Endometriosis and dyspareunia: Solving the enigma

Introduction

Endometriosis is a chronic oestrogen-dependent disease that affects 1 in 10 women of childbearing age. Half of these women have deep dyspareunia. The presence of this symptom has been shown to negatively affect your quality of life. There are few studies in the literature that address this issue and its pathophysiology remains poorly understood.

Materials and methods

A case-control study has been carried out in order to assess the multi-causality of dyspareunia in patients with endometriosis. All the patients were assessed in a unit specialising in endometriosis and pelvic pain and their disease was staged using high-resolution ultrasound following the criteria of the IDEA group. The patients were divided into two groups, patients with dyspareunia n = 45 (cases) and those without it n = 55 (controls).

Results

The only element that was statistically significant in explaining the dyspareunia was the presence of nodules in the retrocervical region with p = 0.000. The odds ratio of dyspareunia in the cases group was 5.3 (95 % CI 2.2-12.5).

Conclusions

Dyspareunia in patients with endometriosis is strongly dependent on the presence of nodules in the retrocervical region, although there are other factors involved that remain unknown, so more studies are still needed to understand and optimally address this symptom.

Challenges in chronic pelvic pain: Diffuse uterine capillary haemangioma simulating a clinical picture of adenomyosis

Introduction:

Adenomyosis is a heterogeneous condition of difficult diagnosis that stands out in our patients for causing abundant menstrual bleeding, dyspareunia and dysmenorrhoea. However, in chronic pelvic pain units it is important to consider other conditions of similar symptomatologies, such as vascular malformations. These include capillary haemangiomas which, although rare in the reproductive tract, can produce serious symptoms.

Case description:

We present the case of a 31-year-old woman under observation by the chronic pelvic pain unit for dysmenorrhoea and dyspareunia since menarche. Ultrasound and magnetic resonance findings were compatible with adenomyosis. The patient showed no improvement with hormonal treatment. Upon failure of the medical treatment and taking into account the patient’s lack of gestational desire, a laparoscopic hysterectomy was performed. The pathological report revealed a diffuse capillary haemangioma as the cause of the symptoms. Given the completely curative nature of surgery for this type of condition, the patient was discharged from our unit.

Conclusion:

The preoperative diagnosis of adenomyosis is still a challenge and units specializing in chronic pelvic pain must consider all possible diagnostic options so as not to overlook rarer conditions such as vascular malformations.

Factors predictive of overall health over the course of the disease in patients with systemic lupus erythematosus from the LUMINA cohort (LXII): use of the SF-6D

OBJECTIVE

Health related quality of life (HRQOL) over course of the disease was ascertained in SLE patients from LUMINA, a multiethnic US cohort, using the SF-36-derived utility measure, the SF-6D.

METHODS

All available visits were examined to predict HRQOL using either variables from the baseline or enrollment visits or from the preceding visits. The physical and mental component summary (PCS and MCS, respectively) measures of the SF-36 were also examined. A total of 2662 visits from 588 SLE patients were included; 90% of the patients were women, 19% Hispanic-Texans, 17% Hispanic-Puerto Ricans, 35% African Americans and 29% Caucasians. The patients' mean (SD) SF-6D was 0.6 (0.1).

RESULTS

In multivariable analyses, Hispanic-Texan ethnicity and higher levels of social support were predictors of HRQOL whereas older age, poverty, greater disease activity and damage and higher levels of fatigue, helplessness and abnormal illness-related behaviors were negative predictors. Prior SF-6D was the strongest variable predictive of subsequent HRQOL, when included. The analyses in which the PCS and MCS were examined as end-points were, overall, consistent with the SF-6D results.

CONCLUSION

We conclude that the SF-6D index provides an adequate measure of self-perceived HRQOL and that patients' self-perception of HRQOL is influenced by disease and non-disease related factors.

2-Methoxyestradiol attenuates hypertension and coronary vascular remodeling in spontaneously hypertensive rats

OBJECTIVES

Accumulating data provide evidence that some metabolites of 17beta-estradiol are biologically active and mediate multiple effects on the cardiovascular and renal systems. We investigated the effect of 2-methoxyestradiol (an active metabolite of estradiol with non-feminizing activity) on the development of hypertension and myocardial vascular remodeling in male and female ovarectomized SHR.

METHODS

Rats were divided into five groups: intact females, ovarectomized (OVX), OVX+ 2-methoxyestradiol (2ME), control males, and male+2ME. Systolic blood pressure was determined from 10 to 18 weeks. Structural changes in coronary vessels were quantified by an image analyzer. Immunoblotting of phosphorylated ERK1/2 and NADPH oxidase activity were performed on mesenteric arteries.

RESULTS

Treatment with 2ME reduced the increase in systolic blood pressure in male and ovarectomized rats to values not different from those obtained in intact females. Myocardial arterioles and small arteries showed significant increases in wall-to-lumen ratio and perivascular fibrosis in male and ovarectomized rats when compared with intact females. NADPH oxidase activity was increased in mesenteric arteries from males and ovarectomized females as compared with intact females. Finally, the expression of phosphorilated ERK1/2 were significantly higher in mesenteric arteries from male and ovariectomized animals than in those from intact females. Those effects of ovarectomy and gender differences were totally or partially prevented by treatment with 2-methoxyestradiol.

CONCLUSIONS

These data demonstrate that 2-methoxyestradiol protects the vasculature from hypertension-induced myocardial arterial remodeling in male and ovarectomized SHR, and that might be in part related to decreased superoxide generation and ERK1/2 activation.

Thermal annealing dependence of high-frequency magnetoimpedance in amorphous and nanocrystalline FeSiBCuNb ribbons

The magnetoimpedance (MI) effect in Fe73.5Si13.5B9Nb3Cu1 melt-spun amorphous ribbons has been studied in the frequency range (1-500 MHz). Isothermal heating treatments in a furnace have been employed to nanocrystallize the ribbons (1 h at 565 degrees C in a vacuum of 10(-3) mbar), while other samples were annealed at lower temperatures (400 and 475 degrees C during 1 h), in order to evaluate the influence of the annealing temperature on the MI effect. The high-frequency impedance was measured using a technique based on the reflection coefficient measurements of a specific transmission line by using a network analyzer. Frequency dependence of the MI ratio, DeltaZ/Z, and both resistive, DeltaR/R, and reactive, DeltaX/X, components of magnetoimpedance were measured in the amorphous and annealed states, at different temperatures. A maximum value of the MI ratio of about 50% at a driving frequency of 18 MHz is obtained in the nanocrystalline (annealed at 565 degrees C) ribbon. Maxima for DeltaR/R of about 81% at 85 MHz and DeltaX/X around 140% at 5 MHz were also achieved. It is revealed that the microstructural evolution in the nanocrystalline sample leads to a magnetic softening, an optimum domain structure and a permeability which is sensitive to frequency and applied magnetic field, generating a large MI response.

Adverse pregnancy outcomes in women with systemic lupus erythematosus from a multiethnic US cohort: LUMINA (LVI) [corrected]

OBJECTIVE

To study the factors associated with an adverse pregnancy outcome in women with systemic lupus erythematosus (SLE).

METHODS

SLE women from LUMINA of Hispanic, African American and Caucasian ethnicity were studied. Adverse pregnancy outcome was a miscarriage or abortion (<20 weeks), a stillbirth (> or = 20) and/or a moderate to severe preterm-baby (<34 weeks); good outcome was either a mild preterm-baby (> or = 34 weeks) or a full-term baby [C-section or vaginal delivery (38-42 weeks)]. Pregnancies occurring after SLE diagnosis (TD) were included; pregnancy outcome was the unit of analyses. The relationship between selected variables and pregnancy outcomes was examined by univariable and multivariable analyses.

RESULTS

Adverse outcomes occurred in 63.7% of 102 pregnancies. In the univariable analyses, Texan Hispanic and African American ethnicities, fewer years of education, higher number of ACR criteria, renal involvement, glucocorticoid exposure and the maximum dose of glucocorticoids used prior to the pregnancy outcome were associated with an adverse pregnancy outcome. Renal involvement was independently associated with an adverse pregnancy outcome [Odds ratio (OR)=5.219 (95% Confidence Interval (CI) 1.416-19.239, p=0.0131] as were the maximum dose of glucocorticoids used prior to the pregnancy outcome (OR=1.028; CI:1.002-1.054; p=0.0315) and fewer years of education (OR=1.204; CI:1.006-1.472; p=0.0437). Ethnicity was not retained in the multivariable model.

CONCLUSION

Renal involvement, the maximum dose of glucocorticoids used prior to pregnancy and fewer years of education were associated with adverse pregnancy outcomes. These data have implications for the management of women with lupus planning to become pregnant.

Predictors of post-partum damage accrual in systemic lupus erythematosus: data from LUMINA, a multiethnic US cohort (XXXVIII)

OBJECTIVE

To determine the impact of pregnancy on systemic lupus erythematosus (SLE) outcome.

METHODS

SLE patients, age >or=16 yrs, disease duration <or=5 yrs at enrolment in LUMINA, a multiethnic cohort (Hispanics, African-Americans and Caucasians), were studied. The first pregnancy after SLE diagnosis was examined. A good pregnancy outcome was a full-term delivery; an adverse outcome was a miscarriage, abortion, premature birth or stillbirth. Dependent variables were disease activity (Systemic Lupus Activity Measure-Revised, SLAM-R) and damage accrual [Systemic Lupus International Collaborating Clinics (SLICC) Damage Index, SDI]. Differences in these variables between the visit immediately prior to, and the first visit after, pregnancy and their relationship with pregnancy outcome were examined. Damage accrual due to pregnancy exposure was examined by a case-crossover design.

RESULTS

Sixty-three SLE women from all ethnic groups were included. The mean (S.D.) age and disease duration at pregnancy outcome were 27.6 (6.5) yrs and 18.3 (22.5) months, respectively. Adverse pregnancy outcomes occurred in 76.2% women. The SLAM-R and SDI scores were statistically different after pregnancy (P = 0.050 and P < 0.001, respectively); the SDI score was independent of pregnancy outcome but strongly associated with pregnancy duration (P = 0.006), disease activity (P = 0.001), damage prior to pregnancy (P < 0.001) and total disease duration (P = 0.039) by multivariable analyses. Exposure to pregnancy itself did not impact on damage accrual in the case-crossover analyses of 142 patients (17 pregnancy exposures) (OR = 1.25; 95% CI 0.336-4.655; P = 0.480).

CONCLUSIONS

Pregnancy duration, total disease duration, disease activity and damage immediately prior to pregnancy decisively impact on damage accrual after pregnancy in patients with SLE.

Systemic lupus erythematosus in a multiethnic U.S. cohort (LUMINA) XXXI: factors associated with patients being lost to follow-up

The objective of this study was to determine the frequency of loss to follow-up and the factors predictive of its occurrence in a systemic lupus erythematosus (SLE) multiethnic cohort. We studied SLE patients from the LUMINA cohort (Hispanics from Texas and from the Island of Puerto Rico, African-Americans and Caucasians). Loss to follow-up was defined as subjects who failed to attend two or more of the latest consecutive yearly study visits. The relationship between baseline features and loss to follow-up was examined by univariable and multivariable Cox regression analyses with loss to follow-up as the dependent variable. The retention rate in the cohort was estimated by the Kaplan-Meier method. Five-hundred and fifty-four patients with a mean (SD) follow-up of 3.4 (2.9) years were studied. One-hundred and fifty-eight (29%) met the definition of lost to follow-up. The cumulative loss to follow-up rate at five years was 36%. The cumulative loss to follow-up rate at five years was higher for the African-Americans. Patients lost to follow-up tended to be younger and more likely to have poor social support and higher levels of helplessness. They also tended to have more renal involvement and more active disease as per the Systemic Lupus Activity Measure-Revised. Disease activity (hazard ratio = 1.04, 95% confidence interval 1.01-1.07, P = 0.02) was the only variable independently contributing to loss to follow-up. Our data suggest that in longitudinal SLE studies, loss to follow-up does not occur at random and it differs between ethnic groups and is also particularly higher among patients with more active disease. Pro-active measures may need to be applied to decrease the probability of patients 'at risk' of becoming lost to follow-up and to preserve the integrity of the cohort.

Association of HLA-DM polymorphism with the production of antiphospholipid antibodies

OBJECTIVE

To investigate whether variation in the HLA-DM gene is important in producing a group of pathogenic autoantibodies-antiphospholipid antibodies (aPL)-on the basis that HLA class II restricted antigen presentation is involved in the production of aPL.

METHODS

HLA-DMA and DMB polymorphisms were genotyped by polymerase chain reaction combined with restriction enzyme digestion in 51 white patients with primary antiphospholipid syndrome (APS), 82 with systemic lupus erythematosus (SLE) (42 with APS and 40 without APS), and 109 healthy white controls. The association with the aPL profile was examined.

RESULTS

The distribution of DMA alleles in APS patients and in patients with APS associated with SLE was significantly different from that in controls by 4x2 chi(2) test with 3 degrees of freedom (p = 0.035 and 0.011, respectively), but it was not different between SLE patients without APS and controls. The allelic distribution of DMA was also different between patients with IgG class anticardiolipin antibody or those with lupus anticoagulant (LA) and controls (p = 0.012 and 0.007, respectively) and between patients with and without LA among SLE patients (p = 0.035). All these differences included the increase in DMA*0102 in the former groups.

CONCLUSIONS

The results suggest that HLA-DMA*0102 or its linked gene(s) form one of the genetic risks for the production of aPL.

Can the weighted criteria improve our ability to capture a larger number of lupus patients into observational and interventional studies? A comparison with the American College of Rheumatology criteria

The objective of this study was to determine if the modified weighted criteria have better psychometric properties than the ACR criteria for the classification of patients with systemic lupus erythematosus (SLE). A computerized list of all patients with the diagnosis of SLE (ICD9 code 710.0) attending an outpatient rheumatology clinic was generated and their medical records reviewed. The attending rheumatologists validated the diagnosis of SLE; this assessment was used as the gold standard to compute the sensitivity, specificity and accuracy of both the American College of Rheumatology (ACR) and the modified weighted criteria. A total of 363 patients were identified and included in the study. Ninety percent were women; the mean age was 44.0 (+/- 14.4) years, and 51% were Caucasians. The modified weighted criteria had a sensitivity of 90.3% and specificity of 60.4%. The ACR criteria had a sensitivity of 86.5% and specificity of 71.90%. Both methods had comparable positive and negative predictive values as well as similar overall accuracy. The modified weighted criteria allow the identification of more lupus patients for clinical or interventional studies; some of these patients, however, may not have SLE according to experienced rheumatologists.

Comparative analysis of the morphological, cytochemical, immunophenotypical, and functional characteristics of normal human peripheral blood lineage(-)/CD16(+)/HLA-DR(+)/CD14(-/lo) cells, CD14(+) monocytes, and CD16(-) dendritic cells

Human peripheral blood (PB) CD14(lo)/HLA-DR(+) cells were initially described as a subset of mature monocytes. Recently, it has been suggested that these represent a part of a new subset of dendritic cells (DC), characterized by the coexpression of MDC-8/HLA-DR/CD16. The aim of the present paper was to analyze the morphological, cytochemical, phenotypical, and functional characteristics of PB CD16(+)/HLA-DR(+) cells compared to both PB CD14(+) monocytes and CD16(-) DC. In contrast to CD14(+) monocytes, purified CD16(+)/HLA-DR(+) cells displayed cytoplasmic veils and lacked cytoplasmic myeloperoxidase and alpha-naphthyl acetate esterase. Normal human PB CD16(+)/HLA-DR(+) cells also displayed phenotypic characteristics different from those of CD14(+) monocytes: they lacked the CD64 Fcgamma receptor, showed lower levels of CD32, and expressed higher amounts of CD16 compared to CD14(+) monocytes. They also displayed a different pattern of expression of other antigens, including CD14, HLA-DR, CD45RA, CD45RO, complement receptors and complement regulatory surface proteins, adhesion and costimulatory molecules, and cytokine receptors, among others. When compared to CD16(-) DC, CD16(+)/HLA-DR(+) cells showed reactivity for CD16, dim positivity for CD14, higher expression of both Ig- and complement-receptors and lower reactivity for HLA-DR, adhesion, and costimulatory molecules (with the exception of CD86). The CD16(+)/HLA-DR(+) cell subset displayed a higher Ig/complement-mediated phagocytic/oxidative activity than CD16(-) DC, although this activity was significantly lower than that of mature monocytes. Regarding cytokine production at the single cell level, LPS plus IFN-gamma-stimulated PB CD16(+)/HLA-DR(+) cells produced significant amounts of IL1beta, IL6, IL12, TNFalpha, and IL8; however, the percentage of cytokine-producing cells and the amount of cytokine/cell were lower in CD16(+)/HLA-DR(+) cells than in CD14(+) monocytes. In addition, upon comparing CD16(+)/HLA-DR(+) cells with CD33(+++)/CD16(-) DC, we found that the percentage of cytokine-producing cells and the amount of cytokine/cell were significantly different in both cell subsets. In summary, our results show that CD16(+)/HLA-DR(+) cells clearly display different morphologic, cytochemical, immunophenotypical, and functional characteristics compared to both mature monocytes and CD16(-) DC. Interestingly, these cells are more frequent than other DC in normal human adult PB and cord blood samples, while they are less represented in normal bone marrow.

Two-dimensional echo Doppler findings in juvenile and adult onset ankylosing spondylitis with long-term disease

The authors' objective was to determine by 2-dimensional echo Doppler (2DECHO) the cardiac abnormalities in juvenile onset ankylosing spondylitis (JOAS) and adult onset ankylosing spondylitis (AOAS) in male patients with long-term disease. Twenty patients with JOAS, 31 with AOAS, and 20 healthy controls of the same age and gender without cardiopulmonary symptoms were studied. Using 2DECHO, the heart dimensions were determined according to American Society of Echocardiography guidelines. The left ventricle ejection fraction (LVEF) was calculated by Teichholz's formula. Cardiomyopathy was established when 2DECHO had diminished LVEF. Statistics used were the Student t and Fisher test, chi2, and ANOVA. Ninety percent of JOAS and 51% of AOAS patients were B27+ (p=0.005). The disease duration was 19.3 +/- 8.8 years in JOAS and 14.8 +/- 12.8 years in AOAS (p=NS). Age at the time of the study was 30.7 +/- 9.9 years in JOAS vs 40.3 +/- 12.7 in AOAS (p=0.003), and vs 40.2 +/- 17 years in controls (p=NS). There was a higher frequency of cardiomyopathy in AOAS (32.2%) than in JOAS (25%) and the controls (0%) (p=0.01). Patients with JOAS had a higher mitral valve gradient (25%) than AOAS patients (19%, p=NS) and controls (0%, p=0.04). Abnormal aortic ring reflectance was shown in 19% of AOAS vs 0% abnormalities in JOAS and controls (p=0.01). The aortic root diameter was increased in 58% of AOAS, 30% of JOAS, and 0% of controls (p=0.001). The frequency of 2DECHO abnormalities was increased in cardiopulmonary asymptomatic spondylitis patients. Despite the high frequency of B27+, JOAS had a lower frequency of aortic abnormalities than AOAS. Mitral valve gradient was found in JOAS and in AOAS that could contribute to a decreased ejection fraction and to left ventricular dysfunction.

Extensive characterization of the immunophenotype and pattern of cytokine production by distinct subpopulations of normal human peripheral blood MHC II+/lineage- cells

Dendritic cells (DC) represent the most powerful professional antigen-presenting cells (APC) in the immune system. The aim of the present study was to analyse, on a single-cell basis by multiparametric flow cytometry with simultaneous four-colour staining and a two-step acquisition procedure, the immunophenotypic profile and cytokine production of DC from 67 normal whole peripheral blood (PB) samples. Two clearly different subsets of HLA-II+/lineage- were identified on the basis of their distinct phenotypic characteristics: one DC subset was CD33strong+ and CD123dim+ (0.16 +/- 0.06% of the PB nucleated cells and 55.9 +/- 11. 9% of all PB DC) and the other, CD33dim+ and CD123strong+ (0.12 +/- 0.04% of PB nucleated cells and 44.53 +/- 11.5% of all PB DC). Moreover, the former DC subpopulation clearly showed higher expression of the CD13 myeloid-associated antigen, the CD29 and CD58 adhesion molecules, the CD2, CD5 and CD86 costimulatory molecules, the CD32 IgG receptor and the CD11c complement receptor. In addition, these cells showed stronger HLA-DR and HLA-DQ expression and a higher reactivity for the IL-6 receptor alpha-chain (CD126) and for CD38. In contrast, the CD123strong+/CD33dim+ DC showed a stronger reactivity for the CD4 and CD45RA molecules, whereas they did not express the CD58, CD5, CD11c and CD13 antigens. Regarding cytokine production, our results show that while the CD33strong+/CD123dim+ DC are able to produce significant amounts of inflammatory cytokines, such as IL-1beta (97 +/- 5% of positive cells), IL-6 (96 +/- 1.1% of positive cells), IL-12 (81.5 +/- 15.5% of positive cells) and tumour necrosis factor-alpha (TNF-alpha) (84 +/- 22.1% of positive cells) as well as chemokines such as IL-8 (99 +/- 1% of positive cells), the functional ability of the CD123strong+/CD33dim+ DC subset to produce cytokines under the same conditions was almost null. Our results therefore clearly show the presence of two distinct subsets of DC in normal human PB, which differ not only in their immunophenotype but also in their functionality, as regards cytokine production.

Population-based prevalence of symptomatic and asymptomatic astrovirus infection in rural Mayan infants

Symptomatic and asymptomatic astrovirus infection was prospectively determined in a 3-year birth cohort of Mayan infants. Stool samples from 271 infants and 268 older siblings were tested for astrovirus, adenovirus 40/41, rotavirus and Salmonella, Shigella and Campylobacter species. Concurrent diarrhea, vomiting, fever, or anorexia were noted. Astrovirus was detected in 164 infants (61%) and 20 siblings (7%). Rotavirus (4%) and adenovirus 40/41 (13%) were isolated less frequently. Of all diarrheal episodes reported at a visit, 26% (78/305) were associated with astrovirus; 17% (78/452) of astrovirus infections were associated with diarrhea and 9% with other symptoms. Only diarrhea was associated with astrovirus infection (odds ratio, 1.4; 95% confidence interval [CI], 1.07-1.92; P = .01). Of infants with astrovirus, 70% shed at multiple visits over a period of 2-17 weeks (median, 5). The point prevalence of astrovirus infection was significantly higher among infants than siblings (relative risk, 6.18; 95% CI, 3.93-9.72; P < .0001, chi2). Astrovirus was identified throughout the year, peaked in March and May, and decreased in September. In this population, astrovirus was the most common enteric pathogen isolated; symptomatic infection was prevalent among infants.

Reduced number of Langerhans cells in oral mucosal washings from HIV-1 seropositives

In order to elucidate mucosal immunity in HIV-1 seropositive individuals, we investigated oral mucosa washings from 20 HIV-1 seropositive patients for the presence of Langerhans cells (LC) and HIV-1 antigen-positive cells, and compared the results with those obtained from 20 HIV-1 seronegative healthy individuals. Monoclonal antibodies directed against CD1a, HLA-DR, CD3, and p24 were used to identify LC, T cells and HIV-1 core-antigens, respectively. In oral mucosa washings from HIV-1 seropositive patients there was a significant reduction in the number of CD1a+ cells as compared with the healthy subjects. HIV-1 antigen-positive cells were not detected. The reduction of LC in oral mucosa washings from HIV-1 seropositive patients is probably associated with HIV-1 infection. The frequent occurrence of oral mucosal disorders in HIV-1 infected patients may in part be caused by a reduced LC-number and/or function.

Antimicrobial activity of a new antipseudomonal dual-action drug, Ro 25-0534

Ro 25-0534, a tertiary amine-linked dual action combination (DAC) of a catechol cephalosporin and ciprofloxacin, was compared with a previously described DAC (Ro 23-9424), ciprofloxacin and cefotaxime. A total of 688 recent clinical isolates were tested and an additional collection of 110 Gram-negative bacilli possessing documented resistance to broad-spectrum antimicrobials were used. Ro 25-0534 was active against all tested species of Enterobacteriaceae (MIC90 range, 0.06-2 micrograms/ml), oxacillin-susceptible staphylococci, beta-hemolytic streptococci, and penicillin-susceptible pneumococci (MIC90 range, 1-2 micrograms/ml). Haemophilus influenzae (MIC90 range, 0.25-0.5 micrograms/ml), Moraxella catarrhalis (MIC90, 0.5 microgram/ml), and most nonenteric Gram-negative bacilli (MIC90 range, 2-4 micrograms/ml) such as Pseudomonas aeruginosa, Acinetobacter spp., and Xanthomonas maltophilia. Enterococci and Bacteroides fragilis isolates were resistant to Ro 25-0534. The Ro 25-0354 potency against most susceptible strains was generally severalfold less than that of Ro 23-9424 (except for Pseudomonas-Xanthomonas) or ciprofloxacin alone.

Occurrence of macrolide-lincosamide-streptogramin resistances among staphylococcal clinical isolates at a university medical center. Is false susceptibility to new macrolides and clindamycin a contemporary clinical and in vitro testing problem?

A total of 2189 staphylococcal strains at the University of Iowa Hospitals and Clinics (Iowa City, IA) were initially screened to determine the incidence of constitutive (29.8%) and potential inducible macrolide-lincosamide-streptogramin (MLS) resistance (11.3%). Staphylococcus haemolyticus and S. epidermidis (62.5% and 55.3%) showed the highest incidence of constitutive resistance. Staphylococcus hominis had the highest incidence of inducible resistance (40.6%), while S. aureus had the lowest rate for both resistance types. The overall ratio of constitutive-inducible MLS resistance was 4:1. Among strains initially speciated using the Vitek System GPI card, there was only a 69% species identification reproducibility, and 78% accuracy versus a reference identification method. A random sample of 105 Staphylococcus spp. isolates with discordant macrolide (erythromycin resistant) and lincosamide (clindamycin susceptible) susceptibility patterns were tested against 16 antimicrobial agents by using a reference broth microdilution method. All erythromycin-resistant Staphylococcus spp. were also resistant to other 14-member macrolides and azithromycin, while all organisms remained susceptible to clindamycin, rifampin, vancomycin, and the streptogramin compounds (RP59500 and virginiamycin). Resistance to teicoplanin was identified among some oxacillin-resistant S. haemolyticus strains. Of 105 isolates, 65 (62%) showed inducible MLS resistance, 28 (27%) were noninducible, and 12 (11%) were either fully susceptible or resistant to the MLS drugs (Vitek System interpretation errors). MLS disk induction tests revealed two inducible resistance phenotypes: ML and MLS. Staphylococcus aureus showed the highest inducible resistance rate at 95% with an MLS-predominant pattern. In contrast, endemic S. haemolyticus isolates did not demonstrate inducible resistance that is, efflux-mediated erythromycin resistance.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of the E test to predict high-level resistance to aminoglycosides among enterococci

The E test and the reference agar dilution methods were compared for detecting high-level aminoglycoside resistance (HLAR) among 71 selected clinical isolates, including 62 Enterococcus faecalis and 9 Enterococcus faecium isolates. High-level gentamicin resistance alone was found in 11% (5 E. faecalis and 3 E. faecium strains) and high-level streptomycin resistance was found in 42% (28 E. faecalis, 2 E. faecium strains) of the strains tested, and 31% of the strains demonstrated high-level resistance to both antimicrobial agents (21 E. faecalis and 1 E. faecium strains). The E test detected all HLAR populations, but the streptomycin strip may require recalibration to achieve absolute MIC comparisons with the reference value (twofold less) or the use of an alternative interpretive resistance breakpoint, e.g., > 1,000 micrograms/ml. By the E test, MIC results indicate that ampicillin, imipenem, penicillin, piperacillin, and vancomycin remain active against the HLAR E. faecalis isolates; however, these tested drugs were less effective on the HLAR E. faecium isolates (< 50%).

A multidisciplinary process to determine, communicate, and manage an antibiotic formulary

This article describes a collaborate process developed by the Pharmacy & Therapeutics Committee to define, determine, communicate, and manage an effective antibiotic formulary. Multiple professional disciplines represented by the antibiotic subcommittee evaluated each classification of antibiotics and recommended a preferred drug(s) for each classification. Decisions were based on relative safety, efficacy, and cost with minimal duplication of therapeutic equivalent antibiotics. A therapeutic interchange policy was unnecessary because extensive communication measures developed by the committee proved effective. The strategy used strengthened pharmacist/physician working relationships. This process permitted rationality and understanding by the medical staff, which resulted in unanimous formulary acceptance.

Ofloxacin, a new broad-spectrum fluoroquinolone. Results from a Multicenter, National Comparative Activity Surveillance Study. The Ofloxacin Surveillance Group

Ofloxacin, a newer broad-spectrum fluoroquinolone, was evaluated against 6967 clinical isolates in a multicenter surveillance trial using a standardized disk diffusion method. Thirty-five geographically diverse laboratories contributed zone diameter results for two (ofloxacin and ciprofloxacin) to five (ofloxacin, ciprofloxacin, ampicillin, cefaclor, and cefixime) antimicrobial agents, depending on the site of infection. Ofloxacin was determined to have the widest spectrum of activity and potential empiric use (90.6%, range 87.1%-92.2%) for respiratory tract, urinary tract, and cutaneous infections. The spectrum was superior to ciprofloxacin (average 85.3% versus three sites), ampicillin (35.5%, respiratory tract), cefaclor (60.5%, respiratory tract), cefixime (60.9%, respiratory tract), and norfloxacin (87.3%, urinary tract). Strains resistant to ofloxacin (35 isolates, 0.5%) were confirmed by reference laboratory tests and cross resistance was observed among several current and investigational fluoroquinolone agents. The species most often found to be fluoroquinolone resistant among the Enterobacteriaceae were Klebsiella pneumoniae, Serratia marcescens, and Providencia spp. Monitoring for increasing fluoroquinolone resistance should be considered as greater use of drugs in this class develops. By these cited statistics, ofloxacin appears to have a broad and balanced spectrum of potential use, particularly against Gram-positive pathogens.

The E-Test applied to susceptibility tests of gonococci, multiply-resistant enterococci, and Enterobacteriaceae producing potent beta-lactamases

The E-Test (AB Biodisk, Solna, Sweden), a new and novel approach developed to test antimicrobial susceptibility, was compared with the agar dilution method. A collection of 57 organisms, including those with known resistances to various antimicrobial agents was tested against 15 drugs using the National Committee for Clinical Laboratory Standard (NCCLS) methods. The E-Test quantitative accuracy (+/- 2 log2 dilutions) compared with agar dilution results was 99% for Neisseria gonorrhoeae, 95% for Escherichia coli strains with extended-spectrum beta-lactamases, 100% for Enterobacter-Citrobacter spp. with type-1 stably derepressed enzymes, and 95% for Enterococcus spp. with various drug resistances (penicillins, ciprofloxacin, gentamicin, and vancomycin). The E-Test procedures with these species were easy to perform, reproducible, and quantitatively and qualitatively accurate (89%-100%). The E-Test appears to be an acceptable option for susceptibility testing of these difficult-to-treat, drug-resistant bacterial strains.

Diagnosis of disseminated candidiasis in hospitalized patients using the Cand-Tec latex agglutination assay

A total of 1,303 sera from 202 patients at risk for disseminated candidiasis were analyzed for the presence of Candida antigen using a commercially available latex agglutination test (Cand-Tec). Twenty-three patients had disseminated candidiasis documented by positive blood cultures, deep biopsy culture and histopathology or autopsy. Six patients had transient candidemia, 15 patients had candiduria, 62 patients were not colonized yet treated empirically with amphotericin B, and 46 patients were not colonized and not treated with amphotericin B. The sensitivity and specificity of the Candida antigen test for the diagnosis of disseminated candidiasis was 87% and 36% (threshold titer of greater than or equal to 1:2), 70% and 60% (greater than or equal to 1:4), and 30% and 85% (greater than or equal to 1:8), respectively. In contrast to previous studies we were unable to demonstrate a prognostic role for the Candida antigen test in patients with documented disseminated candidiasis. The lack of sensitivity and specificity of the Cand-Tec Candida antigen test precludes its use in the diagnosis of disseminated candidiasis.

In vitro activity of decaplanin (M86-1410), a new glycopeptide antibiotic

The in vitro activity of decaplanin (formerly M86-1410), a novel glycopeptide antimicrobial agent, was tested against 169 gram-positive bloodstream isolates from patients at the University of Iowa Hospitals and Clinics and 12 selected vancomycin-resistant strains. Enterococcus faecalis, E. faecium, Staphylococcus aureus, streptococci, bacilli, corynebacteria, and listeria were inhibited by decaplanin (MICs for 90% of the strains tested [MIC90s], 0.12 to 4 micrograms/ml). However, some rarely isolated and selected Enterococcus sp. populations had a MIC90 of 16 micrograms/ml, and S. haemolyticus strains had a MIC90 of 8 micrograms/ml. These in vitro results suggest that decaplanin may be useful against most gram-positive strains, even though some Enterococcus species and coagulase-negative staphylococci were potentially resistant (MICs, greater than or equal to 8 micrograms/ml).

Cardiopulmonary bypass, profound hypothermia, and circulatory arrest for neurosurgery

Six female and 4 male patients (age, 23 to 75 years) underwent operation for difficult intracranial lesions. Preoperative diagnoses included four giant intracranial aneurysms, three base of skull glomus jugulare tumors, two arteriovenous malformations, and one cerebellar hemangioblastoma. All lesions were inoperable or nearly so by standard neurosurgical techniques. All patients were placed on total bypass via groin cannulations. Bypass times ranged from 111 to 269 minutes (mean, 174 minutes) with cooling times of 26 to 83 minutes (mean, 48 minutes) and warming times of 68 to 110 minutes (mean, 83 minutes). Circulatory arrest times ranged from 1.25 to 60 minutes with 1 patient not requiring arrest. The lowest core temperatures recorded varied from 8.4 degrees to 13.7 degrees C. There was one postoperative death and one major complication, both in patients with arteriovenous malformations. Eight patients (80%) have achieved an excellent result. Profound hypothermia with the option of circulatory arrest and exsanguination has been an indispensable adjunct to the safe management of intracranial aneurysm, glomus jugulare tumor, and hemangioblastoma.

Luteinizing hormone triggers a molecular association between its receptor and the major histocompatibility complex class I antigen to produce cell activation

We studied the involvement of major histocompatibility (MHC) class I antigens on the mechanism of LH/hCG receptor activation. For this purpose we investigated the effects of anti-MHC class I antibodies on hormone-receptor interaction, signal transduction, and MHC class I antigen-receptor interaction. Monoclonal antibodies against MHC class I antigen were able to stimulate testosterone production in mouse Leydig cells with the same potency as LH. This biological effect depends on the concentration of antibody used and could be abolished by a LH antagonist. There is a perfect parallelism, for each monoclonal antibody, between the specificity for a particular haplotype and the response of the target cells from the strains carrying such a haplotype. The same antibodies were able to precipitate the soluble LH/hCG receptors, as both a hormone-receptor complex and a free receptor. The results suggest that bound hormone triggers an association of the MHC class I antigen with the LH/hCG receptor, resulting in activation of the target cell.