Results from a Search for Dark Matter in the Complete LUX Exposure

We report constraints on spin-independent weakly interacting massive particle (WIMP)-nucleon scattering using a 3.35×10^{4}  kg day exposure of the Large Underground Xenon (LUX) experiment. A dual-phase xenon time projection chamber with 250 kg of active mass is operated at the Sanford Underground Research Facility under Lead, South Dakota (USA). With roughly fourfold improvement in sensitivity for high WIMP masses relative to our previous results, this search yields no evidence of WIMP nuclear recoils. At a WIMP mass of 50  GeV c^{-2}, WIMP-nucleon spin-independent cross sections above 2.2×10^{-46}  cm^{2} are excluded at the 90% confidence level. When combined with the previously reported LUX exposure, this exclusion strengthens to 1.1×10^{-46}  cm^{2} at 50  GeV c^{-2}.

Treatment of infections in patients with the acquired immunodeficiency syndrome

The microorganisms that regularly infect patients with the acquired immunodeficiency syndrome (AIDS) have become well recognized. Most take advantage of defects in T-lymphocyte function, but others, such as Streptococcus pneumoniae and Haemophilus influenzae, take advantage of B-cell defects. Still others, such as Staphylococcus aureus and Shigella species, occur or persist for reasons that are unclear. Infections with organisms associated with hospitalization and medical procedures are also seen and should be anticipated. Among the infections taking advantage of T-cell defects, Pneumocystis carinii pneumonia is the most commonly diagnosed, but cytomegalovirus infection may be equally common. Disseminated Mycobacterium avium-intracellulare infection has been found in one half of our patients at postmortem examination. The retrovirus responsible for AIDS commonly infects the central nervous system, as does Toxoplasma gondii. Although candida infections are common, dissemination is uncommon. Many of the infections respond to appropriate therapy but tend to recur when treatment is stopped. Often treatment courses must be prolonged even beyond those used in other immunocompromised hosts.

Mapping of a second locus for familial hemiplegic migraine to 1q21-q23 and evidence of further heterogeneity

Familial hemiplegic migraine (FHM) is an autosomal dominant variety of migraine with aura. We previously mapped an FHM gene on the short arm of chromosome 19. Mutations in this gene, recently shown to be the alpha1 subunit of a P/Q-type voltage-dependent calcium channel, CACNL1A4, are involved in approximately 50% of unselected FHM families and in all families where migraine attacks are associated with permanent cerebellar ataxia. As a first step toward the identification of other FHM genes, we conducted a genetic linkage analysis in one large French pedigree and showed significant linkage to two microsatellite markers D1S2635 (Zmax: 3.33 at theta = 0.05) and D1S2705 (Zmax: 3.64 at theta = 0.05), establishing the existence of a second locus for FHM (FHM2) on chromosome 1q21-q23. Analysis of six additional FHM families favored linkage to this locus in two of them; linkage was excluded in the last four families, indicating further heterogeneity. Chromosome 1-linked families differ from the ones linked to chromosome 19, because penetrance in those families is much lower, and in some of their members, epileptic seizures occur during severe migraine attacks.

First results from the LUX dark matter experiment at the Sanford underground research facility

The Large Underground Xenon (LUX) experiment is a dual-phase xenon time-projection chamber operating at the Sanford Underground Research Facility (Lead, South Dakota). The LUX cryostat was filled for the first time in the underground laboratory in February 2013. We report results of the first WIMP search data set, taken during the period from April to August 2013, presenting the analysis of 85.3 live days of data with a fiducial volume of 118 kg. A profile-likelihood analysis technique shows our data to be consistent with the background-only hypothesis, allowing 90% confidence limits to be set on spin-independent WIMP-nucleon elastic scattering with a minimum upper limit on the cross section of 7.6 × 10(-46) cm(2) at a WIMP mass of 33 GeV/c(2). We find that the LUX data are in disagreement with low-mass WIMP signal interpretations of the results from several recent direct detection experiments.

Acute traumatic aortic rupture: early stent-graft repair

OBJECTIVE

Prospective evaluation of early stent-graft repair of acute traumatic aortic rupture.

METHODS

Twelve patients with acute traumatic aortic rupture of the descending aorta, out of a series of 337 endovascular aortic procedures, were treated by implantation of self-expanding stent-grafts. The procedures were performed within a mean post-injury time-period of 5+/-7 days (median: 1 day). The feasibility of stent-grafting was assessed by CT scanning and echography. Implantation was performed under local (n=6), or general anesthesia (n=6) if patients were already intubated (n=5) or required a common iliac artery access (n=1).

RESULTS

The immediate technical success rate was 100%. There were no post-procedure complications in all but one patient, who died 12 h postoperatively (8% mortality). Complete sealing of the aortic rupture in the remaining 11 patients was confirmed by postoperative CT scans. There were no intervention-related morbidity or mortality during the mean follow-up of 17 months. One patient with peri-graft leakage was successfully repaired with an additional stent-graft 12 months postoperatively.

CONCLUSION

Non-delayed or early stent-grafting in acute traumatic rupture of the descending aorta is feasible. This technique seems to be a valuable option, in particular when associated lesions may interfere with the surgical outcome. Immediate post-procedural CT scanning and/or echography should be performed, in order to rule out residual leakage.

Downgrading, downsizing, degazettement, and reclassification of protected areas in Brazil

Protected areas (PAs) are key elements for biodiversity conservation and ecosystem services. Brazil has the largest PA system in the world, covering approximately 220 million ha. This system expanded rapidly in the mid-1990s to the mid-2000s. Recent events in Brazil, however, have led to an increase in PA downgrading, downsizing, and degazettement (PADDD). Does this reflect a shift in the country's PA policy? We analyzed the occurrence, frequency, magnitude, type, spatial distribution, and causes of changes in PA boundaries and categories in Brazil. We identified 93 PADDD events from 1981 to 2012. Such events increased in frequency since 2008 and were ascribed primarily to generation and transmission of electricity in Amazonia. In Brazilian parks and reserves, 7.3 million ha were affected by PADDD events, and of these, 5.2 million ha were affected by downsizing or degazetting. Moreover, projects being considered by the Federal Congress may degazette 2.1 million ha of PA in Amazonia alone. Relaxing the protection status of existing PAs is proving to be politically easy in Brazil, and the recent increase in frequency and extension of PADDD reflects a change in governmental policy. By taking advantage of chronic deficiencies in financial and personnel resources and surveillance, disputes over land tenure, and the slowness of the Brazilian justice, government agencies have been implementing PADDD without consultation of civil society. If parks and reserves are to maintain their integrity, there will need to be investments in Brazilian PAs and a better understanding of the benefits PAs provide.

Analysis of risk factors for surgical wound infections following vascular surgery

Although surgical wound infections (SWI) following implantation of prosthetic devices can be catastrophic and often require removal of the prosthesis, few studies have identified risk factors for these infections. We conducted a prospective multicenter study to identify risk factors for SWI. Of 561 vascular surgery patients enrolled in the study, 23 (4.1%) developed SWI. Multivariate analysis using logistic regression analyses identified surgery on lower extremities, delayed surgery, diabetes mellitus, past history of vascular surgery, and short antimicrobial prophylaxis (three doses of cefamandole) as independent risk factors for SWI. Consequences of SWI were serious; two (9%) died, 11 (48%) required reoperation, and five (22%) had their prosthesis removed. A risk index was developed using the independent risk factors for SWI identified by logistic regression analyses. When no risk factors were present, no SWI was observed (0 of 100), and the rate of SWI increased from 2.5% when one risk factor was present to 53.8% (7 of 13) when greater than or equal to 4 risk factors were present.

Evaluation of teicoplanin for treatment of endocarditis caused by gram-positive cocci in 20 patients

Teicoplanin, a new glycopeptide antibiotic similar to vancomycin, was evaluated for the treatment of bacterial endocarditis in an open multicenter study from May 1985 to August 1987. A total of 20 patients with positive blood culture endocarditis received teicoplanin once daily as a mean intravenous injection of 7.3 mg/kg of body weight (range, 4.8 to 10.6 mg/kg); in 17 patients, teicoplanin was combined with another antibiotic, usually an aminoglycoside. The mean duration of therapy was 28 days (range, 7 to 66 days). The diagnosis of endocarditis was confirmed by echocardiography or anatomical findings in 15 patients and established on the basis of clinical manifestations plus positive blood cultures in 5 patients. The tricuspid valve was involved in 11 of the 20 patients. Isolates from blood were 12 Staphylococcus aureus, 1 Staphylococcus hominis, 1 Micrococcus sedentarius, 1 Enterococcus faecalis, 3 Streptococcus bovis, and 2 nongroupable Streptococcus sp. At the end of therapy, bacterial eradication was achieved in 17 of 20 patients (85%), and a favorable clinical outcome had occurred in 14 of 17 evaluable patients (82%). Of these 14 patients, one relapsed 4 months after the end of treatment. Thus, teicoplanin was effective in 13 of 17 patients (76%). Mean peak levels of teicoplanin in serum were lower, 23.1 +/- 2.9 micrograms/ml, in patients who failed than in those who were cured (45.8 +/- 8.4 micrograms/ml). Side effects occurred in 7 of 20 patients (35%), and required premature discontinuation of teicoplanin in 3 patients. These side effects were fever in three patients, rash in three patients, hearing loss in two patients, and increased serum transaminase levels in two patients. This study demonstrates the efficacy of teicoplanin in the treatment of endocarditis and the need for achieving peak levels in serum close to 40 micrograms/ml. Teicoplanin should now be further evaluated in endocarditis caused by gram-positive cocci means of controlled comparative study with standard therapy.

Phase separation induced by melittin in negatively-charged phospholipid bilayers as detected by fluorescence polarization and differential scanning calorimetry

Interactions between melittin and a variety of negatively-charged lipid bilayers have been investigated by intrinsic fluorescence, fluorescence polarization of 1,6-diphenylhexatriene and differential scanning calorimetry. (1) Intrinsic fluorescence of the single tryptophan residue of melittin shows that binding of this peptide to negatively-charged phospholipids is directly related to the surface charge density, but is unaffected by the physical rate of lipids, fluid or gel, single-shell vesicles or unsonicated dispersions. (2) Changes in the thermotropic properties of negatively-charged lipids upon melittin binding allow to differentiate two groups of lipids: (i) A progressive disappearance of the transition, without any shift in temperature, is observed with monoacid C14 lipids such as dimyristoylphosphatidylglycerol and -serine (group 1). (ii) With a second group of lipids (group 2), a transition occurs even at melittin saturation, and two transitions are detected at intermediate melittin content, one corresponding to remaining unperturbed lipids, the other shifted downward by 10-20 degrees C. This second group of lipids is constituted by monoacid C16 lipids, dipalmitoylphosphatidylglycerol and -serine. Phosphatidic acids also enter this classification, but it is the net charge of the phosphate group which allows to discriminate: singly charged phosphatidic acids belong to group 2, whereas totally ionized ones behave like group 1 lipids, whatever the chain length. (3) It is concluded that melittin induces phase separations between unperturbed lipid regions which give a transition at the same temperature as pure lipid, and peptide rich domains in which the stoichiometry is 1 toxin per 8 phospholipids. The properties of such domains depend on the bilayer stability: in the case of C16 aliphatic chains and singly charged polar heads, the lipid-peptide domains have a transition at a lower temperature than the pure lipid. With shorter C14 chains or with two net charges by polar group, the bilayer structure is probably totally disrupted, and the new resulting phase can no longer lead to a cooperative transition.

Determination of optimal dosage regimen for amikacin in healthy volunteers by study of pharmacokinetics and bactericidal activity

The pharmacokinetics and serum killing curves of amikacin, which was administered by a 30-minute intravenous infusion of single doses of 7.5 mg/kg and then 15 mg/kg, were investigated in six healthy volunteers who received the two doses in a crossover study with a washout period of 20 days. The serum killing curves were determined for four bacterial species: Escherichia coli, Serratia marcescens, Enterobacter cloacae, and Pseudomonas aeruginosa. All strains were serum resistant, and the bactericidal activity was analyzed by separating the early phase (first 5 h) and the late phase (24 h) of the killing curve. For the early phase, the bactericidal activity was evaluated by correlating an index of surviving bacteria with amikacin concentrations. This methodology allowed determination of two parameters: the maximal effective concentration and the lowest effective concentration. For the late phase, the threshold values separating bacteriostatic and bactericidal activities were lower than 10 mg/liter for each strain. The concentration dependence of amikacin bactericidal activity was confirmed for Escherichia coli and Enterobacter cloacae and, to a lesser extent, for Serratia marcescens and Pseudomonas aeruginosa. Correlation of these data with amikacin pharmacokinetic data in volunteers indicated that a daily dose of 15 mg/kg may be effective in the treatment of Escherichia coli and Enterobacter cloacae infections. For Pseudomonas aeruginosa and Serratia marcescens, the partially time-dependent activity probably necessitates two daily administrations and combination with another antibiotic.

Structure-function relationships for cardiotoxins interacting with phospholipids

Four cardiotoxins (CTX I-IV) from Naja mossambica mossambica were compared for their ability to interact with phospholipid vesicles and their capacity to bind erythrocytes. It is concluded that the affinity of the toxins always increases in the order: I approximately equal to II less than III less than IV. The binding is specific for charged lipids even in lipid mixtures. Proteolytic attack of the free and lipid-bound cardiotoxin indicates that at least the first loop Leu1-Thr13 is at the lipid contact. Tryptic and synthetic peptides constitutive of this loop are shown to interact with lipids. Arg5 residue increases the affinity toward the bilayer. The Raman spectra of lipid-bound cardiotoxin indicate a secondary and tertiary structure mainly similar to that of the free toxin. On charged lipids cardiotoxins induce a decrease of the enthalpy and an increase of disorder without change in the transition temperature; at saturating amounts of toxin the transition is abolished. In binary mixtures of phosphatidylcholine and charged lipids the observed effects can be accounted by a phase separation induced by the toxin.

Application of DNA amplification to pneumocystosis: presence of serum Pneumocystis carinii DNA during human and experimentally induced Pneumocystis carinii pneumonia

Pneumocystis carinii pneumonia is a leading cause of morbidity and mortality in patients with the acquired immunodeficiency syndrome (AIDS). Much remains unknown about the basic biology of P. carinii and studies of this infection have been hampered by the lack of cultivation methods. We developed a sensitive and specific assay for P. carinii by utilizing DNA amplification of the P. carinii dihydrofolate reductase (DHFR) gene. By this method, P. carinii DNA was detected in the lungs of rats with experimentally induced P. carinii pneumonia 2 wk before the onset of histopathological changes. DNA amplification analysis of serum demonstrated that by 10 wk of corticosteroid treatment, 12 of 12 (100%) infected rats had circulating DHFR DNA. P. carinii DHFR DNA also was detected in the serum of patients with AIDS and active P. carinii pneumonia (12 of 14 sera collected prospectively). Patients with advanced AIDS but without a history of P. carinii pneumonia were negative by this assay (0 of 6 sera examined). Serum polymerase chain reaction may facilitate investigations into the natural history and epidemiology of P. carinii infection, provide insight into the pathogenesis of parasite dissemination, and offer a useful, noninvasive diagnostic test for the detection of human pneumocystosis.

Intestinal and extraintestinal Isospora belli infection in an AIDS patient. A second case report

A 30-year-old black female, from Burkina Faso, had AIDS in 1990. She died in March 1993 following a cachexia secondary to a chronic intestinal isosporiasis. The autopsy revealed a massive parasitic infection by I. belli of the small intestine mesenteric and mediastinal lymph nodes and liver and spleen. The parasite stage observed in extra intestinal sites corresponded to unizoite tissue cysts. This is the first report of I. belli infection in liver and spleen.

Importance of sebaceous glands in cutaneous penetration of an antiandrogen: target effect of liposomes

The significance of the sebaceous gland pathway in the cutaneous permeation of an antiandrogen, 4-[3-(4-hydroxybutyl)-4,4-dimethyl -2,5-dioxo-1-imidazolidinyl]-2-(trifluoromethyl)benzonitrile (RU 58841), was studied with normal hairless rat skin and an induced scar hairless rat skin without sebaceous glands. RU 58841 was dissolved in an alcoholic solution and encapsulated in liposomes for comparison. After 24 h, the cumulative percentage of RU 58841 absorbed in vitro was 3-4-fold higher in the normal skin than in the scar skin; in the case of liposomes, the accumulation of the drug in the normal dermis was significantly higher than in the scar one. In the in vivo cutaneous distribution, the epidermis and dermis of the normal skin contained higher amounts of RU 58841 than the scar skin (ninefold with the solution and 16-fold with liposomes). An autoradiography study showed that with the solution, the drug was mainly localized in the stratum corneum/epidermis, and with the liposomes, the drug was mainly localized in the sebaceous glands. We concluded that the sebaceous glands constituted the main pathway for RU 58841. The alcoholic solution encouraged the localization of the drug into the stratum corneum, whereas liposomes targeted the sebaceous glands.

Indications and impact of postoperative transesophageal echocardiography in cardiac surgical patients

OBJECTIVE

Transesophageal echocardiography (TEE) has gained widespread acceptance among intensivists as a tool to facilitate decision-making in the management of critically ill patients. This observational study analyzes the indications and impact of TEE and the outcome in patients following cardiac surgery.

DESIGN

Standardized reports containing indication, main diagnosis, and impact on patient management were completed during TEE.

SETTING

Intensive care unit in a university hospital.

PATIENTS

Postoperative cardiac surgery patients requiring TEE.

INTERVENTION

TEE in sedated and mechanically ventilated patients.

MEASUREMENTS AND RESULTS

Reports were obtained in 301 adult patients between June 1996 and June 2000. Indications were postoperative control of left ventricular function in 102 (34%) cases; unexplained, sudden hemodynamic deterioration in 89 (29%); suspicion of pericardial tamponade in 41 (14%); cardiac ischemia in 26 (9%); and "other" in 43 (14%). In 136 patients (45%), a new diagnosis was established or an important pathology was excluded. Pericardial tamponade was diagnosed in 34 cases (11%) and excluded in 36 cases (12%). Other diagnoses included severe left ventricular failure, large pleural effusion, and others. Therapeutic impact was found in 220 cases (73%): change of pharmacologic treatment and/or fluid therapy in 118 cases (40%), resternotomy in 43 (14%), no reoperation necessary in 39 (13%), and various in 20 (7%). No impact was found in 81 cases (27%). In a subgroup of patients in whom preoperative risk scores were evaluated, the indication for a postoperative TEE was significantly associated with a prolonged stay in the intensive care unit: 7 (5.6, 8.4) days vs. 1 (0.8, 1.2) day (median, [95% confidence interval]) (p <.0001), more neurologic complications (18/137 = 13.1% vs. 21/680 = 3.0%) (p <.0001), and increased mortality (34/153 = 22.2% vs. 18/709 = 2.5%) (p <.0001). Corrected for preoperative risk scores, these differences were still significant.

CONCLUSION

Although TEE provided important findings and therapeutic impact in postoperative cardiac surgical patients, patients with comparable preoperative risk who had postoperative TEE examinations had a significantly worse outcome than those without the need for postoperative TEE.

Systemic infection with Trichosporon cutaneum in a patient with acute leukemia: report of a case

A case of disseminated infection with Trichosporon cutaneum, a fungus that causes white piedra, is described. The patient, a 58-year-old barber with acute leukemia, had fever, myalgias and skin lesions. He was receiving cytotoxic drug therapy and prednisone, was severely neutropenic and was being treated with broad spectrum antibiotics. Blood cultures and a biopsy of the skin lesion grew T. cutaneum. He died despite amphotericin B therapy. At autopsy, widespread infection with T. cutaneum was present. T. cutaneum is another fungus capable of causing widespread systemic disease in the immunocompromised host.

Improved Limits on Scattering of Weakly Interacting Massive Particles from Reanalysis of 2013 LUX Data

We present constraints on weakly interacting massive particles (WIMP)-nucleus scattering from the 2013 data of the Large Underground Xenon dark matter experiment, including 1.4×10^{4}  kg day of search exposure. This new analysis incorporates several advances: single-photon calibration at the scintillation wavelength, improved event-reconstruction algorithms, a revised background model including events originating on the detector walls in an enlarged fiducial volume, and new calibrations from decays of an injected tritium β source and from kinematically constrained nuclear recoils down to 1.1 keV. Sensitivity, especially to low-mass WIMPs, is enhanced compared to our previous results which modeled the signal only above a 3 keV minimum energy. Under standard dark matter halo assumptions and in the mass range above 4  GeV c^{-2}, these new results give the most stringent direct limits on the spin-independent WIMP-nucleon cross section. The 90% C.L. upper limit has a minimum of 0.6 zb at 33  GeV c^{-2} WIMP mass.

Targeting neonatal ischemic brain injury with a pentapeptide-based irreversible caspase inhibitor

Brain protection of the newborn remains a challenging priority and represents a totally unmet medical need. Pharmacological inhibition of caspases appears as a promising strategy for neuroprotection. In a translational perspective, we have developed a pentapeptide-based group II caspase inhibitor, TRP601/ORPHA133563, which reaches the brain, and inhibits caspases activation, mitochondrial release of cytochrome c, and apoptosis in vivo. Single administration of TRP601 protects newborn rodent brain against excitotoxicity, hypoxia-ischemia, and perinatal arterial stroke with a 6-h therapeutic time window, and has no adverse effects on physiological parameters. Safety pharmacology investigations, and toxicology studies in rodent and canine neonates, suggest that TRP601 is a lead compound for further drug development to treat ischemic brain damage in human newborns.

Influence of male gonadal hormones on the parasitemia and humoral response of male Calomys callosus infected with the Y strain of Trypanosoma cruzi

Effects of orchiectomy on male Calomys callosus infected with the Y strain of Trypanosoma cruzi were studied. Male C. callosus of the same age and weight were divided into three groups: intact, sham operated, and castrated. After 1 month they were inoculated (i.p.) with 4000 blood trypomastigotes. Parasitemia was lower in orchiectomized animals than in the intact and sham groups. Hormone replacement with decanoate testosterone raised the parasitemia of castrated animals to levels similar to those of their intact and sham counterparts. Antibody levels were monitored by complement-mediated lysis. The trypomastigote lysis percentage varied through the course of infection, according to hormonal status and number of parasites during the acute phase. The most significant differences were found on the 30th day after infection, when lytic antibodies of intact males were high compared to the orchiectomized and sham groups. Higher resistance with lower lysis indexes were observed after orchiectomy, compared to intact and sham males.

Extracerebral toxoplasmosis in the acquired immunodeficiency syndrome (AIDS)

Although Toxoplasma gondii frequently causes lesions of the central nervous system in AIDS, the exact incidence of extracerebral toxoplasmosis in these immunodepressed patients remains difficult to determine. Isolation of the parasite outside the central nervous system is rarely performed ante mortem, and most diagnoses of extracerebral toxoplasmosis are made post mortem. This article describes 23 cases of extracerebral toxoplasmosis diagnosed between 1987 and 1991 in an autopsy series of 170 patients infected with the human immunodeficiency virus (HIV). Ante mortem diagnosis of extracerebral involvement was affirmed in 4 of these 23 patients by identification of trophozoites in bronchoalveolar lavage fluid (2 cases), a surgical pulmonary biopsy specimen, and a bladder biopsy. Clinical and paraclinical findings suggested cardiac involvement in 4 other patients. Post mortem examination demonstrated disseminated toxoplasmosis in 18 cases and extracerebral monovisceral involvement in 5 cases. Extracerebral toxoplasmosis was directly responsible for the death of 6 patients. The most frequent extracerebral sites of Toxoplasma gondii involvement were the heart (21/23 cases; 91%), the lungs (14/23 cases; 61%) and the pancreas (6/23 cases; 26%). The tissular consequences of toxoplasmic involvement varied considerably, from formation of pseudocysts or cysts without any surrounding inflammatory reaction to necrotic lesions rich in neutrophilic polynuclear cells containing numerous free parasites. Immunoperoxidase study using antitoxoplasmic antibodies contributed to the diagnosis of 8 extracerebral localizations. Electron microscopy examination of a surgical lung biopsy and myocardial specimens (2 cases) demonstrated the ultrastructural characteristics of Toxoplasma gondii trophozoites.(ABSTRACT TRUNCATED AT 250 WORDS)

Unusual cutaneous manifestations of miliary tuberculosis

Cutaneous manifestations of miliary tuberculosis are extremely rare. We describe a 62-year-old woman with leukopenia who developed infiltrated dermal-hypodermal and ulcerative cutaneous lesions during the course of miliary tuberculosis. Miliary tuberculosis was diagnosed when Mycobacterium tuberculosis bacilli were isolated by cultures of the bronchoalveolar lavage fluid and blood and when acid-fast bacilli were detected on histopathologic examination of hepatic, pulmonary, and cutaneous biopsy specimens. With the increasing incidence of immunocompromised patients, unusual presentations of tuberculosis may be observed more often. Acute miliary tuberculosis of the skin is an exceptional manifestation that is due to acute hematogenous dissemination of M. tuberculosis to the skin. We describe a patient who had unusual cutaneous manifestations of miliary tuberculosis.

Ability of stroke volume variation measured by oesophageal Doppler monitoring to predict fluid responsiveness during surgery

BACKGROUND

The objective of this study was to test whether non-invasive assessment of respiratory stroke volume variation (ΔrespSV) by oesophageal Doppler monitoring (ODM) can predict fluid responsiveness during surgery in a mixed population. The predictive value of ΔrespSV was evaluated using a grey zone approach.

METHODS

Ninety patients monitored using ODM who required i.v. fluids to expand their circulating volume during surgery under general anaesthesia were studied. Patients with a preoperative arrhythmia, right ventricular failure, frequent ectopic beats, or breathing spontaneously were excluded. Haemodynamic variables and oesophageal Doppler indices [peak velocity (PV), stroke volume (SV), corrected flow time (FTc), cardiac output (CO), ΔrespSV, and respiratory variation of PV (ΔrespPV)] were measured before and after fluid expansion. Responders were defined by a >15% increase in SV after infusion of 500 ml crystalloid solution.

RESULTS

SV was increased by ≥15% after 500 ml crystalloid infusion in 53 (59%) of the 90 patients. ΔrespSV predicted fluid responsiveness with an area under the receiver-operating characteristic (AUC) curve of 0.91 [95% confidence interval (95% CI): 0.85-0.97, P<0.0001]. The optimal ΔrespSV cut-off was 14.4% (95% CI: 14.3-14.5%). The grey zone approach identified 12 patients (14%) with a range of ΔrespSV values between 14% and 15%. FTc was not predictive of fluid responsiveness (AUC 0.49, 95% CI: 0.37-0.62, P=0.84).

CONCLUSIONS

ΔrespSV predicted fluid responsiveness accurately during surgery over a ΔrespSV range between 14% and 15%. In contrast, FTc did not predict fluid responsiveness.

The diffusion of pefloxacin into bone and the treatment of osteomyelitis

Pefloxacin was evaluated in the treatment of bone infections. A clinical trial was performed in 15 patients with chronic osteitis (5 Staphylococcus aureus, 5 Pseudomonas aeruginosa, 3 Serratia sp., 1 Proteus mirabilis, and a mixed infection with a Streptococcus faecalis and Escherichia coli). Patients were given pefloxacin 400 mg 12-hourly iv for 48 h followed by oral treatment. Bone biopsies from the iliac crest were carried out after at least seven days treatment, 2 h after the last dose. Serum levels were estimated at the same time. In 13 patients the pefloxacin levels were between 2 and 10 mg per g of bone and always greater than, or equal to, the MIC for the infecting organism. In 11 patients treated for six months and followed up for up to 14 months after the completion of treatment, the therapy was successful. In another two patients, the results were excellent with closure of fistulae, but there was only limited follow-up. There were two failures: in one (post-radiation osteitis) the infection persisted and in the other there was intolerance of the antimicrobial. In both cases there was no increase in the MIC of pefloxacin against the organisms. Three patients underwent operations for orthopaedic indications, after at least two months of treatment. Bone cultures from the initial focus remained sterile. Side-effects were mild.

Transoesophageal echocardiography in cardiac and vascular surgery: implications and observer variability

Transoesophageal echocardiography (TOE) has gained widespread acceptance among cardiac anaesthetists as a tool to facilitate peri-operative decision-making. This observational study analyses the impact of TOE and its inter-observer variability on intra-operative patient management during cardiac and major vascular surgery. From June 1996 to December 1998, standardized reports were obtained from 11 anaesthetists in 1891 adult cardiac and vascular surgery patients undergoing routine biplane or multiplane TOE. Inter-observer variability and the difference between variables of interest were tested using the chi-squared test or factorial analysis of variance as appropriate. TOE examinations were performed before and after the operation; 1,673 (88.5%) patients underwent cardiopulmonary bypass (CPB), and 218 (11.5%) patients had surgery without CPB, including 42 (2.2%) coronary revascularizations. In 923 patients (49%), TOE provided additional information that influenced the patient's therapy. In 968 patients (51%), TOE had only minor or no impact on clinical decision-making. In two patients (0.10%) the scheduled operation was not performed, and in another two patients the TOE examination led to major complications. Observer-dependent variables were: implications of TOE for intraoperative decision-making (P<0.0001), estimation of image quality (P < 0.0001), pre-operative left ventricular fractional area change (FAC) (P = 0.0026), difference between pre-operative FAC and post-operative FAC (P = 0.033), and requests for supervision (P < 0.0001). There was no significant difference in the case mix between observers. TOE had an important impact on intraoperative patient management. Inter-observer variability was significant for several variables but not for the frequency of additional surgical procedures.