Predictive factors for invasive disease due to penicillin-resistant Streptococcus pneumoniae: a population-based study

A prospective population-based study was carried out to determine predictive factors associated with penicillin-resistant pneumococcal invasive disease. A total of 374 patients (250 males and 124 females; mean age, 50.3 +/- 27 years) with invasive pneumococcal infection were admitted to one of the five hospitals in El Vallés County (an industrial area with 800,000 inhabitants in the province of Barcelona, Spain) over a period of 5 years. Of the 374 episodes, 21 (5.6%) were due to highly penicillin-resistant pneumococci and 67 (17.9%) to intermediately penicillin-resistant pneumococci. Multivariate analysis showed a statistically significant association between infection with intermediately penicillin-resistant pneumococci and an age of 0-4 years (odds ratio [OR] = 5.3; 95% confidence interval [CI] = 2.2-12.6), the presence of an immunosuppressive underlying disease (OR = 3.0; 95% CI = 1.5-6.0), and the previous use of beta-lactam antibiotics (OR = 2.1; 95% CI = 1.0-4.5). Infection with highly penicillin-resistant pneumococci was associated only with the previous use of beta-lactam antibiotics (OR = 5.9; 95% 95% CI = 2.2-15.8). Highly resistant strains were of serotypes 6, 9, 14, 15, 19, and 23, of which all but serotypes 9 and 15 are included in the newly formulated conjugated vaccine.

Magnetic resonance imaging as a predictor of response to somatostatin analogs in acromegaly after surgical failure

CONTEXT

Transsphenoidal surgery is considered first-line therapy for acromegaly; however, there is often a need for adjunctive therapy. Somatostatin analogs (SSA) have greatly improved the effectiveness of medical treatment, but one third of patients are resistant.

OBJECTIVE

The aim was to evaluate whether magnetic resonance imaging (MRI) signal could predict long-term response to SSA in patients with active acromegaly after neurosurgery.

PATIENTS AND METHODS

Sixty-two patients who were active acromegalic after surgery were included in this retrospective study. Remaining pituitary tumor was classified as hyper-, iso-, or hypointense by evaluating T2-weighted MRI signal. Treatment with SSA at maximal effective doses was prescribed and evaluated at 6 and 12 months by monitoring IGF-I, GH, and T2 MRI.

RESULTS

Complete response to SSA treatment (defined as normal IGF-I) at 6 months was observed in 30%, partial response (defined as IGF-I between 2 and 3 sd score) in 15%, and no response in 55% of patients. At 12 months, 28, 20, and 52% were observed, respectively. MRI signal was hypointense in 40%, hyperintense in 48%, and isointense in 12%. At 6 months, complete response to SSA was observed in 71% of cases having hypointense MRI signal and in 20% of hyperintense (P = 0.04). At 12 months, 62% of hypointense remained well controlled, whereas in the hyperintense group, good, partial, or no response results did not change from that observed at 6 months (P = 0.04).

CONCLUSION

In active acromegalic patients after surgery, a hypointense T2-weighted MRI signal is associated with a better response to SSA treatment at 6 and 12 months.

Predictors of mortality in patients with bacteremia: the importance of functional status

OBJECTIVE

To evaluate the influence of functional status on the outcome in older patients with bacteremia.

DESIGN

Prospective study of all episodes of bacteremia that occurred in adults during a 27-month period (January 1991 to March 1993).

SETTING

A 280-bed community hospital.

PARTICIPANTS

During the study period, bacteremia was diagnosed in 242 consecutive patients (incidence of 11.2 bacteremic episodes per 1000 hospital admissions). One hundred twenty-seven of these patients were 65 years of age or older, and 115 were less than age 65.

MEASUREMENTS

On identification of a positive blood culture, data on demographics, clinical findings, and a series of factors frequently cited as predisposing to infection were collected. The patient's functional status was assessed using the Barthel index (a score of < 60 identifies moderately and highly dependent patients).

RESULTS

The overall mortality rate was 14.9% (36 of 242). In the univariate analysis, mortality was associated significantly with age greater than 65 years, nosocomial infection, absence of fever, shock, leukocytosis or leukopenia, inappropriate therapy, more than one underlying disease, immuno-compromised state, and limited functional status. Multiple logistic regression analysis revealed that shock (OR = 27.6, 95% CI 5.7-133), a Barthel score less than 60 (OR = 11.7, 95% CI 3.2-43), nosocomial infection (OR = 6.7, 95% CI 1.8-25.5), absence of fever (OR = 5.2, 95% CI 1.05-26), and immunocompromised state (OR = 15.6, 95% CI 2.4-101.5) were significantly associated with death attributable to bacteremia.

CONCLUSION

The main prognostic factors in a patient with bacteremia were the presence of shock, impaired functional status, immunodeficiency state, acquisition of infection in the hospital, and absence of fever on admission. Age alone did not influence outcome.

Meningococcal meningitis with 'normal' cerebrospinal fluid

A prospective study was made of all patients with normal CSF counts and positive cultures for Neisseria meningitidis diagnosed in "El Vallés" County, Barcelona between January 1987 and December 1990. Meningococcal meningitis was documented in 82 patients, eight of whom (seven children, five boys and two girls with a mean age of 5.6 +/- 3.3 years, and a 69-year-old male patient) had no apparent CSF abnormalities in the initial lumbar puncture. At the time of admission all patients had fever (mean 39.1 degrees C) of 10.8 +/- 5.6 hour duration and petechial rash which had been present for a mean of 3.6 +/- 3.3 hours. Signs of meningeal irritation were not found. A 4-month-old infant with symptoms of circulatory collapse, intracranial hypertension and impairment of consciousness subsequently died of septicemia in 48 hours. Group B N. meningitidis was isolated in six cases (reduced penicillin-susceptibility in two cases) and group C N. meningitidis in the remaining two (reduced penicillin-susceptibility in one case). Patients without pleocytosis did not differ in a statistically significant fashion from the patients with high pleocytosis in the duration of temperature, and petechial rash, leukopenia, positive blood culture and fatal outcome.

Quality of life in patients with pituitary tumors

PURPOSE OF REVIEW

Quality of life (QoL) is impaired in patients with pituitary tumors, even after biochemical cure. However, it is not usually assessed in daily practice. The aim of this study is to highlight recent findings on QoL in the different types of pituitary adenomas and hypopituitarism.

RECENT FINDINGS

Patients with acromegaly or Cushing's syndrome have the greatest impairment of QoL, and concomitant hypopituitarism worsens it further. The use of disease-generated QoL questionnaires allows dimensions specifically affected in that disease to be addressed and these dimensions are more sensitive to change after successful therapy; in some cases, improvement in patients' sense of well-being has been shown despite no hormonal change, indicating that evaluation of QoL is not such a soft end-point as thought by some.

SUMMARY

Systematic evaluation of QoL in patients with pituitary diseases provides information not always contemplated by hormonal and routine clinical evaluation; this allows detection of not often contemplated health problems, which may then be approached and treated, improving the care provided to these patients.

Neisseria meningitidis with reduced sensitivity to penicillin: observations in 10 children

10/84 strains (11.9%) of Neisseria meningitidis isolated from blood and/or cerebrospinal fluid in children 1986-1987 had reduced sensitivity to benzylpenicillin (MICs 0.1-0.4 mg/l). Group C meningococci predominated among these strains. The clinical course was satisfactory in all cases regardless of the antibiotic treatment used, although the time to abatement of fever was prolonged compared to that of children infected with susceptible strains.

Prospective epidemiological study of invasive Haemophilus influenzae disease in adults

The incidence and characteristics of invasive Haemophilus influenzae disease were studied in 43 adult patients admitted to the acute care hospitals in El Vallés County (Barcelona, Spain) between January 1987 and June 1992. The annual incidence of Haemophilus influenzae disease was 1.2 per 100,000 inhabitants. Pneumonia occurred in 24 patients, meningitis in five, intraabdominal infections in three, obstetric infections in two, epiglottitis in two and cellulitis in one. In six patients the source of infection was unknown. Ten (23%) of the infections were hospital acquired. Underlying conditions were diagnosed in 30 (70%) patients. Nontypeable Haemophilus influenzae strains predominated in all adult age groups. Sixty-one percent of type b and 34% of nontypeable strains were ampicillin resistant (p = 0.08). Multiple antibiotic resistance was also high among type b (53%) and nontypeable (18%) strains. The mortality rate was significantly higher in patients with pneumonia, bacteremia from an unidentified focus or shock at presentation.

Screening for chemicals with thyroid hormone-disrupting effects using zebrafish embryo

Thyroid disruption is an increasingly recognized issue in the use and development of chemicals and new drugs, especially to help toxicologist to complement the reproductive and developmental toxicology information of chemicals. Still, adequate assessment methods are scarce and often suffer a trade-off between physiological relevance and labor- and cost-intensive assays. Here, we present a tiered approach for a medium-throughput screening of chemicals to identify their thyroid disrupting potential in zebrafish embryos as a New Approach Methodology (NAM). After identifying the maximum tolerated concentrations, we exposed zebrafish larvae to sub-adverse effect levels of the reference compounds benzophenone-2, bisphenol A, phenylthiourea, potassium perchlorate, propylthiouracil, and phloroglucinol to exclude any systemic toxicity. Applying the transgenic zebrafish line that carries a gene for the red fluorescence protein (Tg(tg:mCherry)) under the thyroglobulin promoter, we could identify the thyroid disrupting effects of the chemicals by a time and cost-effective image analysis measuring the fluorescence levels in the thyroid glands. Our observations could be confirmed by altered expression patterns of genes involved in the hypothalamus-pituitary-thyroid (HPT) axis. Finally, to anchor the observed thyroid disruption, we determined some changes in the Thyroid hormone levels of triiodothyronine (T3) and Thyroxine (T4) using a newly developed liquid chromatography mass spectrometric (LCMS) method. The presented approach carries the potential to extend the toolbox for legislative authorities and chemical producers for the assessment of thyroid-specific endocrine disruption and to overcome current challenges in the evaluation of endocrine disruptors.

Closer versus Long Range Interaction Effects on the Non-Arrhenius Behavior of Quasi-Resonant O2 + N2 Collisions

We report in this paper an investigation on energy transfer processes from vibration to vibration and/or translation in thermal and subthermal regimes for the O₂ + N₂ system performed using quantum-classical calculations on different empirical, semiempirical, and ab initio potential energy surfaces. In particular, the paper focuses on the rationalization of the non-Arrhenius behavior (inversion of the temperature dependence) of the quasi-resonant vibration-to-vibration energy transfer transition rate coefficients at threshold. To better understand the microscopic nature of the involved processes, we pushed the calculations to the detail of the related cross sections and analyzed the impact of the medium and long-range components of the interaction on them. Furthermore, the variation with temperature of the dependence of the quasi-resonant rate coefficient on the vibrational energy gap between initial and final vibrational states and the effectiveness of quantum-classical calculations to overcome the limitations of the purely classical treatments were also investigated. These treatments, handled in an open molecular science fashion by chaining data and competencies of the various laboratories using a grid empowered molecular simulator, have allowed a rationalization of the dependence of the computed rate coefficients in terms of the distortion of the O₂-N₂ configuration during the diatom-diatom collisions. A way of relating such distortions to a smooth and continuous progress variable, allowing a proper evolution from both long to closer range formulation of the interaction and from its entrance to exit channel (through the strong interaction region) relaxed graphical representations, is also discussed in the paper.

[Role of health-related quality of life in clinical practice: subjectivity in evidence]

The incorporation of subjective elements provided by the patient to medical practice constitutes a new bridge between two historical movements of human culture: naturalism and rationalism. In recent years, medical sciences have identified these movements as patient-centered medicine and evidence-based medicine. By revisiting the paradigms of medicine, theories of causality, doctor-patient relationship models, bioethical principles and examples of clinical studies, their role and meaning has been revised. The applicability for neuroendocrinology has been demonstrated by validating therapeutic results with measurement of health-related quality of life. The need to incorporate the patient's subjective perception poses a challenge that, when accepted, can advance the understanding and care of human beings--ultimately rational, thinking subjects, and therefore subjective--as our species has been defined.

[Abdominal aortic injury as a complication of laparoscopic cholecystectomy]

A 58-year-old woman with a history of high blood pressure and cesarean section by median laparotomy underwent elective laparoscopic cholecystectomy under general anesthesia. After initiation of pneumoperitoneum, hemodynamic instability developed (blood pressure 75/40 mm Hg, heart rate 47 beats/min) and resolved after volume replacement and administration of vasoactive drugs. The rest of the procedure was completed without further adverse events. After extubation, the patient was transferred to the anesthetic recovery ward, where she tended to hypotension that was unresponsive to volume replacement, with a hematocrit of 18% and hemoglobin concentration of 6.9 g/dL. Hemoperitoneum was suspected, and an emergency median laparotomy revealed 300 cc of blood in the peritoneal cavity, a large hematoma putting pressure on retroperitoneal structures, and 2 infrarenal aortic lesions (anterior and posterolateral). During the reoperation the patient required multiple transfusions and vasoactive drugs to maintain hemodynamic stability. Recovery in the postanesthetic care unit was uneventful. After transfer to the ward, on the 20th day after surgery she developed septic shock with intraabdominal fluid requiring surgical drainage and admission to the intensive care unit. Abdominal aortic injury during laparoscopic surgery usually occurs upon introduction of trocars for initiating pneumoperitoneum. The technique must be performed correctly and monitored properly to assure early detection of adverse events associated with high mortality.

[Characterization of Haemophilus influenzae's resistance to ampicillin]

BACKGROUND

The resistance of Haemophilus influenzae to ampicillin is nearly always dependent on plasmid-mediated betalactamase production. The betalactamase type most frequently identified was TEM-1; type ROB has occasionally been identified. The presence of plasmid-mediated betalactamase has been studied in H. influenzae strains moderately susceptible or resistant to ampicillin.

METHODS

The test used in the detection of the presence of betalactamase was nitrocefin hydrolysis; the enzyme type was identified by analytic isoelectric focusing; the codifying gene of this betalactamase was identified by hybridisation with a TEM-1 probe labeled with digoxigenine. Strains studied were 110, obtained during the period 1987 to 1989 and isolated from four Hospitals of the Vallés area of Barcelona.

RESULTS

Enzyme production was detected in 105 of 110 strains studied; TEM-1 type betalactamase was identified in 108 and positive hybridisation was obtained in these strains with the TEM-1 probe.

CONCLUSIONS

Nitrocefin hydrolysis is a reliable test for the detection of betalactamase production, although it may be unable to detect it (falses negatives) when the production is low. The only betalactamase type identified was TEM-1. The frequency of the strains with non-enzymatic resistance was 1.8%.

[Bacteremia in 13 general hospitals of the province of Barcelona. Prospective study of 1,674 episodes. Group of Microbiologists of the County Hospitals of Catalonia]

BACKGROUND

Clinical and microbiological description of bacteremias seen in 13 regional hospitals of Barcelona.

METHODS

From January to December of 1991 a multicenter prospective study of bacteremia in regional hospitals was performed. The filiation, clinical findings and microbiological results were registered according to a common protocol.

RESULTS

We studied 1674 episodes of bacteremia (13.8 per 1000 admissions). Patients were distributed into 3 groups according to age: under 14: 204 patients, between 14 to 65: 759 and over 65: 711 patients. Men account for 55% and women for 45% of episodes. The bacteremia was hospital-acquired in 24.4% of cases. The most common foci of infection were: urinary tract (32%), respiratory tract (14%), intestinal tract (8%), intravascular catheter (7%), biliary tract (7%) and unknown (10%). The most commonly isolated strains were: Escherichia coli 544 cases, Streptococcus pneumoniae 212, Staphylococcus aureus 139, coagulase negative staphylococi 85, Non-typhoid Salmonella 66, Neisseria meningitidis 63, Pseudomonas sp. 59, Enterococcus sp. 59 and Bacteroides sp. 58. Polimicrobial bacteremia was detected in 83 episodes (5%). Related mortality rate was 9.6% (161 patients).

Photophysical properties of neutral and cationic tetrapyridinoporphyrazines

We describe the synthesis and photophysical properties of a series of neutral and cationic 3,4-tetrapyridinoporphyrazines, potential lead photosensitizers for photodynamic inactivation of bacteria. Tetracationic TPyPzs exist essentially as monomers in aqueous systems, but the presence of trialkylated compounds due to incomplete quaternization of the outer nitrogen atoms induces severe aggregation. The absorption, fluorescence, triplet, and singlet oxygen quantum yields for both the neutral and cationic compounds are comparable to those of the related phthalocyanines.