Imipenem versus moxalactam in the treatment of serious infections

Imipenem (formerly imipemide, N-formimidoyl thienamycin, or MK0787) was compared to moxalactam in a randomized therapeutic trial involving 39 evaluable patients with serious bacterial infections. Of those treated with imipenem, 89% were cured or improved versus 60% for moxalactam (P = 0.06). Although mucocutaneous fungal infections occurred in both groups (25 and 10%, respectively), Streptococcus faecalis superinfection was seen in two patients in the moxalactam group only. Adverse drug reactions occurred with both drugs, although bleeding occurred in three patients treated with moxalactam.

Bacteremia due to Mycobacterium avium-intracellulare in the acquired immunodeficiency syndrome

The presence of Mycobacterium avium-intracellulare has frequently been demonstrated in tissue specimens from patients with the acquired immunodeficiency syndrome. The importance of this mycobacterium as a cause of constitutional symptoms and organ dysfunction has been unclear, however, because of the sparse inflammatory response evoked and the frequent concurrence of other pathogenic organisms. We detected M. avium-intracellulare in blood samples from eight patients with the acquired immunodeficiency syndrome, seven of whom had a previously recognized M. avium-intracellulare infection. Blood cultures were positive on 1 to 14 occasions over 135 days using the Dupont isolator system or the Bactec 12B medium system. Cultures were positive within 14 to 51 or 7 to 14 days with the respective techniques. The ability to rapidly isolate M. avium-intracellulare from blood may provide a useful diagnostic technique for detecting disseminated mycobacterial disease in patients with the acquired immunodeficiency syndrome as well as in other patient populations. This technique may also be useful for assessing the efficacy of drug therapy.

Accumulation of bone-scanning agents in hepatoma

A case of hepatocellular carcinoma demonstrating intense uptake of Tc-99m methylene diphosphonate (MDP) is described. This is one of three cases seen by the authors who suggest that hepatoma be considered along with other previously described entities when there is localized accumulation of a bone-scanning agent in the liver.

Distribution and origin of bombesin, substance P and somatostatin in cat spinal cord

Bombesin (BN), substance P-(SP) and somatostatin (SRIF) were measured in individual laminae of the cervical, thoracic and lumbar (L) spinal cord of control cats, and in the L6 segment of cats receiving a spinal hemisection (L2) or deafferentation via dorsal rhizotomy at L6, 7, S1. The interlaminar distribution of BN, SP, and SRIF was remarkably similar. Highest concentrations were found in the superficial dorsal horn, and progressively less was found proceeding ventrally. Some intersegmental variations in peptide concentration within a single lamina were found. Dorsal rhizotomy caused a significant decline in BN, SP and SRIF in lamina I-III, therefore all three peptides appear to be contained in dorsal root ganglion cells. Evidence is presented for the existence of ascending BN and SP projections originating in lamina I-III and VII, for a descending SRIF pathway terminating in lamina VIII, and for an ascending BN path in lamina VIII. Dorsal root afferents to lamina VIII influence levels of BN, SP and SRIF.

A rapid diagnosis of Campylobacter enteritis by direct smear examination

Diagnosis of Campylobacter enteritis by direct smear examination of stool specimens, using 1% aqueous basic fuchsin, was compared with a conventional cultural method (Campy-BAP). After examination of 485 stool specimens the direct smear method produced a sensitivity and specificity of 94% and 99.5%, respectively.

Cavo-portal shunting in superior and inferior vena caval obstruction

Focal radionuclide accumulation of Tc-99m sulfur colloid (SC) and tc-99m macroaggregated albumin (MAA) in the liver has been reported in both inferior and superior vena caval obstruction. We studied a patient with uniform radionuclide accumulation of Tc-99m MAA in the liver during lung scintigraphy. In this patient, both the superior vena cava (SVC) and the inferior vena cava (IVC) were obstructed. Most of the systemic venous return appeared to be passing through the liver on its way to the heart, through the anastomoses between the systemic veins and the portal vein. The the best of our knowledge, uniform hepatic uptake in vena caval obstruction is not reported in the literature.

Abnormal thallium-201 scans in patients with chest pain and angiographically normal coronary arteries

We reviewed the exercise thallium-201 (TI-201) scans and clinical data of 41 patients with chest pain and normal coronary arteries to identify clinical factors associated with "false-positive" studies. Exercise TI-201 studies were performed before angiography and often precipitated referral. Sex, beta-blocker therapy, anginal pattern, and results of exercise electrocardiography were evaluated and compared with TI-201 imaging. A negative TI-201 study was the most common finding (p less than 0.005). Of the 41 patients, 11 (27%) had abnormal exercise TI-201 scans. No clinical factor was significantly associated with a false-positive TI-201 scans. Of the 11 patients with abnormal scans, 9 had greater than or equal to 1 cardiac abnormality: right bundle branch block in 2, mitral valve prolapse in 3, paroxysmal atrial fibrillation in 2, abnormal left ventricular diastolic pressure in 3, and left bundle branch block in 1. Thus, (1) when results of exercise TI-201 imaging are used to refer patients for angiography, "false-positive" TI-201 studies are common; (2) sex, beta blockade, anginal pattern, and results of exercise electrocardiogram are not useful predictors of a false-positive TI-201 study; and (3) patients with chest pain, normal coronary arteries, and abnormal TI-201 scans frequently have other cardiac abnormalities.

Ceftriaxone therapy of serious bacterial infections

Ceftriaxone, a broad spectrum cephalosporin with a markedly extended half-life, was administered to 68 patients with 71 infections in an open trial. Sixty-three infections (89%) had a satisfactory clinical response with eradication of bacteria present at the initiation of therapy in 62 infections (87%). The eight treatment failures correlated well with the development of resistance to ceftriaxone during therapy in Enterobacter and Pseudomonas species (two cases) and with superinfection with Bacteroides fragilis (three cases). Treatment was discontinued in eight patients because of unwanted effects. Serious side effects included leukopenia, rash, fever, and enterocolitis.

Ceftazidime in patients with Pseudomonas infections

Ceftazidime was administered to 41 patients with serious infections caused by Pseudomonas aeruginosa (24 cases) and other bacteria (17 cases). The clinical response rate of pseudomonas infections (88%) was similar to that of other bacteria (94%) with microbiological eradication of 83% of initial pseudomonas isolates compared to 82% of non-pseudomonas strains. The development of resistance to ceftazidime during therapy was observed in 3 cases (Enterobacter agglomerans, Enterobacter cloacae, and Ps. aeruginosa), and superinfection by a resistant Enterobacter agglomerans occurred in one case. Adverse reactions of clinical significance included two cases of leukopenia and one case each of azotaemia, diarrhoea (Clostridium difficile toxin positive), and rash.

Piperacillin therapy for Pseudomonas infections

Piperacillin, a new broad spectrum semisynthetic penicillin derivative, was administered to 22 patients with 25 Pseudomonas aeruginosa infections. All initially responded favorably, although five complicated urinary tract infections and two infections involving prostheses relapsed. In 15 cases, microbiologic eradication of the Pseudomonas was achieved. Failure to achieve a clinical cure was correlated in all cases with the inability to eradicate the organism, which was the result of development of in vitro resistance to piperacillin during therapy (four cases) and of underlying disease impairing host responses. Adverse reactions to piperacillin included leukopenia (eight cases) and nephrotoxicity (two cases).

Malignant lymphocytic lymphoma. Demonstration of a serum inhibitor of myelopoiesis and response to combination chemotherapy

A case of diffuse well differentiated lymphocytic lymphoma with associated leukopenia, is described. The colony-forming unit (CFU-C) assay was used to quantitate myeloid precursor cells and to test for the presence of suppressor cells and/or serum factors inhibiting myeloid cell proliferation. Mild suppression of CFU-C was noted with the patient's bone marrow cells in coculture studies with normal marrow. The patient's serum, when added to the culture of normal bone marrow cells, produced a marked decrease in CFU-C. Treatment with combination chemotherapy (prednisone, cyclophosphamide, and vincristine) produced a clinical response with correction of the leukopenia. Post-treatment serum did not produce a significant reduction in CFU-C from normal bone marrow.

Ceftriaxone therapy of bone and soft tissue infections in hospital and outpatient settings

Ceftriaxone, a broad-spectrum cephalosporin with a markedly extended half-life, was administered to 100 patients with 56 bone and 44 soft tissue infections. Sixty-eight received 1 g twice daily, and 32 received 2 g once daily intravenously. Overall, 91% had a satisfactory clinical response, with similar efficacies in both treatment regimens. In six patients, failure to achieve a cure correlated well with the development of resistance to ceftriaxone during therapy in Enterobacter and Pseudomonas species (two cases) and with superinfection with Bacteroides fragilis (four cases). In 41 patients, intravenous drug therapy was continued after discharge from the hospital. In this group, 1,093 patient-days of hospitalization were saved, amounting to $150,020 in cost savings. The prolonged half-life facilitated the administration of ceftriaxone in this setting.

Clinical correlations of leukemic clonogenic cell chemosensitivity assessed by in vitro continuous exposure to drugs

This study was performed to assess the value of prolonged, as opposed to short-pulse, in vitro exposure of leukemic cells to chemotherapeutic drugs in leukemic clonogenic assay for prediction of clinical response. In 21 patients with acute nonlymphocytic leukemia treated with intensive combination chemotherapy based on an anthracycline and 1-beta-D-arabinofuranosylcytosine infusion, chemotherapy sensitivity of leukemic clonogenic cells was assessed in comparison with that of normal myeloid clonogenic cells by the in vitro continuous exposure to drugs throughout the entire culture period. Analysis of these in vitro data in terms of prediction of achieving clinical complete remission was carried out in comparison with data on 22 cases in which in vitro sensitivity was assessed by the pulse 1-hr exposure. The in vitro sensitivity index, expressed as a log odds ratio, was positive (greater than 0) in 8 of 11 patients achieving complete remission and negative (less than 0) in 7 of 10 patients failing to achieve complete remission, with an overall correlation of 71%. This is at least as good as the pulse exposure method, which has a correlation of 68%. If sensitivity indexes of marginal magnitudes (--1.0 approximately +1.0) are excluded, the correlation increases to 92% (12 of 13 patients). The correlation appears to improve especially for 1-beta-D-arabinofuranosylcytosine by the continuous exposure method (71%) as compared with the pulse method (57%). This study establishes the feasibility of an in vitro chemotherapy sensitivity testing of leukemic clonogenic cells by continuous in vitro drug exposure and suggests that the continuous exposure method may be better than the pulse method for antimetabolites such as 1-beta-D-arabinofuranosylcytosine. The data also suggest that simulation of the in vivo drug schedule may be important in this in vitro test.

Effect of mannitol and plasma on the cytotoxicity of cisplatin

A soft agar cell culture for human granulocyte precursor cells (CFU-c) was used to assess the cytotoxic effect of cisplatin before and after preincubating the drug with either mannitol and/or fresh human plasma. Consistent growth inhibition of CFU-c was found with survival of 87, 64 and 34% at cisplatin concentrations of 10(-7) M, 10(-6) M and 10(-5) M respectively. Dose-related survival was not changed by preincubating cisplatin with mannitol in molar ratios of 1:100 and 1:1000 for 4 and 24 hr. Preincubating 10(-5) M cisplatin with human plasma increased CFU-c survival corresponding to a loss of activity of 92 and 98% after 4- and 24-hr preincubations respectively. No significant difference in survival of CFU-c was noted whether bone marrow cells were exposed to cisplatin in human plasma or in the ultrafiltrate of human plasma. Mannitol did not change the decrease in cisplatin activity due to plasma protein binding. These data indicate that the cytotoxic effect of cisplatin can be reduced by exposure to human plasma but not to mannitol.

Tissue and plasma carcinoembryonic antigen in early breast cancer. A prognostic factor

A prospective study of plasma and tissue carcinoembryonic antigen (P-CEA and T-CEA) levels in 63 patients with early (Stage I and II) breast cancer was undertaken to determine if the presence of CEA in tissue and/or plasma at the time of primary surgery can be used as a prognostic factor. Thirty-two Stage I and 31 Stage II patients were evaluable with a median follow-up time of 26 months: 29/63 were T-CEA and/or P-CEA positive while 34/63 were T-CEA and P-CEA negative; 9/63 were both T-CEA and P-CEA positive; 13/63 were P-CEA positive alone, while 25/63 were T-CEA positive alone; 5/29 T-CEA and/or P-CEA positive showed disease progression with a mean DFI of 11.8 months, compared with 0/34 T-CEA and P-CEA negative patients (P less than 0.02); 2/9 T-CEA and P-CEA positive compared with 0/34 negative patients progressed (P less than 0.01). There was a significant difference (P less than 0.05) between P-CEA positive (3/13) patients with recurrence and P-CEA negative (2/50). When T-CEA positive patients (4/25) were compared with T-CEA negative (1/38), the difference approaches significance. When the recurrences were analyzed with respect to CEA, estrogen receptor (ER) and nodal status, only in the CEA + versus CEA - group was there a significant difference. The early data show that patients with positive T-CEA and/or P-CEA have a higher recurrence rate with probable poor prognosis. Prognosis correlates better with CEA status than with ER or nodal status.

Hepatic lipid peroxidation in vivo in rats with chronic iron overload

Peroxidative decomposition of cellular membrane lipids is a postulated mechanism of hepatocellular injury in parenchymal iron overload. In the present study, we looked for direct evidence of lipid peroxidation in vivo (as measured by lipid-conjugated diene formation in hepatic organelle membranes) from rats with experimental chronic iron overload. Both parenteral ferric nitrilotriacetate (FeNTA) administration and dietary supplementation with carbonyl iron were used to produce chronic iron overload. Biochemical and histologic evaluation of liver tissue confirmed moderate increases in hepatic storage iron. FeNTA administration produced excessive iron deposition throughout the hepatic lobule in both hepatocytes and Kupffer cells, whereas dietary carbonyl iron supplementation produced greater hepatic iron overload in a periportal distribution with iron deposition predominantly in hepatocytes. Evidence for mitochondrial lipid peroxidation in vivo was demonstrated at all three mean hepatic iron concentrations studied (1,197, 3,231, and 4,216 micrograms Fe/g) in both models of experimental chronic iron overload. In contrast, increased conjugated diene formation was detected in microsomal lipids only at the higher liver iron concentration (4,161 micrograms Fe/g) achieved by dietary carbonyl iron supplementation. When iron as either FeNTA or ferritin was added in vitro to normal liver homogenates before lipid extraction, no conjugated diene formation was observed. We conclude that the presence of conjugated dienes in the subcellular fractions of rat liver provide direct evidence of iron-induced hepatic mitochondrial and microsomal lipid peroxidation in vivo in two models of experimental chronic iron overload.

In vitro growth promotion of T-lymphocyte colonies from normal human bone marrow with 12-O-tetradecanoylphorbol-13-acetate (TPA)

An in vitro culture system for the growth of T-lymphocyte colonies from normal human bone marrow has been described. This culture system features the use of 12-O-tetradecanoylphorbol-13-acetate (TPA) at moderately high concentrations (10(-7)-10(-6) M) and daily feeding with growth medium containing leukocyte-conditioned medium primed with phytohemagglutinin. T-lymphocyte colonies in this system can reach a size of over 10,000 cells/colony, suggesting that cells assayed in this system are early progenitors of T-lymphocytes with extensive proliferative capacity. TPA, at a higher concentration (10(-5) M), is inhibitory to the growth of T-lymphocytes, but this level is 5 orders of magnitude higher than the minimum TPA concentration (10(-10) M) inhibitory to myeloid colony forming cells. This demonstrates marked difference in the sensitivity of T-lymphocyte colony forming cells and myeloid colony forming cells to TPA. It appears that this assay system should be useful for the study of the early progenitors of human bone marrow T-lymphocytes.

Ceftazidime therapy of serious bacterial infections

Ceftazidime, a new broad-spectrum cephalosporin, was administered to 30 patients with serious bacterial infections in a randomized dosing trial with daily doses of 1.5 or 3 g. Both regimens were equally efficacious, with satisfactory clinical responses in 28 instances (93%) and microbiological eradication of 79% of initial bacterial isolates. The development of resistance to ceftazidime during therapy was observed in three cases (Enterobacter agglomerans, Enterobacter cloacae, and Pseudomonas aeruginosa) and superinfection by a resistant Enterobacter agglomerans strain occurred in one case. Adverse reactions of clinical significance included one case each of leukopenia, azotemia, diarrhea (Clostridium difficile toxin positive), and rash.

Myelosuppression in Legionnaires' disease

A patient undergoing examination for moderately severe renal insufficiency had fulminant five-lobed pneumonia caused by Legionella pneumophila. Her clinical course was complicated by granulocytopenia. Bone marrow aspiration showed notable inhibition of myelopoiesis, involving all stages of maturation. The presence of a serum inhibitor of granulopoiesis was demonstrated by in vitro bone marrow culture. Normal bone marrow cultured in the presence of serum from two normal control subjects yielded 69 +/- 5.2 (mean +/- SE) and 61 +/- 5 granulocyte colonies. When the patient's serum was substituted for normal human serum only 14.3 +/- 2.3 colonies were formed. Each of the drugs to which she had been exposed was tested in the in vitro system, using therapeutic concentrations, and none showed significant suppression of granulocyte colony formation. These observations indicate that legionnaires' disease was associated with a serum factor that notably inhibited the growth of granulocyte colonies in this patient.

Chemotherapy sensitivity assessment of leukemic colony-forming cells with in vitro simultaneous exposure to multiple drugs: clinical correlations in acute nonlymphocytic leukemia

For 13 patients with acute nonlymphocytic leukemia receiving four-drug combination chemotherapy (14 chemotherapy trials), leukemic bone marrow cells were obtained before treatment and were exposed in vitro to all four-drug-mixture solutions simultaneously followed by the survival assessment of leukemic colony-forming cells (L-CFU). Survival of normal marrow colony-forming cells (CFU-C) was also assessed concurrently, and the sensitivity index (SI) of leukemic cells was determined as the ratio of the survival of CFU-C to that of L-CFU. Correlations of in vitro results to clinical results were excellent: four of five trials resulting in complete remission had high SI and eight of nine trials without complete remission had low SI (P = 0.02). The potential advantages of this method of exposing cells to drug mixture are discussed in terms of detecting drug synergism and improving the efficiency of in vitro chemotherapy sensitivity studies.