Reversible agranulocytosis associated with oral terbinafine in a pediatric patient

We report a case of terbinafine-induced agranulocytosis in a pediatric patient. This effect was noted 4 weeks after starting terbinafine and resolved within 1 week without the institution of therapy with granulocyte colony-stimulating factor, a course similar to reports in adults. With the incidence of severe side effects still unclear in children, this case argues for continued blood surveillance during courses of terbinafine and for the confirmation of infection before initiation of the drug.

Outbreak of infection with extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a Mexican hospital

Thirty-one strains of Klebsiella pneumoniae (including 10 duplicates) from 21 septicemic pediatric patients (age, <2 months) were studied during a 4-month period (June to October 1996) in which the fatality rate was 62% (13 of 21). These isolates identified by the API 20E system yielded the same biotype. Pulsed-field gel electrophoresis experiments revealed the same clone in 31 strains. The isolates were multidrug-resistant but were still susceptible to ciprofloxacin, imipenem, and cefoxitin. A 135-kb plasmid was harbored in all of the isolates. No transconjugants were obtained that were resistant to ampicillin, cefotaxime, tetracycline, or gentamicin. Isoelectric focusing for beta-lactamases was performed on all strains, and three bands with pIs of 5.4, 7.6, and 8.2 were obtained. Of these, the pI 8.2 beta-lactamase had an extended-spectrum beta-lactamase phenotype. PCR amplification of both TEM- and SHV-type genes was obtained. The sequence analysis of the SHV PCR product indicated a mutation corresponding to the SHV-5 beta-lactamase.

Analysis of histones by on-line capillary zone electrophoresis-electrospray ionisation mass spectrometry

The on-line combination of capillary electrophoresis and electrospray ionisation mass spectrometry was applied for the determination of some basic histones from calf thymus. The separation performance of those basic proteins was significantly improved by coating the capillaries with hydroxypropylmethylcellulose. The coating appeared to mask effectively the underlying silanol groups thus avoiding undesirable adsorption of the histones onto the capillary walls, while it was also shown to be an effective way to avoid contamination of the mass spectrometer. Finally, capillary electrophoresiselectrospray ionisation mass spectrometry with coaxial sheath liquid was successfully applied to the analysis of histones using a simple dialysis step of the sample as sample pretreatment.

Monitoring of antifouling agents in water samples by on-line solid-phase extraction–liquid chromatography–atmospheric pressure chemical ionization mass spectrometry

An automatic method for determining diuron, irgarol 1051, folpet and dichlofluanid in seawater samples have been developed. This method is based on the on-line coupling of solid-phase extraction (SPE) with a highly crosslinked polymeric sorbent, LiChrolut EN, to liquid chromatography followed by atmospheric pressure chemical ionization (APCI) and mass spectrometry. The operational parameters affecting the APCI interface have been studied in both positive and negative ionization modes. The use of LiChrolut EN in the SPE produced recoveries of over 85% for all the compounds when 100 ml of seawater sample was preconcentrated. Calibration was carried out in both ionization modes and in full-scan and selected-ion monitoring (SIM). The method allowed all the analytes to be detected at 5 ng l(-1) in SIM acquisition mode except folpet, which, because of its low response, could only be detected at 250 ng l(-1). The method was used to analyse water samples taken from five different marina and fishing ports along the coast of Tarragona, Catalonia (Spain), over a 5-month period. Diuron and irgarol 1051 were detected and quantified in most samples at concentration levels ranging from 27 to 420 ng l(-1) for diuron and from 15 to 511 ng l(-1) for irgarol 1051.

An emerging role for interferon in haemophiliacs with chronic hepatitis C?

The combination of interferon (IFN) and ribavirin is the current gold standard for treatment of chronic hepatitis C virus (HCV) infection with sustained remission rates of 35--40% being achieved in haemophilic patients. A similar beneficial effect of this combined therapy has been suggested even for patients with compensated liver cirrhosis and some authors have reported a possible role for IFN and ribavirin in the prevention or delay in the development of hepatocellular carcinoma (HCC), a well known complication of HCV infection in haemophiliacs. The absence, due to design difficulties, of definite randomized controlled clinical trials remains a handicap for the routine use of specific therapy of HCV infected patients with the aim of preventing HCC. A discussion of these important issues has been performed in this paper.

Cryofibrinogenaemia with a good response to stanozolol

We report a 63-year-old patient with an IgA-kappa multiple myeloma in complete remission who developed necrotic lesions on both ears and papular, purpuric lesions on his legs and cheeks. Initial differential diagnosis included perniosis and skin necrosis secondary to interferon treatment but subsequent investigation revealed cryofibrinogenaemia as the underlying cause. Stanozolol therapy, 2 mg/12 h, achieved a complete clearance of the skin lesions. Cryofibrinogenaemia is a disease which can be under-diagnosed unless it is considered in the work-up of a patient with thrombotic skin lesions. Stanozolol is useful as first line therapy for this disorder.

sigma(54) Promoters control expression of genes encoding the hook and basal body complex in Rhodobacter sphaeroides

Gene expression of the flagellar system is tightly controlled by external stimuli or intracellular signals. A general picture of this regulation has been obtained from studies of Salmonella enterica serovar Typhimurium. However, these regulatory mechanisms do not apply to all bacterial groups. In this study, we have investigated regulation of the flagellar genetic system in Rhodobacter sphaeroides. Deletion analysis, site-directed mutagenesis, and 5'-end mapping were conducted in order to identify the fliO promoter. Our results indicate that this promoter is recognized by the factor sigma(54). Additionally, 5'-end mapping of the flgB and fliK transcripts suggests that these mRNAs are also transcribed from sigma(54) promoters. Finally, we showed evidence that suggests that fliC transcription is not entirely dependent on the presence of a complete basal body-hook structure. Our results are discussed in the context of a possible regulatory hierarchy controlling flagellar gene expression in R. sphaeroides.

Effect of D-002 on gastric mucus composition in ethanol-induced ulcer

This study was designed to determine the effect of D-002, a natural product isolated and purified from beeswax (Apis mellifera), on gastric mucus composition on ethanol-induced ulcer in rats. The morphology of the lesions was analysed histologically, and morphometric analysis of gastric-gland content in total glycoprotein and sulphated macromolecules were done. Oral pretreatment with D-002 at 5 and 25 mgkg(-1)1 before oral administration of ethanol at 60%, produced a significant increase in the amount of gastric mucus and total protein. The histomorphometric evaluation of the gastric damage at the same doses showed a significant increase in neutral glycoproteins and sulfated macromolecules. It is concluded that enhancement of the quantity and quality of the mucus could partly explain the gastroprotective effect of D-002.

A systematic review of newer pharmacotherapies for depression in adults: evidence report summary

BACKGROUND

Depressive disorders are persistent, recurring illnesses that cause great suffering for patients and their families.

PURPOSE

To evaluate the benefits and adverse effects of newer pharmacotherapies and herbal treatments for depressive disorders in adults and adolescents.

DATA SOURCES

English-language and non-English-language literature from 1980 to January 1998 was identified from a specialized registry of controlled trials, meta-analyses, and experts.

STUDY SELECTION

Randomized trials evaluating newer antidepressants (such as serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and St. John's wort) that reported clinical outcomes were selected.

DATA EXTRACTION

Two persons independently abstracted data that were then synthesized descriptively; some data were pooled by using a random-effects model.

DATA SYNTHESIS

Of 315 eligible trials, most evaluated antidepressants in adults with major depression, were conducted among outpatients, and examined acute-phase treatment. Newer antidepressants were more effective than placebo for major depression (relative benefit, 1.6 [95% CI, 1.5 to 1.7]) and dysthymia (relative benefit, 1.7 [CI, 1.3 to 2.3]). They were effective among older adults and primary care patients. Efficacy did not differ among newer agents or between newer and older agents. Hypericum (St. John's wort) was more effective than placebo for mild to moderate depression (risk ratio, 1.9 [CI, 1.2 to 2.8]), but publication bias may have inflated the estimate of benefit. Newer and older antidepressants did not differ for overall discontinuation rates, but side effect profiles varied significantly. Data were insufficient for determining the efficacy of newer antidepressants for subsyndromal depression, depression with coexisting medical or psychiatric illness, or depression in adolescents.

CONCLUSIONS

Newer antidepressants are clearly effective in treating depressive disorders in diverse settings. Because of similar efficacy, both newer and older antidepressants should be considered when making treatment decisions. Better information is urgently needed on the efficacy of newer antidepressants in patients with nonmajor depression and in special populations, including adolescents.

TLA-1: a new plasmid-mediated extended-spectrum beta-lactamase from Escherichia coli

Escherichia coli R170, isolated from the urine of an infected patient, was resistant to expanded-spectrum cephalosporins, aztreonam, ciprofloxacin, and ofloxacin but was susceptible to amikacin, cefotetan, and imipenem. This particular strain contained three different plasmids that encoded two beta-lactamases with pIs of 7.0 and 9.0. Resistance to cefotaxime, ceftazidime, aztreonam, trimethoprim, and sulfamethoxazole was transferred by conjugation from E. coli R170 to E. coli J53-2. The transferred plasmid, RZA92, which encoded a single beta-lactamase, was 150 kb in length. The cefotaxime resistance gene that encodes the TLA-1 beta-lactamase (pI 9.0) was cloned from the transconjugant by transformation to E. coli DH5alpha. Sequencing of the bla(TLA-1) gene revealed an open reading frame of 906 bp, which corresponded to 301 amino acid residues, including motifs common to class A beta-lactamases: (70)SXXK, (130)SDN, and (234)KTG. The amino acid sequence of TLA-1 shared 50% identity with the CME-1 chromosomal class A beta-lactamase from Chryseobacterium (Flavobacterium) meningosepticum; 48.8% identity with the VEB-1 class A beta-lactamase from E. coli; 40 to 42% identity with CblA of Bacteroides uniformis, PER-1 of Pseudomonas aeruginosa, and PER-2 of Salmonella typhimurium; and 39% identity with CepA of Bacteroides fragilis. The partially purified TLA-1 beta-lactamase had a molecular mass of 31.4 kDa and a pI of 9.0 and preferentially hydrolyzed cephaloridine, cefotaxime, cephalothin, benzylpenicillin, and ceftazidime. The enzyme was markedly inhibited by sulbactam, tazobactam, and clavulanic acid. TLA-1 is a new extended-spectrum beta-lactamase of Ambler class A.

Extended-spectrum beta-lactamases in clinical isolates of enterobacteria in Mexico

Resistance to extended-spectrum cephalosporins within members of the family Enterobacteriaceae occurs virtually world-wide. Nevertheless, nothing was known about this problem among isolates from Mexico. To address this issue, we studied oximino-cephalosporin resistant isolates of Klebsiella pneumoniae (13), Escherichia coli (7), and Enterobacter cloacae (23) recovered from patients in Mexico City hospitals during 1990 to 1992. In the presence of clavulanic acid, these strains increased susceptibility to cefotaxime and ceftazidime (MIC90 64 and >256 microg/ml, respectively). The ability of these isolates to transfer resistance to both antibiotics by conjugation was most successfully demonstrated by K. pneumoniae. In all the clinical isolates tested, the largest plasmid coded for the extended-spectrum beta-lactamases (ESBL). Characteristics of pI, by isoelectric focusing (IEF)/bioassay and DNA hybridization with specific probes of TEM and SHV, indicated that in most of the clinical isolates and all transconjugates, the most frequent beta-lactamase coded were SHV-derived (20 strains as 41% of isolates) and a plasmid-encoded beta-lactamase (12 strains as 25% of isolates) (with a pI of >8.2), which is not related to TEM/SHV. Apparently, isolates from Mexico show characteristics similar to isolates from other geographic areas. The type of beta-lactamases coded in these resistant isolates is documented for the first time in Mexico.

Comparison of the minimum fungicidal concentration of amphotericin B determined in filamentous fungi by macrodilution and microdilution methods

Minimum fungicidal concentration (MFC) determination could be useful in severe fungal infections in immunocompromised patients. No reference tests to determine the MFC are available, and both macro- and microdilution methods are commonly used. In this study, discrepancies between minimum inhibitory concentrations (MICs) and MFCs of amphotericin B against 58 isolates of filamentous fungi other than Aspergillus (46 Fusarium spp., six Paecilomyces spp. and six Scopulariopsis spp.), obtained with macro- and microdilution methods, were evaluated. Additionally, the agreement between MFCs obtained by both methods were analyzed. In general MFCs were higher than the corresponding MICs overall using the macrodilution method. MFCs were more than one dilution higher than MICs in 52.3% of the cases in the macrodilution test and in 20.5% of the cases in microdilution test. The degree of agreement between MFCs obtained with the two methods was of 70.4% (Kappa coefficient of 0.5). In general, the macrodilution method showed higher MFC values than the microdilution method. Differences of up to six drug dilutions were observed between MFCs obtained by both methods.

Comparison of three methods of determining MICs for filamentous fungi using different end point criteria and incubation periods

Three different methods were used to determine the in vitro activities of amphotericin B, ketoconazole, itraconazole, and flucytosine against 30 isolates of different genera of filamentous fungi. MICs were determined visually, with or without agitation, and spectrophotometrically by using a broth microdilution method. For amphotericin B, there was one end point reading criterion (the minimum concentration of antifungal that inhibited 100% of growth), but for azoles and flucytosine there were two (the minimum concentrations that inhibited 50 and 75% of fungal growth, respectively) after 48 and 72 h of incubation. All tests were performed in triplicate. An intraclass correlation coefficient (ICC) was used to evaluate the reproducibility of each of the methods and the correlation among them. The reproducibility of the three methods was very high (ICC of 0.808 to 0.992), particularly in the case of azoles and flucytosine. In general, the degree of reproducibility was highest for azoles and amphotericin B after 72 h of incubation and for flucytosine after 48 h of incubation. The degree of correlation among the three methods was very high (ICC of >0.98) with all of the antifungals under all the conditions tested. The end point reading criteria and the time of incubation affected neither the reproducibility of the methods nor their correlation, and their effect on MICs was statistically significant.

On-line coupling of equilibrium-sorptive enrichment to gas chromatography to determine low-molecular-mass pollutants in environmental water samples

On-line combination of equilibrium sorptive enrichment and gas chromatography is used for the analysis of a group of pollutants varying widely in polarity and volatility in aqueous samples at trace levels. For the ESE process open-tubular traps were used. The newly developed hyphenated method shows a high sensitivity for all the compounds under study. The detection limits were typically between 0.1 and 1 microg/l. The sample volumes required for the compounds to reach equilibrium with the stationary phase are in the range of 20 ml for the aromatic hydrocarbons included in the study (benzene, toluene and p-xylene), to 200 ml for epichlorohydrin and dichlorohydrin. Within- and between-day precision of the absolute peak areas varied between 3 and 16%. The performance of the new method was tested by the analysis of different environmental water samples.

Efficacy of newer medications for treating depression in primary care patients

PURPOSE

Several medications have recently been introduced for the treatment of depression. We reviewed the literature to summarize their efficacy in the treatment of depression in adult patients in primary care settings.

METHODS

We searched the literature published from 1980 to January 1998 using the Cochrane Collaboration Depression Anxiety and Neurosis Group's specialized registry of 8,451 clinical trials, references from trials and 46 pertinent meta-analyses, and consultation with experts. We included randomized controlled trials of at least 6 weeks' duration that measured clinical outcomes and compared one of 32 newer medications with another newer antidepressant, an older antidepressant, a placebo, or a psychosocial intervention for the treatment of depressed patients in primary care settings. The primary outcome was response rate, defined as the proportion of patients experiencing a 50% or greater improvement in depressive symptoms.

RESULTS

There were 28 randomized controlled trials involving 5,940 adult primary care patients with major depression, depression requiring treatment, dysthymia, or mixed anxiety depression. Newer agents, including selective serotonin re-uptake inhibitors, serotonin norepinephrine inhibitors, reversible inhibitors of monoamine oxidase, and dopamine antagonists, were usually compared with tricyclic agents. Average response rates were 63% for newer agents, 35% for placebo, and 60% for tricyclic agents. Newer agents were significantly more effective than placebo [risk ratio = 1.6; 95% confidence interval (CI), 1.2 to 2.1), but similar to tricyclic agents (risk ratio = 1.0; 95% CI, 0.9 to 1.1). Response rates were similar in the different types of depressive disorders, except that two small trials in frail older patients showed no significant effects of newer agents compared with placebo. Dropout rates as a result of adverse effects were 8% with newer agents and 13% with tricyclic agents (P <0.05).

CONCLUSIONS

In primary care settings, newer antidepressants are more effective than placebo and have similar efficacy compared with tricyclic agents in the acute treatment of depression. Dropout rates as a result of adverse effects are lower with newer compared with tricyclic agents. Future studies should compare the effectiveness of different therapies among primary care patients with less severe depression and greater medical and psychiatric comorbidity.

Mycotic keratitis due to Curvularia senegalensis and in vitro antifungal susceptibilities of Curvularia spp

A case of mycotic keratitis due to Curvularia senegalensis is reported. This case represents the third known reported infection caused by this rare species. Fungal hyphae were detected in corneal scrapings, and repeated cultures were positive for this fungi. The patient was presumed cured after a corneal transplant and treatment with itraconazole, but the infection recurred and the patient is waiting for a keratoplasty. The in vitro antifungal susceptibilities of the case strain and another 24 strains belonging to seven species of Curvularia were tested for six antifungal agents. With the exception of flucytosine, and occasionally fluconazole, the other drugs assayed (amphotericin B, miconazole, itraconazole, and ketoconazole) were highly effective in vitro.