Infection due to Paecilomyces lilacinus: a challenging clinical identification

We describe a case of noninvasive sinusitis caused by Paecilomyces lilacinus in a patient with diabetes mellitus. Cure was achieved by endoscopic drainage and aspiration of the fungal mass. We discuss the difficulty in and clinical importance of distinguishing Paecilomyces from Aspergillus.

[Impulse oscillometry and body position]

To assess diurnal profiles of impulse-oscillometry (IOS) changes of IOS-parameters between different body positions have been studied using a special set IOS-Bedside for individual home care. IOS has been applied in lateral lying and in sitting position in 20 healthy female and male probands, aged 10-67, during 24 hours in intervals of 3 hours. In each test during normal breathing for approximately 30 sec about 130 spectral and structural analyses have been performed at an impulse distance of 0.2 sec. The global means of resistance at 5 Hz (R5) in lying position are in men about 0.6 and in women about 0.3 hPa/l/s higher than in sitting position, those of reactance in men and women are only about 0.2 hPa/l/s lower. There is a distinct diurnal periodicity of the differences. The maxima of them may occur at different hours of the day in single probands; but at the average mean the maxima are found at the end of night. The differences of oscillation parameters between lying and sitting position are bigger at end-expiration than at end-inspiration. The resistance-flow-gradients, representing the component of turbulent flow, are enlarged in lying position especially at night.

[Diurnal profile of impulse oscillometric impedance in healthy subjects]

Diurnal profiles of impulse oscillometry during 24 hours in 3 hour intervals in sitting and lateral lying position have been studied in 20 healthy female and male probands 10-67 years of age. Approximating the profiles by a sine-cosine-function the amplitude of resistance was found up to 3, that of reactance up to 1 hPa/l/s in single cases, preferably for end-expiratory values and for the resistance-flow- and the resistance-volume-gradients, more pronounced in lying than in sitting position. The daytime reaching maxima of resistance and minima of reactance is different in single individuals. Single persons with obviously high vitality or sensibility showed very high amplitudes reproducible within IOS measuring limits of 0.2 hPa/l/s after 6 months.

Recurrent septicemias with Enterococcus faecium

A 17-year-old male patient with extrahepatic biliary atresia underwent an orthotopic liver transplantation in September 1994. In blood cultures drawn in November and (6 weeks later) December 1994, from bile secretions in May 1995, stool in June 1995 an wound abscess in August 1995, ampicillin-resistant Enterococcus faecium was isolated. Pulsed-field gel electrophoresis demonstrated the clonal identity of the isolates. To our knowledge, repeated infections with the same E. faecium strain over a period of 9 months have not been described before. As multiple-resistant enterococci may colonize and reinfect liver transplant recipients for such a long time, preoperative antibiotic therapy should be administered cautiously in order not to select these organisms.

Comparison of intravenous nutrients on gut mucosal proteins synthesis

BACKGROUND

Total parenteral nutrition (TPN) is associated with atrophy of the intestinal mucosa. This study compared the relative effectiveness of a short-chain fatty acid (butyrate), a physical mixture of medium-chain and long-chain triglycerides, structured lipid, and glutamine as components of a TPN regimen, and their ability to support mucosal protein synthesis.

METHODS

Rats were parenterally fed one of six isocaloric (1003 kJ/kg.d-1) and isonitrogenous (1.5 g.kg-1.d-1 of nitrogen) diets for 5 days. Diet 1, glucose 90% and long-chain triglycerides 10% (standard TPN); diet 2, glucose 50% and long-chain triglycerides 50%; diet 3, glucose 50% and a 50/50 physical mixture of long-chain and medium-chain triglycerides 50%; diet 4, glucose 50% and structured lipid 50%; diet 5, glucose 91% and sodium butyrate 9%; and diet 6, same as group 1 except that some of the amino acids were replaced with glycyl glutamine. A control group of rats also underwent catheter placement and were instead fed diet 1 orally for 5 days. Five days after catheterization, all rats were given a 4-hour constant infusion of [U-14C]leucine to determine the mucosal fractional protein synthesis rates.

RESULTS

(1) Mucosal fractional protein synthesis rates were much higher with the oral diet (control) than with any of the intravenous diets. (2) Diet-related differences in the mucosal fractional synthesis rates were found with the jejunum and the proximal and distal colon but not with the ileum. (3) Standard TPN was the least effective diet in supporting mucosal protein synthesis. (4) Structured lipid and butyrate were most effective for the jejunum. (5) For the colon, medium-chain triglycerides and structured lipid were most effective.

CONCLUSION

Standard TPN leads to a decrease in gut mucosal protein synthesis in rats, and this decrease can be partially attenuated by adding nutrients for the gut to the TPN mixture.

Glycerol kinetics with parenteral lipid emulsions (long-chain triglycerides, medium-chain triglycerides, and structured lipids) in rats

Several studies have reported that parenteral lipid emulsions containing medium-chain triglycerides (MCT) and structured lipids (SL) are better utilized than those containing long-chain triglycerides (LCT). The objective of this study was to test the hypothesis that parenteral LCT require more extensive modification via hydrolysis and reesterification (triglyceride-free fatty acid [TG-FFA] recycling) for effective utilization, whereas MCT and SL do not. As an index of TG-FFA cycling activity, we measured glycerol and palmitate kinetics in rats (204 to 243 g) fed parenterally one of three isocaloric (250 kcal/kg/d) isonitrogenous (1.5 g N/kg/d) diets with half of the nonprotein energy from glucose and the rest from either LCT, LCT plus MCT, or SL for 5 days. Two experiments were performed. On day 5, rats were given a 7-to 8-hour infusion of either 5H2 Glycerol and 1-14C Palmitate bound to albumin to measure palmitate and glycerol kinetics (experiment 1), or U-13C glucose to determine the proportion of endogenous glycerol production derived from glucose (experiment 2). Data are presented as means +/- SEM. Endogenous glycerol production was significantly higher with LCT (11.33 +/- 2.89 mmol/kg/h) than with SL (2.91 +/- 0.62 mmol/kg/h). The value for the physical mixture of LCT plus MCT (5.46 +/- 1.29 mmol/kg/h) fell midway between that for LCT and SL (P = NS). There were no significant differences in palmitate kinetics or oxidation. The increased glycerol production is due to the mobilization of endogenous triglyceride and is consistent with a higher rate of TG-FFA cycling being involved in the metabolism of LCT than of SL.(ABSTRACT TRUNCATED AT 250 WORDS)

Two cystic fibrosis patients with the genotype G542X/G551D

Two adult sisters affected by cystic fibrosis were both shown to carry two different alterations within exon 11 of the CFTR gene, the nonsense mutation G542X and the missense mutation G551D. Both patients exhibit a relatively benign clinical course. In the described patients, G542X functions as a "mild" allele and is, in this respect, dominant to the "severe" G551D.

Effect of excess xylitol on nitrogen and glucose metabolism in parenterally fed rats

The objectives of this study were to investigate the effects of an excess of xylitol on nitrogen balance and glucose metabolism in parenterally fed rats. Female Sprague-Dawley rats (200-250 g, n = 17) were catheterized for total parenteral nutrition and then randomized into two groups based on subsequent diet. The two diets used were isonitrogenous (1.5 g of nitrogen per kilogram per day) and isocaloric, with half the calories (125 kcal/kg per day) being derived from lipid (125 kcal/kg per day) and the other half from either glucose or xylitol (125 kcal/kg per day). The rats were fed a half-strength total parenteral nutrition diet for the day after surgery and a full-strength total parenteral nutrition diet for the following 4 days. Urines were collected daily for the determination of nitrogen balance. On day 5, the rats were given a 7- to 8-hour infusion of 6.6-d2 glucose (6 mg/h and 2-d1 glucose (12 mg/h). At the conclusion of the isotope infusion period, the rats were killed and blood was collected. Urine output was increased by 22% per day in the xylitol-treated rats, and they excreted 46.5 mmol of xylitol per liter per kilogram per day (7.1 g/kg per day, approximately 22.7% of dose). The xylitol group lost weight, had poorer nitrogen balance (341 +/- 31 vs 83 +/- 29 mg/kg per day [mean +/- standard error of the mean], p < .05), and developed fatty livers. Analysis of the liver fat distribution pattern indicated that the source of the excess hepatic lipid was dietary fat.(ABSTRACT TRUNCATED AT 250 WORDS)

A novel CFTR mutation, 4035delA, detected by non-radioactive SSCP analysis

German cystic fibrosis patients were screened for mutations in exon 21 of the cystic fibrosis transmembrane conductance regulator gene by a non-radioactive variation of the single-strand conformation polymorphism technique. Asymmetric polymerase chain reaction amplification was used to produce single strands of exon-containing genomic sequences that were analyzed on polyacrylamide gels subsequently stained with ethidium bromide. This rapid technique led to the identification of a novel mutation, a 1-bp deletion at position 4035(A) of the cDNA sequence. The patient, who is also heterozygous for the delta F508 mutation, exhibits an intermediate form of the disease.

Effect of bolus fluid intake on energy expenditure values as determined by the doubly labeled water method

The doubly labeled water (DLW, 2H(2)18O) method is a highly accurate method for measuring energy expenditure (EE). A possible source of error is bolus fluid intake before body water sampling. If there is bolus fluid intake immediately before body water sampling, the saliva may reflect the ingested water disproportionately, because the ingested water may not have had time to mix fully with the body water pool. To ascertain the magnitude of this problem, EE was measured over a 5-day period by the DLW method. Six subjects were dosed with 2H2(18)O. After the reference salivas for the two-point determination were obtained, subjects drank water (700-1,000 ml), and serial saliva samples were collected for the next 3 h. Expressing the postbolus saliva enrichments as a percentage of the prebolus value, we found 1) a minimum in the saliva isotopic enrichments were reached at approximately 30 min with the minimum for 2H (95.48 +/- 0.43%) being significantly lower than the minimum for 18O (97.55 +/- 0.44, P less than 0.05) and 2) EE values calculated using the postbolus isotopic enrichments are appreciably higher (19.9 +/- 7.5%) than the prebolus reference values. In conclusion, it is not advisable to collect saliva samples for DLW measurements within approximately 1 h of bolus fluid intake.

Community-based treatment of psychiatric disorders in U.S.A. and Norway: insights for new service delivery systems

This article reports on a successful community-based psychiatric treatment program in Philadelphia, Pennsylvania and describes subsequent experiences seeking approval of similar programs in Philadelphia and in Oslo, Norway. Previous studies have shown that the Philadelphia community-based program, which used patient social networks and indigenous community workers assisted by psychological and psychiatric professionals, provided better treatment outcomes than traditional hospital programs and socioenvironmental treatment programs. On the basis of these experiences a new service delivery system was proposed which integrates patient social networks, community workers, and lay community organizations with mental health center professionals. Examination of differences in official responses to the proposal shows the importance of several factors, including the mental health bureaucracy's perception of patient potential, their openness to social psychological therapy, and the power struggles within the bureaucracy and the professional community.

Automated sulfur hexafluoride washout functional residual capacity measurement system for any mode of mechanical ventilation as well as spontaneous respiration

A new sulfur hexafluoride (SF6) washout functional residual capacity (FRC) measurement system has been developed which will work with any mode of mechanical ventilation, as well as with spontaneous respiration. This system was evaluated in three different human studies. In the first two studies, the accuracy of the system was compared with He dilution and body plethysmography in 12 spontaneously breathing normal volunteers and in 12 spontaneously breathing chronic obstructive pulmonary disease (COPD) patients. In the third study, the reproducibility and efficacy of using the system in the ICU was tested in 12 adult respiratory distress syndrome (ARDS) patients who were mechanically ventilated with PEEP. In the normal volunteers, there was no significant difference between the three measurement techniques. In the COPD group, there was an overall significant difference between measurement techniques (F[2,28] = 17.18, p less than .0001) and the rank of the magnitude of the FRC measurements from lowest to highest was SF6 washout, He dilution, and body plethysmography. There was a significant difference in accuracy between the COPD and normal volunteer groups (F[2,28] = 12.24, p less than .0002). There were a total of 1,227 FRC measurements made on the 12 ARDS patients. The number of FRC measurements per patient was 102 +/- 13 (SEM). The "stable" periods were 14 +/- 2 h long and ranged from 60 min to 63.5 h. The reproducibility for all 12 patients was 188 +/- 17 ml or 11.7 +/- 0.7%. This automated SF6 washout system should make routine FRC measurements in patients who are being mechanically ventilated simple and easy to do.(ABSTRACT TRUNCATED AT 250 WORDS)