A Radiation Therapy Contouring Atlas for Delineation of the Level I-II Axilla in the Prone Position

PURPOSE/OBJECTIVE(S)

When patients are treated prone for whole breast irradiation (WBI), the axilla typically receives less dose than when patients are treated with WBI in the supine position. There are situations, however, where the axilla is a target as in a situation where the physician intends to treat with "high tangents" to provide good coverage of both the breast and level I-II axilla. In these scenarios, ideal target delineation when the patient is in the prone position is not well-defined. While different consensus guidelines exist for delineation of the nodal areas in the supine position, to our knowledge there are no contouring guidelines for the regional nodes in the prone position based on bone, skin, vascular and muscle landmarks.

MATERIALS/METHODS

Forty-three patients treated with high tangents in the prone position from 2012-2018 were identified as representative cases. The level I and II regional nodal contours from the Radiation Therapy Oncology Group (RTOG) breast cancer atlas were adapted for prone position by a radiation oncologist and a breast radiologist based on anatomic considerations and changes observed from supine to prone positioning on diagnostic imaging. The revised nodal contours were reviewed by an expanded expert multidisciplinary panel including additional breast radiation oncologists and surgical oncologists to delineate the level I and II axilla on noncontrast computed tomography (CT) scans.

RESULTS

We adapted the RTOG breast cancer atlas, supported by detailed figures, in order to create a CT based atlas of the level I and II axillary lymph node stations in the prone position. For the level I axilla, the cranial and caudal anatomic boundaries remain unchanged. With transition to the prone position from supine, tenting of the pectoralis major occurs displacing the muscle from the chest wall and shifting the axillary space anteromedial to the lateral border of the pectoralis major. Therefore, the anterior boundary is now defined by the plane of the anterior extent of the pectoralis major to skin. The medial boundary is defined by the plane of the lateral border of the pectoralis major and pectoralis minor including to ribs and intercostal muscles. The lateral boundary is defined by the skin, cropped by 5mm. The posterior boundary is defined by the plane of the anterior surface of the latissimus dorsi and subscapularis muscle to skin. For the level II axilla, the cranial, posterior, medial and lateral boundaries remain unchanged. With transition from supine to prone, the axilla exhibits an anterolateral shift, now laterally abutting the lateral border of the pectoralis minor. The anterior boundary is now defined as the posterior aspect of the pectoralis major muscle. The caudal boundary is where the pectoralis minor inserts into ribs.

CONCLUSION

The adaptations to the RTOG breast cancer atlas for prone positioning will enable radiation oncologists to more accurately target the level I and II axilla when treating patients prone in whom the axilla is a target in addition to the breast.

GWAS meta-analysis of over 29,000 people with epilepsy identifies 26 risk loci and subtype-specific genetic architecture

Epilepsy is a highly heritable disorder affecting over 50 million people worldwide, of which about one-third are resistant to current treatments. Here we report a multi-ancestry genome-wide association study including 29,944 cases, stratified into three broad categories and seven subtypes of epilepsy, and 52,538 controls. We identify 26 genome-wide significant loci, 19 of which are specific to genetic generalized epilepsy (GGE). We implicate 29 likely causal genes underlying these 26 loci. SNP-based heritability analyses show that common variants explain between 39.6% and 90% of genetic risk for GGE and its subtypes. Subtype analysis revealed markedly different genetic architectures between focal and generalized epilepsies. Gene-set analyses of GGE signals implicate synaptic processes in both excitatory and inhibitory neurons in the brain. Prioritized candidate genes overlap with monogenic epilepsy genes and with targets of current antiseizure medications. Finally, we leverage our results to identify alternate drugs with predicted efficacy if repurposed for epilepsy treatment.

Incidents of violence and disruption reported by the National Abortion Federation's Canadian members in 2017

OBJECTIVE

To explore violence and disruption events reported by Canadian facilities providing abortion care in 2017, when only 3 provinces had passed safe access zone legislation.

METHODS

We reviewed self-reported data from 16 of 38 Canadian members of the National Abortion Federation.

RESULTS

Twelve facilities in 7 provinces reported 571 instances of picketing (97%), trespassing (>1%), threats of harm (>2%), and harassing calls/mail/emails (2%); 4 facilities reported no incidents. Freestanding clinics reported more picketing than hospital-based facilities.

DISCUSSION

Abortion providing facilities in Canada experienced picketing and other kinds of violence and disruption in 2017. These data serve as a baseline for future studies.

Increased Functional Connectivity After Listening to Favored Music in Adults With Alzheimer Dementia

BACKGROUND

Personalized music programs have been proposed as an adjunct therapy for patients with Alzheimer disease related dementia, and multicenter trials have now demonstrated improvements in agitation, anxiety, and behavioral symptoms. Underlying neurophysiological mechanisms for these effects remain unclear.

METHODS

We examined 17 individuals with a clinical diagnosis of Alzheimer disease related dementia using functional MRI following a training period in a personalized music listening program.

RESULTS

We find that participants listening to preferred music show specific activation of the supplementary motor area, a region that has been associated with memory for familiar music that is typically spared in early Alzheimer disease. We also find widespread increases in functional connectivity in corticocortical and corticocerebellar networks following presentation of preferred musical stimuli, suggesting a transient effect on brain function.

CONCLUSIONS

Findings support a mechanism whereby attentional network activation in the brain's salience network may lead to improvements in brain network synchronization.

The association of lung ultrasound images with COVID-19 infection in an emergency room cohort

Lung ultrasound could facilitate the triage of patients with suspected COVID‐19 infection admitted to the emergency room. We developed a predictive model for COVID‐19 diagnosis based on lung ultrasound and clinical features. We used ultrasound to image the lung bilaterally at two anterior sites, one and two hands below each clavicle, and a posterolateral site that was the posterior transverse continuation from the lower anterior site. We studied 100 patients, 31 of whom had a COVID‐19 positive reverse transcriptase polymerase chain reaction. A positive test was independently associated with: quick sequential organ failure assessment score ≥1; ≥3 B‐lines at the upper site; consolidation and thickened pleura at the lower site; and thickened pleura line at the posterolateral site. The model discrimination was an area (95%CI) under the receiver operating characteristic curve of 0.82 (0.75–0.90). The characteristics (95%CI) of the model’s diagnostic threshold, applied to the population from which it was derived, were: sensitivity, 97% (83–100%); specificity, 62% (50–74%); positive predictive value, 54% (41–98%); and negative predictive value, 98% (88–99%). This model may facilitate triage of patients with suspected COVID‐19 infection admitted to the emergency room.

Towards Semantic Brain Mapping Methodology Based on a Multidimensional Markup of Continuous Russian-Language Texts: an Attempt at Validation and Development

In the present study, we combine linguistic annotation of oral texts in Russian with the registration of BOLD signal in functional MRI experiments to determine how and where semantic categories are represented in the human brain. Using the same stimuli material, we also analyze the differences in cortical activation in three thematic domains: description of nature, description of working principles of technical devices and more self-referential texts, addressing the question of human identity in conflict situations. We discuss methodological problems within the two approaches (microanalysis and macroanalysis) to study brain activation in natural conditions, i.e. under a continuous speech flow. Within the thematic domain studies, only minimally significant differences in brain activation were registered during the listening to texts from the three thematic groups. This outcome leads to the conclusion that the approach of thematic group contrasts (cognitive subtraction methodology) is not sufficient to study the mechanisms of text comprehension, and should be replaced by the modeling of multidimensional representations of semantic categories in time. Within the semantic category approach, we describe the neurolinguistic process of text understanding as the activation of 15 clusters responsible for semantic categories (e.g. “Conflict”, “Mental”, “Social”). Our data demonstrate that the clusters are widely distributed across the human brain. In contrast to the previous studies, we suggest that deep subcortical structures are involved in the processing of certain categories as well. The observed lateralization of category processing underlines the involvement of the right hemisphere in the processing of meaning.

Use of a Dynamic Genetic Testing Approach for Childhood-Onset Epilepsy

IMPORTANCE

Although genetic testing is important for bringing precision medicine to children with epilepsy, it is unclear what genetic testing strategy is best in maximizing diagnostic yield.

OBJECTIVES

To evaluate the diagnostic yield of an exome-based gene panel for childhood epilepsy and discuss the value of follow-up testing.

DESIGN, SETTING, AND PARTICIPANTS

A case series study was conducted on data from clinical genetic testing at Children's Hospital of Philadelphia was conducted from September 26, 2016, to January 8, 2018. Initial testing targeted 100 curated epilepsy genes for sequence and copy number analysis in 151 children with idiopathic epilepsy referred consecutively by neurologists. Additional genetic testing options were offered afterward.

EXPOSURES

Clinical genetic testing.

MAIN OUTCOMES AND MEASURES

Molecular diagnostic findings.

RESULTS

Of 151 patients (84 boys [55.6%]; median age, 4.2 years [interquartile range, 1.4-8.7 years]), 16 children (10.6%; 95% CI, 6%-16%) received a diagnosis after initial panel analysis. Parental testing for 15 probands with inconclusive results revealed de novo variants in 7 individuals (46.7%), resulting in an overall diagnostic yield of 15.3% (23 of 151; 95% CI, 9%-21%). Twelve probands with nondiagnostic panel findings were reflexed to exome sequencing, and 4 were diagnostic (33.3%; 95% CI, 6%-61%), raising the overall diagnostic yield to 17.9% (27 of 151; 95% CI, 12%-24%). The yield was highest (17 of 44 [38.6%; 95% CI, 24%-53%]) among probands with epilepsy onset in infancy (age, 1-12 months). Panel diagnostic findings involved 16 genes: SCN1A (n = 4), PRRT2 (n = 3), STXBP1 (n = 2), IQSEC2 (n = 2), ATP1A2, ATP1A3, CACNA1A, GABRA1, KCNQ2, KCNT1, SCN2A, SCN8A, DEPDC5, TPP1, PCDH19, and UBE3A (all n = 1). Exome sequencing analysis identified 4 genes: SMC1A, SETBP1, NR2F1, and TRIT1. For the remaining 124 patients, analysis of 13 additional genes implicated in epilepsy since the panel was launched in 2016 revealed promising findings in 6 patients.

CONCLUSIONS AND RELEVANCE

Exome-based targeted panels appear to enable rapid analysis of a preselected set of genes while retaining flexibility in gene content. Successive genetic workup should include parental testing of select probands with inconclusive results and reflex to whole-exome trio analysis for the remaining nondiagnostic cases. Periodic reanalysis is needed to capture information in newly identified disease genes.

Gender differences in homocysteine concentrations, a population-based cross-sectional study

BACKGROUND AND AIMS

High concentrations of homocysteine are considered a risk factor for atherosclerosis and coronary artery disease. The aim of this study was to assess whether or not there are gender differences in the plasma concentrations of homocysteine.

METHODS AND RESULTS

Data were collected from medical records of individuals examined at a screening center in Israel between the years 2000-2014. Cross sectional analysis was carried out on 9237 men and 4353 women. Mean (SD) age of the study sample was 48.4 (9.7) and 47.7 (9.7) years for men and women respectively. Average homocysteine concentrations were 12.6 (5.9) and 9.6 (3.2) μmol/L in men and women respectively (p < 0.001). Prevalence of homocysteine concentrations above 15 μmol/L was found to be significantly higher in men than in women; 15.5% vs 3.9% respectively (p < 0.001). Low concentrations of vitamin (B12 < 200 pmol/L) and low concentrations of folate (<12 nmol/L) were found to be significantly higher in men than in women 20.4% vs. 16.0% and 18.5% vs. 10.8% respectively. Compared to women, men had a significantly higher odds ratio (95% CI) of having homocysteine concentrations above 15 μmol/L: non adjusted model, 4.47 (3.80-5.26); adjusted model for age, smoking status, body mass index, diabetes mellitus, kidney function and low serum concentrations of vitamin B12 and folate, 3.44 (2.89-4.09).

CONCLUSION

Plasma homocysteine concentrations are higher in men than in women. This may be a contributing factor to gender differences for developing atherosclerosis and coronary artery disease.

The sixth vital sign: HIV status assessment and severe illness triage in Uganda

Setting: Four in-patient health facilities in western Uganda. Objective: To determine the impact of an innovative multi-modal quality improvement program on human immunodeficiency virus (HIV) status assessment and the impact of HIV status on severe illness conditions and mortality. Design: This was a staggered, pre-post quasi-experimental study designed to assess a multi-modal intervention (collaborative improvement meetings, audit and feedback, clinical mentoring) for improving quality of care following formal training in the management of severe illness in low-income settings. Results: From August 2014 to May 2015, 5759 patients were hospitalized, of whom 2451 (42.6%) had their HIV status assessed; 395 (16.1%) were HIV-infected. HIV-infected patients were significantly more likely to meet criteria for shock (27.5% vs. 15.1%, risk ratio [RR] 1.8, 95% confidence interval [CI] 1.7-1.9, P < 0.001) and severe respiratory distress (6.7% vs. 4.3%, RR 1.5, 95%CI 1.2-2.0, P < 0.001), and were significantly more likely to die in hospital (12.0% vs. 2.9%, RR 4.1, 95%CI 3.2-5.4, P < 0.001). There was no evidence of improved HIV status assessment during the intervention period (36.5% vs. 44.8%, +8.3%, 95%CI -8.3 to 24.8, P = 0.33). Conclusions: Hospitalized HIV-infected patients in western Uganda are at high risk for severe illness and death. Novel quality improvement strategies are needed to enhance hospital-based HIV testing in high-burden settings.

Neurodevelopmental Disorders Caused by De Novo Variants in KCNB1 Genotypes and Phenotypes

Importance

Knowing the range of symptoms seen in patients with a missense or loss-of-function variant in KCNB1 and how these symptoms correlate with the type of variant will help clinicians with diagnosis and prognosis when treating new patients.

Objectives

To investigate the clinical spectrum associated with KCNB1 variants and the genotype-phenotype correlations.

Design, Setting, and Participants

This study summarized the clinical and genetic information of patients with a presumed pathogenic variant in KCNB1. Patients were identified in research projects or during clinical testing. Information on patients from previously published articles was collected and authors contacted if feasible. All patients were seen at a clinic at one of the participating institutes because of presumed genetic disorder. They were tested in a clinical setting or included in a research project.

Main Outcomes and Measures

The genetic variant and its inheritance and information on the patient's symptoms and characteristics in a predefined format. All variants were identified with massive parallel sequencing and confirmed with Sanger sequencing in the patient. Absence of the variant in the parents could be confirmed with Sanger sequencing in all families except one.

Results

Of 26 patients (10 female, 15 male, 1 unknown; mean age at inclusion, 9.8 years; age range, 2-32 years) with developmental delay, 20 (77%) carried a missense variant in the ion channel domain of KCNB1, with a concentration of variants in region S5 to S6. Three variants that led to premature stops were located in the C-terminal and 3 in the ion channel domain. Twenty-one of 25 patients (84%) had seizures, with 9 patients (36%) starting with epileptic spasms between 3 and 18 months of age. All patients had developmental delay, with 17 (65%) experiencing severe developmental delay; 14 (82%) with severe delay had behavioral problems. The developmental delay was milder in 4 of 6 patients with stop variants and in a patient with a variant in the S2 transmembrane element rather than the S4 to S6 region.

Conclusions and Relevance

De novo KCNB1 missense variants in the ion channel domain and loss-of-function variants in this domain and the C-terminal likely cause neurodevelopmental disorders with or without seizures. Patients with presumed pathogenic variants in KCNB1 have a variable phenotype. However, the type and position of the variants in the protein are (imperfectly) correlated with the severity of the disorder.

De novo GABRG2 mutations associated with epileptic encephalopathies

Epileptic encephalopathies are a devastating group of severe childhood onset epilepsies with medication-resistant seizures and poor developmental outcomes. Many epileptic encephalopathies have a genetic aetiology and are often associated with de novo mutations in genes mediating synaptic transmission, including GABAA receptor subunit genes. Recently, we performed next generation sequencing on patients with a spectrum of epileptic encephalopathy phenotypes, and we identified five novel (A106T, I107T, P282S, R323W and F343L) and one known (R323Q) de novo GABRG2 pathogenic variants (mutations) in eight patients. To gain insight into the molecular basis for how these mutations contribute to epileptic encephalopathies, we compared the effects of the mutations on the properties of recombinant α1β2γ2L GABAA receptors transiently expressed in HEK293T cells. Using a combination of patch clamp recording, immunoblotting, confocal imaging and structural modelling, we characterized the effects of these GABRG2 mutations on GABAA receptor biogenesis and channel function. Compared with wild-type α1β2γ2L receptors, GABAA receptors containing a mutant γ2 subunit had reduced cell surface expression with altered subunit stoichiometry or decreased GABA-evoked whole-cell current amplitudes, but with different levels of reduction. While a causal role of these mutations cannot be established directly from these results, the functional analysis together with the genetic information suggests that these GABRG2 variants may be major contributors to the epileptic encephalopathy phenotypes. Our study further expands the GABRG2 phenotypic spectrum and supports growing evidence that defects in GABAergic neurotransmission participate in the pathogenesis of genetic epilepsies including epileptic encephalopathies.

Risk factors for long-term mortality of Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia (SAB) is a fatal disease. We aimed to describe risk factors for long-term mortality with SAB. We analyzed data from a retrospectively collected database including 1,692 patients with SAB. We considered variables of infection and background conditions for the analysis of long-term survival. The Kaplan-Meier procedure was used for analysis of long-term survival. Variables significantly associated with mortality were analyzed using a Cox regression model. We included 1,692 patients in the analysis. Patients were followed for up to 22 years. Within one year, 62% of patients died and within 5 years 72% died. A total of 82% of patients aged 65 years and older died within 5 years. Independent predictors of long-term mortality were older age (Hazard ratio 1.029, 95% confidence interval 1.022-1.036), female gender (HR 1.302, 95% CI 1.118-1.517), pneumonia or primary/ unknown source of infection (HR 1.441, 95% CI 1.230-1.689), dementia (HR 1.234, 95% CI 1.004-1.516), higher Charlson score (HR 1.155, 95% CI 1.115-1.196), shock at onset (HR 1.776, 95% CI 1.430-2.207) and arrival to hospitalization from an institution (HR 1.319, 95% CI 1.095-1.563). Long-term survival of patients older than 65 years and of women with SAB is severely curtailed.

Multidrug-resistant Acinetobacter baumannii infections in lung transplant patients in the cardiothoracic intensive care unit

BACKGROUND

Multidrug-resistant (MDR) gram-negative bacteria are a growing threat to solid organ transplantation (SOT) patients in the intensive care unit (ICU). We aimed to examine the mortality rates of gram-negative MDR bacterial infection in SOT patients compared with patient population undergoing other cardiothoracic surgeries and hospitalized under similar ICU conditions.

METHODS

A retrospective study from a single medical center, including patients with MDR Acinetobacter baumannii and carbapenem-resistant Klebsiella pneumoniae infection, hospitalized in the cardiothoracic ICU. Data were collected from computerized databases, and data were verified using the hospitalization files. Microbiological data were provided by the microbiology laboratory.

RESULTS

During the study period, 205 SOT patients and 5031 other patients were hospitalized in the cardiothoracic ICU. Active infection with gram-negative MDR bacteria was identified in 147 patients, of which 37 underwent SOT (18% of total transplant recipients) and 110 underwent another cardiothoracic surgery (2% of total patients who are not transplant recipients). Mortality rates were high among both groups of patients, with no significant difference between them.

CONCLUSIONS

Infection with resistant bacteria is more prevalent among patients following SOT compared with patients following other cardiothoracic surgeries. Mortality is high in all patients regardless of the immunocompromised condition.

Association of vancomycin serum concentrations with efficacy in patients with MRSA infections: a systematic review and meta-analysis

Recent Infectious Diseases Society of America guidelines for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections recommend maintaining vancomycin trough concentrations of 15-20 mg/L for serious infections. We conducted a systematic review and meta-analysis of all studies assessing the impact of low (<15 mg/L) vs. high (≥ 15 mg/L) vancomycin trough level on the efficacy of MRSA infections treatment. Four prospective and 12 retrospective studies were included (2003 participants). No significant difference was demonstrated between low and high vancomycin trough level for the outcome of all-cause mortality (odds ratio (OR) 1.07, 95% confidence interval (CI) 0.78-1.46, I(2) = 28%). In studies evaluating mainly MRSA pneumonia, there was significantly higher mortality with low vancomycin level (OR 1.78, 95% CI 1.11-2.84). No significant difference was demonstrated in treatment failure rates (OR 1.25, 95% CI 0.88-1.78, I(2) = 51%). However, excluding one outlier study from the analysis, treatment failure became significantly higher in patients with low vancomycin trough level (OR 1.46, 95% CI 1.12-1.91, I(2) = 16%). Microbiologic failure rates were significantly higher in patients with low vancomycin levels (OR 1.56, 95% CI 1.08-2.26, I(2) = 0%). Nephrotoxicity was significantly higher with vancomycin levels of ≥ 15 mg/L. However, no cases of irreversible renal damage were reported. Current data on the effectiveness of higher vancomycin trough levels in the treatment of MRSA infections are limited to few prospective and mainly retrospective studies. Our findings support the current recommendations for maintaining vancomycin trough levels of ≥ 15 mg/L in the treatment of severe MRSA infections, although no difference in all-cause mortality was observed.

Predicting Clostridium difficile infection in diabetic patients and the effect of metformin therapy: a retrospective, case-control study

Data on risk factors for Clostridium difficile infection (CDI) in diabetic patients are scarce. Recently, it has been shown that metformin increases the Bacteroidetes/Firmicutes ratio; therefore, it may yield a protective effect against CDI. We aimed to assess risk factors for CDI in diabetic patients beyond antibiotic treatment, and to determine the impact of metformin therapy on the development of CDI in these patients. In this retrospective, case-control study, all consecutive CDI diabetic patients, from January 2009 to December 2013, were included and compared to consecutive diabetic patients without CDI, hospitalized during the same period and in the same departments. Of 7,670 patients tested for C. difficile toxins, 486 were diabetics. Of them, 150 (30.8 %) were positive for C. difficile toxins and 336 (69.1 %) were negative. On multivariate analysis, metformin treatment was associated with a significant reduction in CDI [odds ratio (OR) = 0.58; 95 % confidence interval (CI), 0.37-0.93; p = 0.023], while heart failure was associated with significantly higher rates of CDI (OR = 1.654; 95 % CI, 1.007-2.716; p = 0.047), together with poor functional status, previous hospitalization, and abdominal surgery. Our findings suggest that, in diabetic patients, in addition to the well-recognized risk factors, heart failure is an additional risk factor for CDI, while metformin treatment seems to have a protective effect against the development of CDI. The exact mechanisms underlying this protective effect remain to be fully understood.

The role of FDG-PET/CT imaging in early detection of extra-cardiac complications of infective endocarditis

The exact incidence of extra-cardiac complications (ECC) in patients with infective endocarditis (IE) is unknown but presumed to be high. These patients, although mostly asymptomatic, may require a more aggressive therapeutic approach. (18)fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) is used for the diagnosis of infections, but its role in the early diagnosis of IE complications is still unclear. This study aimed to evaluate the role of FDG-PET/CT in the early diagnosis of ECC in IE and its implications for medical management. We prospectively studied 40 consecutive patients with a confirmed diagnosis of IE (according to the modified Duke criteria) who underwent a whole body FDG-PET/CT study within 14 days from diagnosis. The FDG-PET/CT demonstrated ECC in 17 (42.5%) patients, while 8 (38.1%) of them were asymptomatic. The most frequent embolic sites were musculoskeletal and splenic. Owing to the FDG-PET/CT findings, treatment planning was modified in 14 (35%) patients. This included antibiotic treatment prolongation (27.5%), referral to surgical procedures (15%) and, most substantially, prevention of unnecessary device extraction (17.7%). According to our experiences, FDG-PET/CT imaging was useful in the detection of embolic and metastatic infections in IE. This clinical information had a significant diagnostic and therapeutic impact in managing IE disease.

Monomicrobial necrotizing fasciitis in a single center: the emergence of Gram-negative bacteria as a common pathogen

BACKGROUND

Necrotizing fasciitis (NF) is a life-threatening soft tissue infection. It is usually caused by Streptococcus pyogenes and other Gram-positive bacteria. Several reports, however, emphasize the importance of Gram-negative rods in this infection.

METHODS

We retrospectively studied all cases of monomicrobial necrotizing fasciitis hospitalized in our center during the years 2002-2012. We compared clinical characteristics and outcomes of patients with Gram-negative versus Gram-positive infection.

RESULTS

Forty-five cases were reviewed, 19 caused by Gram-negative organisms, 10 of them Escherichia coli, and 26 caused by Gram-positive organisms, 10 of them S. pyogenes. Compared to Gram-positive infections, patients with Gram-negative infections were more likely to have a baseline malignancy (9/19, 47.4%) or to have undergone recent surgery (4/19, 42.3%). The 30-day mortality was higher among Gram-negative infected patients (8/19, 42.1% vs. 8/26, 30.8%). Creatine phosphokinase (CPK) was elevated in a minority of patients with Gram-negative necrotizing fasciitis, and its absolute value was lower than in Gram-positive necrotizing fasciitis.

CONCLUSIONS

In our center, 42% of monomicrobial necrotizing fasciitis cases were found to be caused by Gram-negative organisms, mostly E. coli. These infections usually appeared in immunocompromised or postoperative patients, often presented with normal CPK levels, and were associated with high mortality rates.

Effect of feeding hemp seed and hemp seed oil on laying hen performance and egg yolk fatty acid content: evidence of their safety and efficacy for laying hen diets

Forty-eight 19-wk-old Bovan White laying hens were fed 1 of 5 diets containing either hemp seed (HS) or hemp seed oil (HO). The level of HO was 4, 8, or 12%, whereas the level was 10 or 20% for the HS. A set of 8 birds fed wheat-, barley-, and corn oil-based diets served as the control. Performance was monitored over 12 wk. Average hen-day egg production was not affected upon feeding of either HS or HO diets. Egg weight was higher than that of the controls for hens consuming the 20% HS diet (P < 0.05). Feed intake was lower than that of the controls for birds consuming the 4% HO diet but similar across other treatments. Final BW were not affected by diet, with the exception of being lower than that of the controls (P < 0.05) in hens consuming the 12% HO diet. The total egg yolk n-3 fatty acid content increased linearly (P < 0.05) with increasing dietary α-linolenic acid provision with the HS- or HO-based diets. A quadratic response (P < 0.05) was observed for docosahexaenoic acid levels in egg yolk in response to increasing dietary α-linolenic acid supply. The expression of hepatic fatty acid desaturase 1 and 2, key genes for the desaturation of long-chain polyunsaturated fatty acids, was significantly decreased (50-60% of controls; P < 0.05) as a result of feeding HS or HO diets. Based on the results from the current study, the inclusion of the hemp products HS or HO in the diets of laying hens up to a maximum level of 20 and 12%, respectively, does not adversely effect the performance of laying hens and leads to the enrichment of the n-3 fatty acid content of eggs.

Organ transplantation from a donor colonized with a multidrug-resistant organism: a case report

The number of intensive care unit patients with infections caused by multidrug-resistant organisms is increasing in most developed countries. We report the case of a deceased multiorgan donor, who was an asymptomatic carrier of carbapenem-resistant Klebsiella pneumoniae (CR-KP) in the respiratory tract, a condition that was not diagnosed before organ harvesting and transplantation. The outcome of the 2 kidney recipients, the liver recipient, and 1 of the lung recipients was uneventful; in particular, no evidence of infection transmission or adverse graft outcomes was noted. The other lung recipient had a complicated postoperative course and, 4 weeks post transplantation, he developed a bacteremic pneumonia with CR-KP from which he subsequently died. These results suggest that, in well defined conditions, organs from donors who are CR-KP positive may be considered for transplantation.

Hippocampal microcircuit dynamics probed using optical imaging approaches

Mammalian cortical structures are endowed with the capacity for plasticity, which emerges from a combination of the dynamics of circuit connectivity and function, and the intrinsic function of the neurons within the circuit. However, this capacity is accompanied by a significant risk: the capability to generate seizure discharges is also a property of all mammalian cortices. How do cortical circuits reconcile the requirement to maintain plasticity, but at the same time control seizure initiation? These issues come into particular focus in the hippocampus. The hippocampus is one of the main plasticity engines in the brain, and is also a structure frequently implicated in the generation of epileptic seizures, with temporal lobe epilepsy constituting the most prevalent form of epilepsy in the adult population. One aspect of hippocampal circuitry that is particularly prominent is its intimate interconnections with the entorhinal cortex. These interconnections create a number of excitatory synaptic loops within the limbic system, which, in addition to being important in cognitive function, can support reentrant activation and seizure generation. In the present review, using optical imaging approaches to elucidate circuit processing at high temporal and spatial resolution, we examine how two targets of entorhinal cortical input within the hippocampus, the dentate gyrus and area CA1, regulate these synaptic pathways in ways that can maintain functions important in generation of normal activity patterns, but that dampen the ability of these inputs to generate seizure discharges.

[Intraarticular fractures of the proximal interphalangeal joint: dynamic early functional therapy with an external fixation system]

The results of treating fracture dislocations of the proximal interphalangeal joint are often unsatisfactory for the patient because conservative methods cannot prevent stiffness of the joint. Thus, early functional treatment with external fixation systems is increasingly favoured. This therapy combines the principles of ligamentotaxis and the possibility of early movement of the injured joint. The frequently modified pins and rubbers traction system is especially effective. It is cheap, easy to apply, and well accepted by patients due to its light weight and small size. This paper gives an overview of the therapeutic options and the clinical results of treating fractures of the proximal interphalangeal joint.

3He spin-dependent cross sections and sum rules

We present a measurement of the spin-dependent cross sections for the 3He over -->(e over -->,e')X reaction in the quasielastic and resonance regions at a four-momentum transfer 0.1< or =Q2< or =0.9 GeV2. The spin-structure functions have been extracted and used to evaluate the nuclear Burkhardt-Cottingham and extended Gerasimov-Drell-Hearn sum rules for the first time. The data are also compared to an impulse approximation calculation and an exact three-body Faddeev calculation in the quasielastic region.

The need for macrolides in hospitalised community-acquired pneumonia: propensity analysis

The present study compared beta-lactam macrolide ("combination") therapy versus beta-lactam alone ("monotherapy") for hospitalised community-acquired pneumonia, using propensity scores to adjust for the differences between patients. A prospective multinational observational study was carried out. Baseline patient and infection characteristics were used to develop a propensity score for combination therapy. Patients were matched by the propensity score (three decimal point precision) and compared with 30-day mortality and hospital stay. The propensity score was used as a covariate in a logistic model for mortality. Patients treated with monotherapy (n = 169) were older (mean+/-sd age 70.6+/-17.3 versus 65.0+/-19.6 yrs), had a higher chronic diseases score and a different clinical presentation compared with patients treated with combination therapy (n = 282). Unadjusted mortality was significantly higher with monotherapy (37 (22%) out of 169 versus 21 (7%) out of 282). Only 27 patients in the monotherapy group could be matched to 27 patients in the combination group using the propensity score. The mortality in these groups was identical, with three (11%) demises each. The multivariable odds ratio for mortality associated with combination therapy, adjusted for the propensity score and the Pneumonia Severity Index, was 0.69 (95% confidence interval 0.32-1.48). The benefit of combination therapy versus monotherapy cannot be reliably assessed in observational studies, since the propensity to prescribe these regimens differs markedly.

Vaccines for preventing typhoid fever

BACKGROUND

Two typhoid vaccines are commercially available, Ty21a (oral) and Vi polysaccharide (parenteral), but neither is used routinely. Other vaccines, such as a new modified, conjugated Vi vaccine called Vi-rEPA, are in development.

OBJECTIVES

To evaluate vaccines for preventing typhoid fever.

SEARCH STRATEGY

In December 2006, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2006, Issue 3), MEDLINE, EMBASE, LILACS, and mRCT. We also searched relevant conference proceedings up to 2004 and scanned the reference lists of all included trials.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials (RCTs) comparing typhoid fever vaccines with other typhoid fever vaccines or an inactive agent (placebo or vaccine for a different disease).

DATA COLLECTION AND ANALYSIS

Two authors independently applied inclusion criteria and extracted data. We computed vaccine efficacy per year of follow up and cumulative three-year efficacy, stratifying for vaccine type and dose. We calculated relative risks (RR) and efficacy (1-RR as a percentage) with 95% confidence intervals (CI).

MAIN RESULTS

Of the 17 included RCTs, 10 evaluated efficacy (Ty21a: 5 trials; Vi polysaccharide: 4 trials, Vi-rEPA: 1 trial), and 11 reported on adverse events.Ty21a vaccine (3 doses). According to one trial (20,543 participants), this vaccine provided statistically significant protection in each of the first three years (one: 35%, 95% CI 8% to 54%; two: 58%, 95% CI 40% to 71%; three: 46%, 95% CI -6% to 72%), and the cumulative efficacy for 2.5 to 3 years was 48% (95% CI 34% to 58%). Four cluster-RCTs that did not adjust for clustering were not included in the meta-analyses. Compared with placebo, this vaccine was not associated with an increased rate of fever, vomiting, diarrhoea, nausea or abdominal pain, headache, or rash.Vi polysaccharide vaccine (1 dose). This vaccine provided protection in year one (68%, 95% CI 50% to 80%; 99,979 participants, 3 trials) and year two (60%, 95% CI 31% to 76%; 142,555 participants, 2 trials), but not in year three (11,384 participants, 1 trial). The three-year cumulative efficacy was 55% (95% CI 30% to 70%; 11,384 participants, 1 trial). Compared with placebo, there was no statistically significant difference in the incidence of fever or erythema, but local swelling was more common with the vaccine.Vi-rEPA vaccine (2 doses). In one trial of 12,008 participants, this vaccine provided protection in year one (94%, 95% CI 75% to 99%) and year two (87%, 95% CI 56% to 96%). Cumulative efficacy at 46 months (3.8 years) was 89% (95% CI 76% to 97%). No swelling or erythema occurred in the vaccine or placebo group; fever was more frequent in the vaccine group.

AUTHORS' CONCLUSIONS

The licensed Ty21a and Vi polysaccharide vaccines are efficacious. The new and unlicensed Vi-rEPA vaccine is as efficacious and may confer longer immunity.