Treatment of complicated intra-abdominal infections in the era of multi-drug resistant bacteria

The management of severe intra-abdominal infections remains a major challenge facing surgeons and intensive care physicians, because of its association with high morbidity and mortality. Surgical management and intensive care medicine have constantly improved, but in the recent years a rapidly continuing emergence of resistant pathogens led to treatment failure secondary to infections with multi-drug resistant bacteria. In secondary peritonitis the rate of resistant germs at the initial operation is already 30%. The lack of effective antibiotics against these pathogens resulted in the development of new broad-spectrum compounds and antibiotics directed against resistant germs. But so far no "super-drug" with efficacy against all resistant bacteria exists. Even more, soon after their approval, reports on resistance against these novel drugs have been reported, or the drugs were withdrawn from the market due to severe side effects. Since pharmaceutical companies reduced their investigations on antibiotic research, only few new antimicrobial derivates are available.

In abdominal surgery you may be in fear that in the future more and more patients with tertiary peritonitis secondary to multi-drug resistant species are seen with an increase of mortality after secondary peritonitis.

This article reviews the current treatment modalities for complicated intra-abdominal infections with special reference to the antibiotic treatment of complicated intra-abdominal infections with multi-drug resistant species.

Health-related quality of life/patient-reported outcomes in relapsed ovarian cancer: Results from a randomized phase III study of trabectedin with pegylated liposomal doxorubicin (PLD) versus PLD alone

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Background: In an open-label, multicenter, randomized phase III study comparing the combination of trabectedin and PLD to PLD alone in patients with relapsed ovarian cancer, the combination demonstrated significantly improved progression free survival and response rates, manageable non-cumulative toxicity, and fewer PLD-associated adverse events. We studied the impact of the combination of trabectedin with PLD on the quality of life (QoL)/patient-reported outcomes (PRO) evaluated as part of the trial. Methods: QoL/PRO questionnaires, EORTC-QLQ C30, OV28, and EQ-5D were completed by patients at screening and on Day 1 of every other treatment cycle starting with Cycle 1, and at the end-of-treatment visit. Global health status/QoL, fatigue, rain subscales from QLQ C30, and abdominal pain/GI symptoms scale from OV28 were chosen a priori for primary analyses. Other scales of the three questionnaires were analyzed on a supportive basis. Results: A total of 672 patients were randomized. 663 (98%) completed at least the baseline questionnaires. Median cycles of treatment was 6 (131 days) for the combination arm and 5 (143 days) for the monotherapy arm. Mixed effects models (using a covariance structure of AR[1]) predicting the score at baseline and follow-up scores as a function of treatment, days after baseline, and interaction between treatment and days after baseline showed no significant differences between the treatment arms for any of the prespecified scales. Similar analyses of other scales, including EQ-5D Health Index scores and Health State on the Visual Analog Scale, support the findings. Conclusions: The addition of trabectedin to PLD results in superior efficacy in patients with relapsed ovarian cancer, with no added decrement to overall health status as assessed by PRO.

[Table: see text]

[Intraductal papillary mucinous neoplasms of the pancreas: pro surgical therapy--pro surveillance]

Intraductal papillary mucinous neoplasms (IPMN) are the most common cystic tumours of the pancreas. The preoperative diagnosis of IPMN malignancy is difficult and the majority of IPMN are malignant upon diagnosis. Thus, only the early radical resection of the pancreas with regional lymph node dissection offers the patient a chance for cure. A discussion of the type "to resect or not to resect" should, furthermore, be held only within the walls of high-volume pancreatic centres and patients managed by the "watchful waiting" strategy (mainly branch-duct type IPMN) should all be recruited into large randomised controlled trials aimed to discover reliable diagnostic criteria to differentiate between invasive and non-invasive IPMN. Until then an aggressive surgical approach should be recommended as the standard treatment for all patients with IPMN.

Symptom severity and treatment course of bulimic patients with and without a borderline personality disorder

There are contradictory results concerning the frequency of borderline personality disorder (BPD) in bulimic patients and its impact on eating pathology and treatment outcome. We evaluated 240 patients with bulimia nervosa using EDI-2, SIAB and SCL-90-R. Only a minority of patients had a BPD (13.8%). There were no differences in binging or purging behaviour between patients with and without BPD, but borderline patients had significantly more feelings of ineffectiveness and more disturbances in interoceptive awareness. Bulimic patients with BPD showed significantly more general psychopathology. Although, BPD patients started with higher levels of pathology, there were similar reductions of symptoms over the course of treatment in both groups. Psychotherapy in bulimic patients with a BPD has to focus not only on eating pathology but also on aspects that are caused by the severe personality disturbance.

Clinical outcome of atypical uterine smooth muscle tumors

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Background: Smooth muscle tumors of uncertain malignant potential (STUMP) and atypical leiomyomas have increased mitotic activity, cellular atypia and necrosis but the degree is less than that used to define uterine leiomyosarcomas. Our objective is to evaluate the clinical outcome of patients with uterine masses histologically defined as smooth muscle tumors of uncertain malignant potential or atypical leiomyomas. Methods: A thorough search of our institution’s pathology database from 1990 to 2005 was performed. A retrospective chart review was performed to obtain initial and subsequent treatments, documented recurrences and clinical outcomes. Pathology reports and slides were reviewed and the presence of atypia, necrosis and number of mitosis was recorded. Statistical analysis was performed by Student’s T-test. Results: Eighteen patients with a histologic diagnosis of atypical leiomyoma were identified with 14 STUMP, 2 bizarre leiomyomas, 1 myxoid and 1 mitotically active leiomyoma. The mean age of these patients was 41.8 years (range: 25–77) and was significantly younger than those with leiomyosarcoma (mean age was 54 years, p < 0.001). The histologic characteristics of the tumors included the presence of atypia at 50%, necrosis at 82% and mitoses at 94%. The rate of necrosis and number of mitosis was significantly less in the atypical group as compared to the leiomyosarcoma group (p values < 0.05). However the rate of cellular atypia was not statistically different between the two groups. The median follow-up period was 25 months, range 1–138 months. One of the eighteen patients developed a pelvic and pulmonary recurrence at which time a low grade leiomyosarcoma was diagnosed. The recurrence occurred 32 months after the initial diagnosis of a mitotically active leiomyoma. Sixteen patients demonstrated no recurrence or metastatic disease at the time of follow-up. Conclusions: Atypical leiomyomas appear to be diagnosed in younger women which leads to challenging treatment issues involving fertility preservation. While these tumors generally behave in a benign fashion, they have histologic characteristics that may allow for progression or recurrence. Close follow-up is warranted for patients who are diagnosed with atypical leiomyomas and smooth muscle tumors of uncertain malignant potential.

No significant financial relationships to disclose.

Progression-free interval in ovarian cancer and predictive value of an ex vivo chemoresponse assay

The study objective was to determine the effectiveness of a phenotypic chemoresponse assay in predicting response to chemotherapy measured by progression-free interval (PFI) in a retrospective series of ovarian cancer patients whose tumor specimens had been tested with the ChemoFx assay. A statistically significant correlation between assay prediction of response and PFI was observed in 256 cases with an exact or partial match between drug(s) assayed and received. In 135 cases with an exact match, the hazard ratio for progression of the resistant group was 2.9 (confidence interval [CI]: 1.4-6.3; P < 0.01) compared to the sensitive group and 1.7 (CI: 1.2-2.5) for the intermediate compared to the sensitive group. The median PFI for patients treated with drugs assayed as resistant was 9 months, 14 months for those with drugs assayed as intermediately sensitive, and PFI had not been achieved for those with drugs assayed as sensitive. These data indicate that the ChemoFx assay is predictive of PFI in ovarian cancer. As the majority of ovarian cancers display different degrees of response to different chemotherapy agents ex vivo, the incorporation of assay information into treatment selection has the potential to improve clinical outcomes in ovarian cancer patients.

Drop outs from in-patient treatment of anorexia nervosa

OBJECTIVE

Aim of the study was to identify patient characteristics that distinguish drop outs and completers from in-patient treatment for anorexia nervosa.

METHOD

A total of 133 consecutively admitted in-patients with anorexia nervosa (age range 16-50 years; 92.5% women) were analysed using sociodemographic variables as well as measures of psychopathology (SCL-90-R, EDI-2) and interpersonal difficulties (IIP-C). Patients were treated in a multimodal treatment setting, combining cognitive-behavioural and psychodynamic components.

RESULTS

Patients, who reported fewer symptoms, were hospitalized before and had a comorbid depression stayed more often in psychotherapy. Patients dropping out of treatment (31.6%) showed a trend to higher levels of maturity fears. Subtype, age, duration of illness, comorbid personality disorders or previous drop outs were not predictive of dropping out.

CONCLUSION

Addressing the high ambivalence and maturity fears of anorexic patients should be an essential issue in psychotherapy with this patient group.

Phase III randomized trial of doxorubicin + cisplatin versus doxorubicin + 24-h paclitaxel + filgrastim in endometrial carcinoma: a Gynecologic Oncology Group study

BACKGROUND

This study was performed to determine whether 24-h paclitaxel plus doxorubicin and filgrastim was superior to cisplatin plus doxorubicin in patients with endometrial cancer with respect to response, progression-free survival (PFS) and overall survival (OS).

PATIENTS AND METHODS

Eligible chemotherapy-naïve patients were randomly assigned to doxorubicin 60 mg/m2 intravenously (i.v.) followed by cisplatin 50 mg/m2 i.v. (arm 1, n=157) or doxorubicin 50 mg/m2 i.v. followed 4 h later by paclitaxel 150 mg/m2 i.v. over 24 h plus filgrastim 5 microg/kg on days 3-12 (arm 2, n=160). Starting doses were reduced for prior pelvic radiotherapy and age > 65 years. Both regimens were to be repeated every 3 weeks for a maximum of seven cycles.

RESULTS

There was no significant difference in response rate (40% versus 43%), PFS (median 7.2 versus 6 months) or OS (median 12.6 versus 13.6 months) for arm 1 and arm 2, respectively. Toxicities were primarily hematological, with 54% (arm 1) and 50% (arm 2) of patients experiencing grade 4 granulocytopenia. Gastrointestinal toxicities were similar in both arms.

CONCLUSIONS

Doxorubicin and 24-h paclitaxel plus filgrastim was not superior to doxorubicin and cisplatin in terms of response, PFS or survival in advanced endometrial cancer.

[Quality criteria for psychosomatic consultation-liaison service]

Besides the integrated psychosomatic models in various medical specialities (e.g. Internal medicine, Obstetrics and Gynaecology or Paediatrics), specific models of cooperation in the form of consultation-liaison (C-L) service between specialised psychosomatic-psychotherapeutic departments and other medical departments play a crucial role in providing psychosomatic care to patients. The concept 'liaison' expresses a particularly close form of cooperative activity, going far beyond the classical model of consultation services. In this context, the psychosomatic consultant has not only a fixed organised presence in the provision of patient care, he/she also participates in case discussions, hospital rounds, ward discussions and continuing education programmes of the 'partner' department. Thus, the liaison service is not only patient-centred, but also team-centred. Such consultation-liaison services, in Austria, were first established at the University Hospitals. As a consequence of laws regulating psychotherapeutic care, according to which such care is to be offered in general hospitals, increasingly C-L services are becoming part of regular care provision in more and more hospitals. Consensus groups, international as well as in German-speaking countries, are currently working on establishing quality standards in the area of psychosomatic C-L services. A working group of the scientific medical representatives has recently published guidelines for the structure, process and results of quality control. A second group, of the European Association of Consultation Liaison Psychiatry and Psychosomatics, is currently working on guidelines for training consultation-liaison service providers. In the present article, an overview of these projects will be presented and the results discussed against the background of the specific health policy situation in Austria.

Disposition of sulfadimethoxine in camels (Camelus dromedarius) following single intravenous and oral doses

Single-dose pharmacokinetics of sulfadimethoxine were determined in six adult camels (Camelus dromedarius) following administration of a mean dosage of 17.5 +/- 2.7 mg/kg both i.v. and p.o. Serial blood samples were collected through an indwelling jugular catheter intermittently for 5 days for both routes. Sulfadimethoxine was assayed using high-performance liquid chromatography. Serum drug concentration versus time data for each animal was subjected to linear regression, with the best-fit model selected based on residual analysis. The data fit best into a two-compartment open model, with first-order input for oral administration. For orally administered drug, mean maximum serum concentration of 19.3 +/- 1.7 microg/ml was reached at 11.41 +/- 2.59 hr, with an elimination rate constant of 0.09/hr +/- 0.05/hr and an elimination half-life of 11.7 +/- 3 hr. Mean peak serum concentration following i.v. administration was 223 +/- 48 microg/ml. Mean volume of distribution at steady state was 0.393 +/- 0.049 L/kg. Elimination rate constants differed with i.v. and oral administration, suggesting a flip-flop model. Oral bioavailability was 103% +/- 38%. Comparison of maximum serum concentrations to the microbial breakpoint concentration reported for sulfadimethoxine (512 microg/ml) suggests that the dose used in this study, 17.5 +/- 2.7 mg/kg, is insufficient for achieving therapeutic serum levels.

Mental disturbances and perceived complexity of nursing care in medical inpatients: results from a European study

AIMS AND OBJECTIVES

The relationship between mental disturbances - anxiety and depression, somatization and alcohol abuse - on admission to internal medicine units and perceived complexity of care as indicated by the nurse at discharge was studied. The goal was to study the utility of short screeners for mental disturbances to select patients for case-management on admission.

DESIGN

The study had a cohort design: patients were included on admission and followed through their hospital stay until discharge. The study was conducted within the framework of the European Biomed 1 Risk Factor study. RESEARCH METHODS AND INSTRUMENTS: In the first 3 days of admission the patients were interviewed by a trained health care professional, who scored the SCL-8D, a somatization questionnaire based on the Whiteley-7 and the CAGE. At discharge, nurses rated the complexity of the patient's care.

RESULTS

Patients with high scores on anxiety and depression (SCL-8D) and on somatization received higher ratings on perceived nursing complexity than those with low scores, with and without control for age, severity of illness and chronicity. The actual nursing intensity and medical care utilization, as measured daily by means of a checklist, could not explain these relations. No differences were found between patients with high or low scores on alcohol abuse.

CONCLUSIONS

The study shows a potential use of screeners for mental disturbances to detect patients for whom nurses might need additional help. However, mental disturbance is not the sole criterion: functional status and other variables that predict medical and nursing care utilization should be included in a screening strategy for case-management programmes.

No evidence for BCL10 mutation in endometrial cancers with microsatellite instability

Previous reports have suggested that the mononucleotide repeats in BCL10 frequently are mutated in both hematologic malignancies and solid tumors. We set out to determine whether these repeats, like simple repeat sequences in other genes, are a target for mutation in endometrial cancers with defective DNA mismatch repair. Primary endometrial cancers (n = 42) and endometrial cancer cell lines (n=5) with microsatellite instability (MSI) were investigated. BCL10 exons 2 and 3 were amplified by PCR and evaluated for mutation using denaturing high-performance liquid chromatography (DHPLC) and single stand conformational variant (SSCV) analysis. Variants were directly sequenced. No BCL10 mutations were detected in exons 2 or 3 by DHPLC or SSCV. A polymorphism in exon 3 (638G-->A) was seen in 4/42 (9.5%) MSI-positive endometrial cancers and 0/5 MSI-positive endometrial cancer cell lines. Thus, mutation in the mononucleotide repeat tracts of BCL10 is not a feature of endometrial cancers with defective DNA mismatch repair.

General anesthesia for interventional neuroradiology: propofol versus isoflurane

STUDY OBJECTIVE

To compare recovery of psychomotor and cognitive ability after isoflurane and propofol-based general anesthesia.

DESIGN

Prospective, blinded interventional study.

SETTING

University hospital.

PATIENTS

24 ASA physical status I and II patients undergoing embolization procedures for intracranial vascular lesions.

INTERVENTIONS

Isoflurane anesthesia or propofol anesthesia was given to patients.

MEASUREMENTS

Awakening time; early recovery (5 minutes, 15 minutes, 30 minutes) was assessed using orientation and Steward tests; medium recovery (30 minutes, 60 minutes, 120 minutes) was tested using Controlled World Association (COWAT) and Digit Span tests; late recovery (4 hours, 24 hours) was assessed using a Verbal Learning and Memory Test and three subtests of a computerized attention test battery.

MAIN RESULTS

Awakening time and early recovery of motor and respiratory function did not differ between groups. The propofol group scored worse in COWAT and Digit Span tests up to 60 minutes after anesthesia. Both groups showed an impairment of higher cognitive functions up to 24 hours after anesthesia.

CONCLUSIONS

Both isoflurane- and propofol-based anesthesia allow early extubation and recovery of basic psychomotor functions. More sophisticated tests show a decline of cognitive functions up to 24 hours after isoflurane- as well as propofol-based anesthesia. Because both anesthetics show similar recovery of psychomotor functions after long duration anesthesia, other factors such as subjective well-being and costs may be considered when deciding between these two anesthetics.

Individual dosing of ASA prophylaxis by controlling platelet aggregation

Acetylsalicylic acid is widely used in the primary and secondary prevention of cardiovascular diseases. In the current study, we used platelet aggregation ex vivo in platelet-rich plasma induced with arachidonic acid as a routine method for the determination of the individual dose of acetylsalicylic acid necessary to inhibit platelet aggregation in 108 patients with cardiovascular diseases. In 40% of all patients studied, a dose of 30 mg/day was sufficient to block the arachidonic acid-induced platelet aggregation nearly completely. In 50% of all patients, a dose of 100 mg/day was necessary. In 10% of all patients, the dose had to be further increased to 300 mg/day or even to 500 mg/day to inhibit platelet aggregation nearly completely. These results demonstrate that platelet aggregation can be used as a simple routine laboratory method to control acetylsalicylic acid treatment in patients with cardiovascular diseases and to determine individual doses of acetylsalicylic acid for a nearly complete inhibition of platelet aggregation. With a standard dose of 100 mg/day, 10% of the patients were nonresponders.

Referral pattern of neurological patients to psychiatric Consultation-Liaison Services in 33 European hospitals

The referral pattern of neurological patients to 33 European psychiatric consultation-liaison (C-L) services in the general hospital was examined. Analyses were conducted on the ECLW CS data set, which consists of 14,717 psychiatric C-L referrals made in 56 European hospitals during 1991. Psychiatric referrals of patients admitted to neurological wards were compared to referrals from other wards. Information was obtained from 33 neurological wards, consisting of 34,506 neurological admissions. Of these admissions, 839 were referred to C-L psychiatry. The median consult rate among the hospitals was 1.8%. Compared to other hospital wards, patients referred from neurology were more frequently diagnosed as suffering from somatoform (P<.01) and dissociative disorders (P<.01), and less from substance abuse (P<.01) and delirium (P<.01). Referral to C-L psychiatry from neurological wards is characterized by an underestimation of psychiatric co-morbidity and a late detection, comparable to other medical specialties. An appeal is made for a standardized referral procedure including admission screening method, detecting patients at risk for nonstandard care during their hospital admission.

COMPRI—An Instrument to Detect Patients With Complex Care Needs: Results From a European Study

The authors developed a screening instrument to detect patients in need of complex care coordination at admission to a general hospital. On the basis of a series of risk factors for care complexity, the authors constructed a short, care complexity prediction instrument (COMPRI) and assessed its qualities. The COMPRI is an easily administered screening instrument that detects patients at risk for complex care needs for whom care coordination is indicated. COMPRI's predictive power exceeds all currently available case-mix instruments.