chloramphenicol, results of therapy were similar in both groups. Nevertheless, the relapse rate of 36% among 25 chloramphenicol-treated patients was significantly higher than the 9% noted among 22 patients treated with ampicillin. Except for one case of hemolytic anemia, serious complications were conspicuously absent, and outcomes were uniformly favorable.

Contribution of echocardiography to cardiac diagnosis

In order to quantify information provided by echocardiography for residents in internal medicine and for cardiologists, 150 selected patients were studied by echocardiography, and the ultrasonic diagnosis was compared with the clinical evaluation. Among 144 patients with adequate visualization of the heart, echocardiography provided findings that were totally unexpected to the residents in 13 (9%) and to the cardiologist in 9 (6%) patients. Echocardiography also provided information relevant to the management of the patient in another one-third of the cases. Both the residents and the cardiologist were able to correctly predict the cause of cardiomegaly and the mechanism of heart failure in most patients presenting with these findings. Despite the introduction of cross-sectional echocardiography, the amount of information contributed by echocardiography has not increased since 1978, when a similar study was performed at our institution. This may reflect increased clinical skill among residents, probably due to long-term exposure to echocardiography during their training.

Sphenoid sinusitis presenting as chronic meningitis

Sphenoid sinusitis is a frequently misdiagnosed infection. Delay in recognition and treatment carries a very poor prognosis. An unusual case of sphenoid sinusitis mimicking a syndrome of chronic meningitis is presented. This case emphasizes the diagnostic challenge of sphenoid sinusitis which may present only through its complications.