1,3-Dioxane-Linked Novel Bacterial Topoisomerase Inhibitors: Expanding Structural Diversity and the Antibacterial Spectrum

Antibacterial resistance continues its devastation of available therapies. Novel bacterial topoisomerase inhibitors (NBTIs) offer one solution to this critical issue. Two series of amine NBTIs bearing tricyclic DNA-binding moieties as well as amide NBTIs with a bicyclic DNA-binding moiety were synthesized and evaluated against methicillin-resistant Staphylococcus aureus (MRSA). Additionally, these compounds and a series of bicyclic amine analogues displayed high activity against susceptible and drug-resistant Neisseria gonorrhoeae, expanding the spectrum of these dioxane-linked NBTIs.

Optimization of TopoIV Potency, ADMET Properties, and hERG Inhibition of 5-Amino-1,3-dioxane-Linked Novel Bacterial Topoisomerase Inhibitors: Identification of a Lead with In Vivo Efficacy against MRSA

Novel bacterial topoisomerase inhibitors (NBTIs) are among the most promising new antibiotics in preclinical/clinical development. We previously reported dioxane-linked NBTIs with potent antistaphylococcal activity and reduced hERG inhibition, a key safety liability. Herein, polarity-focused optimization enabled the delineation of clear structure-property relationships for both microsomal metabolic stability and hERG inhibition, resulting in the identification of lead compound 79. This molecule demonstrates potent antibacterial activity against diverse Gram-positive pathogens, inhibition of both DNA gyrase and topoisomerase IV, a low frequency of resistance, a favorable in vitro cardiovascular safety profile, and in vivo efficacy in a murine model of methicillin-resistant Staphylococcus aureus infection.

Urate lowering therapy is associated with a lower risk of heart failure hospitalisation or mortality in hyperuricaemic patients with heart failure: a comparative effectiveness study

Background

There is a strong association between hyperuricemia (elevated serum uric acid) and the risk of heart failure. However, it remains unclear whether prescribing urate lowering therapies have any bearing on long term clinical outcomes.

Purpose

In this study, we assessed the impact of urate lowering therapy treatment on the risk of adverse health outcomes (hospitalisation for heart failure and all-cause mortality) in patients with hyperuricemia and heart failure.

Methods

We utilised data from Clinical Practice Research Datalink (CPRD) GOLD, a UK-based primary care database linked to secondary care (Hospital Episode Statistics) and mortality data (Office of National Statistics). The study population included patients with a first record of hyperuricemia (serum uric acid >7 mg/dl for men and >6 mg/dl for women or a gout diagnosis) between 1990 and 2019 with a history of heart failure. Incident urate lowering therapy users were identified post hyperuricemia diagnosis. To account for potential confounding variables and potential treatment paradigm changes over the study period, a propensity score matched cohort was constructed for urate lowering therapy initiators and non-initiators within 6 month accrual blocks. Adverse health outcomes were compared between matched treatment groups using Cox regression analysis adjusted for the same variables used in the propensity score. Due to extensive treatment switching and discontinuation, on-treatment analysis was the main analysis.

Results

A total of 2,174 propensity score matched pairs were identified. We found that urate lowering therapy was associated with a 43% lower risk of all-cause mortality or hospitalization for heart failure (Figure 1, adjusted hazard ratio 0.57, 95% confidence interval 0.51–0.65), and a 19% lower risk of cardiovascular mortality or hospitalization for heart failure (Figure 2, adjusted hazard ratio 0.81, 95% confidence interval 0.71–0.92) within five years compared to those not on therapy (on-treatment analysis). In an intention-to-treat sensitivity analysis, urate lowering therapy was associated with a 17% lower risk of all-cause mortality or hospitalization for heart failure (adjusted hazard ratio 0.83, 95% confidence interval 0.76–0.91), and a 11% lower risk of cardiovascular mortality or hospitalization for heart failure (adjusted hazard ratio 0.89, 95% confidence interval 0.81–0.98) within five years compared to those not on urate lowering therapy. Adjusted and non-adjusted hazard ratios were consistent for all outcomes.

Conclusion

We found that urate lowering therapy was associated with a lower risk of adverse outcomes in hyperuricemia or gout patients with a history of heart failure. These results are consistent with the hypothesis that uric acid lowering may lead to improved outcome in patients with heart failure and hyperuricemia, emphasizing the need to investigate the potential benefits of intense uric acid lowering in prospective randomized controlled trials.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca Figure 1 (HF = heart failure)Figure 2 (CV = cardiovascular)

178 Outcomes After Paediatric Extracorporeal Cardiopulmonary Resuscitation (ECPR) In A Tertiary Centre

Objective

To report our outcomes in utilizing extracorporeal membrane oxygenation (ECMO) institution for cardiac arrest.

Method

Retrospective records of all patients that needed ECPR between January 2015 and July 2020 have been reviewed. Primary outcomes were survival to ECMO decannulation, hospital discharge and one year survival. Secondary outcomes were the need for ECMO re-cannulation and neurology outcome using Paediatric Cerebral Performance Category (PCPC).

Results

A total of 44 consecutive patients were identified. 75 % were post cardiac surgery (n = 33), mean time from arrest to initiation of ECMO was 39.5 mins +/- 17.7 mins. Mean highest lactate prior to ECMO was 12.9 +/- 4.4. 79.6 % of patients received central cannulation. 11.4 % of patients (n = 5) needed more than one run of ECMO. Mean hours on ECMO were 175.4 +/- 212.5 hours and mean PCPC score was 2.14 +/- 1.68. Mean ICU stay was 16.2 +/- 16.9 days and total hospital stay was 47 +/- 68.5 days. Overall Survival to ECMO weaning was 68.4 % (n = 13) vs 92 % (n = 23) in neonates and paediatric patients, respectively. Survival to hospital discharge was 47.4 % (n = 9) vs 72 % (n = 18) and one year survival was 42.1 % (n = 8) vs 72 % (n = 18) in the neonatal and paediatric cohort, respectively.

Conclusions

Our survival rates are encouraging and in line with current published literature and comparable favourably to International ELSO (Extracorporeal life support organisation) registry for neonates and paediatric patients of all cause ECPR. Paediatric patients showed a survival advantage over neonates after ECPR.

Dioxane-Linked Amide Derivatives as Novel Bacterial Topoisomerase Inhibitors against Gram-Positive Staphylococcus aureus

In recent years, novel bacterial topoisomerase inhibitors (NBTIs) have been developed as future antibacterials for treating multidrug-resistant bacterial infections. A series of dioxane-linked NBTIs with an amide moiety has been synthesized and evaluated. Compound 3 inhibits DNA gyrase, induces the formation of single strand breaks to bacterial DNA, and achieves potent antibacterial activity against a variety of Gram-positive pathogens, including methicillin-resistant Staphylococcus aureus (MRSA). Optimization of this series of analogues led to the discovery of a subseries of compounds (22-25) with more potent anti-MRSA activity, dual inhibition of DNA gyrase and topoisomerase IV, and the ability to induce double strand breaks through inhibition of S. aureus DNA gyrase.

Landspreading with co-digested cattle slurry, with or without pasteurisation, as a mitigation strategy against pathogen, nutrient and metal contamination associated with untreated slurry

North Atlantic European grassland systems have a low nutrient use efficiency and high rainfall. This grassland is typically amended with unprocessed slurry, which counteracts soil organic matter depletion and provides essential plant micronutrients but can be mobilised during rainfall events thereby contributing to pathogen, nutrient and metal incidental losses. Co-digesting slurry with waste from food processing mitigates agriculture-associated environmental impacts but may alter microbial, nutrient and metal profiles and their transmission to watercourses, and/or soil persistence, grass yield and uptake. The impact of EU and alternative pasteurisation regimes on transmission potential of these various pollutants is not clearly understood, particularly in pasture-based agricultural systems. This study utilized simulated rainfall (Amsterdam drip-type) at a high intensity indicative of a worst-case scenario of ~11 mm hr^-1 applied to plots 1, 2, 15 and 30 days after grassland application of slurry, unpasteurised digestate, pasteurised digestate (two conditions) and untreated controls. Runoff and soil samples were collected and analysed for a suite of potential pollutants including bacteria, nutrients and metals following rainfall simulation. Grass samples were collected for three months following application to assess yield as well as nutrient and metal uptake. For each environmental parameter tested: microbial, nutrient and metal runoff losses; accumulation in soil and uptake in grass, digestate from anaerobic co-digestion of slurry with food processing waste resulted in lower pollution potential than traditional landspreading of slurry without treatment. Reduced microbial runoff from digestate was the most prominent advantage of digestate application. Pasteurisation of the digestate further augmented those environmental benefits, without impacting grass output. Anaerobic co-digestion of slurry is therefore a multi-beneficial circular approach to reducing impacts of livestock production on the environment.

Behavioural, social and structural-level risk factors for developing AIDS among HIV-positive people who use injection drugs in a Canadian setting, 1996-2017

People who use injection drugs (PWID) experience high rates of HIV acquisition and, as a result of lower rates of optimal access and adherence to combination antiretroviral therapy (ART), experience worse HIV treatment outcomes than other key affected populations. However, the incidence and risk factors for the development of AIDS among HIV-positive PWID have not been completely described. We used data from a community-recruited prospective cohort of HIV-positive PWID in Vancouver, Canada, a setting with universal no-cost ART and a comprehensive clinical monitoring registry. We used multivariable extended Cox models to identify factors associated with time to AIDS. Between 1996 and 2017, 396 participants, including 140 (35.4%) women, were followed for a median of 39.0 months (interquartile range: 16.6-76.2), among whom 165 (41.7%) developed AIDS. In a multivariable model, homelessness (Adjusted Hazard Ratio [AHR] = 1.76 (1.18-2.61)) and injection drug use within the preceding six months (AHR = 1.74 (1.17-2.58)) were independently associated with a higher risk of developing AIDS. Despite widespread scale-up of programmes to improve ART utilization, significant risk factors for the development of AIDS remain among HIV-positive PWID in this setting.

Determination of Naringin and Neohesperidin in Orange Juice by Liquid Chromatography with UV Detection to Detect the Presence of Grapefruit Juice: Collaborative Study

Fifteen collaborating laboratories were sent 9 samples of citrus juice mixtures as blind duplicates for determination of naringin and neohesperidin by liquid chromatography. Two sample pairs were 100% orange juice and did not contain any naringin or neohesperidin. The remaining 7 sample pairs contained naringin at levels ranging from 3.9 to 46.5 ppm and neohesperidin at levels ranging from 0.14 to 35.6 ppm. Five sample pairs consisted of orange juice mixtures containing 1, 3, and 5% grapefruit juice; 5% sour orange; and 5% K-Early citrus variety. Two sample pairs were orange juice spiked with naringin, neohesperidin, sodium benzoate, and potassium sorbate. Data were received from 13 laboratories. Data from 1 collaborator were eliminated because the method protocol was not followed. Neohesperidin values from another laboratory were also not used because of problems with a coeluting component. Repeatability relative standard deviations ranged from 2.95 to 15.23% for naringin and from 3.00 to 11.74% for neohesperidin. Reproducibility relative standard deviations ranged from 11.34 to 31.94% for naringin and from 10.45 to 26.17% for neohesperidin. The method is reliable for detecting the presence of grapefruit juice in orange juice as indicated by a finding of ≥10 ppm naringin and ≤2 ppm neohesperidin. The method was adopted First Action by AOAC INTERNATIONAL.

Dispensation of antiretroviral therapy and methadone maintenance therapy at the same facility in a low-barrier setting linked to optimal adherence to HIV treatment

OBJECTIVES

We sought to examine the association between dispensation of methadone maintenance therapy (MMT) and antiretroviral therapy (ART) at the same facility, across multiple low-barrier dispensing outlets, and achieving optimal adherence to ART among people who use illicit drugs (PWUD).

METHODS

We used data from the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS) study, a long-running study of a community-recruited cohort of HIV-positive PWUD, linked to comprehensive HIV clinical records in Vancouver, Canada, a setting of no-cost, universal access to HIV care. The longitudinal relationship between MMT-ART dispensation at the same facility and the odds of ≥ 95% ART adherence was analysed using multivariable generalized linear mixed-effects modelling. We conducted a further analysis using a marginal structural mode with inverse probability of treatment weights as a sensitivity analysis.

RESULTS

This study included data on 1690 interviews of 345 ART- and MMT-exposed participants carried out between June 2012 and December 2017. In the final multivariable model, MMT-ART dispensation, compared with nondispensation at the same facility, was associated with greater odds of achieving ≥ 95% adherence [adjusted odds ratio (AOR) 1.56; 95% confidence interval (CI) 1.26-1.96]. A marginal structural model estimated a 1.48 (95% CI 1.15-1.80) greater odds of ≥ 95% adherence among participants who reported MMT-ART dispensation at the same facility compared with those who did not.

CONCLUSIONS

The odds of achieving optimal adherence to ART were 56% higher during periods in which MMT and ART medications were dispensed at the same facility, in a low-barrier setting. Our findings highlight the need to consider a simpler integrated approach with medication dispensation at the same facility in low-threshold settings.

1,3-Dioxane-Linked Bacterial Topoisomerase Inhibitors with Enhanced Antibacterial Activity and Reduced hERG Inhibition

The development of new therapies to treat methicillin-resistant Staphylococcus aureus (MRSA) is needed to counteract the significant threat that MRSA presents to human health. Novel inhibitors of DNA gyrase and topoisomerase IV (TopoIV) constitute one highly promising approach, but continued optimization is required to realize the full potential of this class of antibiotics. Herein, we report further studies on a series of dioxane-linked derivatives, demonstrating improved antistaphylococcal activity and reduced hERG inhibition. A subseries of analogues also possesses enhanced inhibition of the secondary target, TopoIV.

Are Irish therapists at heightened risk for low back pain?

BACKGROUND

Within the international literature, no studies have been identified that compare prevalence rates of low back pain (LBP) in chartered physiotherapists, physical and athletic therapists and those in the national working population, making it unclear whether such therapists are an occupational group at high risk of developing LBP.

AIMS

To establish the prevalence of LBP among therapists (both employed and self-employed) in Ireland, to compare the employment status-, gender- and age-specific LBP prevalence rates between therapists and the national working population and to estimate the adjusted odds of developing LBP among therapists relative to the national working population.

METHODS

An analysis of data from the Health In Hand Intensive Tasks and Safety (HITS) study and the third national Survey on Lifestyle, Attitudes and Nutrition (SLÁN). The HITS study was a cross-sectional study investigating work-related musculoskeletal disorders in practising therapists. The SLÁN 2007 was a face-to-face interview study of adults.

RESULTS

LBP prevalence in therapists was 49% with no significant difference by employment status. Therapists had a much higher prevalence compared with the national working population across all demographic strata, with therapists nearly five times more likely to suffer from LBP than the national working population after careful adjustment for differences in sociodemographic factors.

CONCLUSIONS

Therapists in Ireland are an occupational group at high risk of developing LBP, warranting further research into their physical and psychosocial work-related risk factors.

Will smaller plates lead to smaller waists? A systematic review and meta-analysis of the effect that experimental manipulation of dishware size has on energy consumption

It has been suggested that providing consumers with smaller dishware may prove an effective way of helping people eat less and preventing weight gain, but experimental evidence supporting this has been mixed. The objective of the present work was to examine the current evidence base for whether experimentally manipulated differences in dishware size influence food consumption. We systematically reviewed studies that experimentally manipulated the dishware size participants served themselves at a meal with and measured subsequent food intake. We used inverse variance meta-analysis, calculating the standardized mean difference (SMD) in food intake between smaller and larger dishware size conditions. Nine experiments from eight publications were eligible for inclusion. The majority of experiments found no significance difference in food intake when participants ate from smaller vs. larger dishware. With all available data included, analysis indicated a marginal effect of dishware size on food intake, with larger dishware size associated with greater intake. However, this effect was small and there was a large amount of heterogeneity across studies (SMD: -0.18, 95% confidence interval: -0.35, 0.00, I(2) = 77%). Evidence to date does not show that dishware size has a consistent effect on food intake, so recommendations surrounding the use of smaller plates/dishware to improve public health may be premature.

Stability of premixed syringes of diamorphine and hyperbaric bupivacaine

BACKGROUND

It is common clinical practice to add diamorphine to heavy bupivacaine when performing spinal anaesthesia for either obstetric or general surgical procedures. If pre-filled syringes were available potential problems arising due to the wrong mixture being administered could be reduced, whilst also providing greater assurances of sterility and accuracy of dosage. It is therefore necessary to establish whether diamorphine 100 microg/mL is stable in solution with 0.5% hyperbaric bupivacaine, to allow production of pre-filled syringes for use in spinal anaesthesia.

METHOD

Diamorphine hydrochloride was dissolved in water for injection, and added to hyperbaric bupivacaine then stored in 5-mL plastic syringes. Eleven syringes were stored at 40 degrees C/75% relative humidity, 25 degrees C/60% relative humidity and 7 degrees C for 90 days. Samples were taken at five time points for measurement of diamorphine and bupivacaine concentrations using high performance liquid chromatography.

RESULTS

Diamorphine concentrations fell over the study period. No significant changes were observed the bupivacaine content of the samples. There was 10% degradation of diamorphine after 4 days at 40 degrees C, after 7 days at 25 degrees C, and after 26 days at 7 degrees C.

CONCLUSION

Diamorphine is stable in hyperbaric bupivacaine at 7 degrees C for long enough to allow preparation of pre-filled syringes in advance (by hospital pharmacy aseptic units) for use in spinal anaesthesia.

Malignant nonfunctioning pheochromocytoma occurring in a mixed multiple endocrine neoplasia syndrome

OBJECTIVE

To present the first documented case of malignant nonfunctioning pheochromocytoma occurring in a mixed multiple endocrine neoplasia (MEN) syndrome.

METHODS

We describe the personal and family history of a 34-year-old man with headaches, increased serum prolactin levels, and hyperparathyroidism and review the details of his clinical course and treatment.

RESULTS

After diagnosis of a prolactinoma, bromocriptine therapy was implemented but eventually discontinued by the patient when severe headaches recurred. A transsphenoidal resection of a prolactinoma was performed; the patient continued to have abnormally high serum prolactin levels. Subsequent left lower flank pain prompted an exploratory laparotomy, and a left nephroad-renalectomy was performed. Pathologic examination disclosed a 1-cm tumor, consistent with malignant pheochromocytoma. Electron microscopy demonstrated neurosecretory granules. A hypercoagulable state complicated the course postoperatively. Despite chemotherapy, extensive metastatic disease ensued, and the patient died.

CONCLUSION

Although pheochromocytomas are usually associated with MEN type IIA and type IIB, this patient had a malignant pheochromocytoma, without the usual clinical and biochemical manifestations, in the setting of MEN type I.

Multiple endocrine neoplasia and polyglandular autoimmune syndrome: a new association

OBJECTIVE

To report a new association between polyglandular autoimmune syndrome and multiple endocrine neoplasia.

METHODS

We present a detailed case report and discuss the various types of polyglandular failure and multiple endocrine neoplasia.

RESULTS

A 56-year-old woman with a past history of primary hypothyroidism and impaired glucose tolerance was admitted to the hospital for removal of renal staghorn calculi. In addition to the presence of mucocutaneous candidiasis, vitiligo, and macroglossia, the patient was found to have truncal obesity, a "buffalo hump," and supraclavicular fat pads. Subsequent workup confirmed the presence of Cushing's disease and primary hyperparathyroidism.

CONCLUSION

A hitherto unreported association between polyglandular autoimmune syndrome type II and multiple endocrine neoplasia type I is documented in our current patient.

High-power 980-nm pump laser modules for erbium-doped fiber amplifiers

High-power fiber-coupled pump modules with an emission wavelength of 980 nm and output powers in excess of 200 mW, as measured at the fiber end, have been fabricated. Laser-to-fiber coupling efficiencies in excess of 77% are observed to be in excellent agreement with a mathematical model. Also, the output power stability of these modules has been monitored during severe temperature cycling, and the relative power variation was less than 4% for all the tested modules.

Intravenous amiodarone for the prevention of atrial fibrillation after open heart surgery: the Amiodarone Reduction in Coronary Heart (ARCH) trial

OBJECTIVES

This study was designed to test whether intravenous (i.v.) amiodarone would prevent atrial fibrillation and decrease hospital stay after open heart surgery.

BACKGROUND

Atrial fibrillation commonly occurs after open heart procedures and is thought to be a significant determinant for prolongation of hospitalization. Oral amiodarone given preoperatively appears to reduce the incidence of atrial fibrillation. This study was designed to test whether the more rapid-acting i.v. formulation of amiodarone given postoperatively would reduce the incidence of atrial fibrillation.

METHODS

Three hundred patients undergoing standard open heart surgery were randomized in a double-blind fashion to i.v. amiodarone (1 g/day for 2 days) versus placebo immediately after open heart surgery. The primary end points of the trial were incidence of atrial fibrillation and length of hospital stay. Baseline clinical variables and mortality and morbidity data were collected.

RESULTS

Atrial fibrillation occurred in 67/142 (47%) patients on placebo versus 56/158 (35%) on amiodarone (p = 0.01). Length of hospital stay for the placebo group was 8.2 +/- 6.2 days, and 7.6 +/- 5.9 days for the amiodarone group (p = 0.34). No differences were noted in baseline variables, morbidity or mortality.

CONCLUSIONS

Low-dose i.v. amiodarone was safe and effective in reducing the incidence of atrial fibrillation after heart surgery, but did not significantly alter length of hospital stay.

Peak expiratory flow associated with change in positioning of the instrument: comparison of five peak flow meters

To determine if peak expiratory flow (PEF) is altered by incorrect positioning of five peak flow meters (PFMs), 16 adults with clinically stable persistent asthma were evaluated. After inhaling two puffs of albuterol via AeroChamber, patients were instructed over the next 15 min in correct PFM technique and two incorrect techniques (PFM angled 20 degrees left in mouth and PFM pointed 20 degrees downward as patient leaned forward with maximal exhalation). Order of use of five peak flow meters and correct vs. incorrect techniques were random. Although mean values generally indicated no clinically meaningful effect of positioning of the PFM, inaccurate PEFs were recorded for several subjects with both incorrect methods and all PFMs.

Causes of erroneous white blood cell counts and differentials in clinically healthy young northern elephant seals (Mirounga angustirostris)

From 1993 to 1995, approximately 10% of the clinically healthy northern elephant seals (Mirounga angustirostris) at The Marine Mammal Center in California exhibited a large unexplained increase in their white blood cell (WBC) count. In these animals, WBC counts ranged from 28,780 to 125,000/mm3, with a mean of 50,087/mm3. Significant correlations between the leukocytosis and weight gain and day of admittance were identified, but no correlation existed between leukocytosis and general state of health, sex, length of stay, or diet. Bone marrow contamination of blood samples, erroneous automated leukocyte counts, and leukogram changes consistent with subclinical inflammation were the major factors contributing to the elevated WBC counts in these apparently clinically healthy animals.

Antimicrobial susceptibility of bacteria isolated from pinnipeds stranded in central and northern California

Over a 2-yr period (1994-1995), the antimicrobial susceptibilities of 129 bacterial isolates recovered from live stranded California sea lions (Zalophus californianus), harbor seals (Phoca vitulina), and northern elephant seals (Mirounga angustirostris) were studied. Nineteen genera of bacteria were isolated from various sites of inflammation; abscesses and umbilici were the most common sites. Seventy-two percent of the bacterial isolated were gram negative, and the Enterobacteriaceae (Escherichia coli, Proteus spp., Klebsiella spp., Salmonella spp.) accounted for 75% of the gram-negative isolates. All of the gram-positive isolates were either Enterococcus spp. or Staphylococcus aureus. Multiple drug resistance was present in all but one of the bacterial isolates. The gram-positive bacteria were most susceptible to amoxicillin-clavulanic acid (77% of 36 isolates) and least susceptible to lincomycin (18% of 11 isolates). The gram-negative bacteria were most susceptible to amikacin (91% of 91 isolates) and least susceptible to clindamycin (3% of 109 isolates).

Bacterial isolates from California sea lions (Zalophus californianus), harbor seals (Phoca vitulina), and northern elephant seals (Mirounga angustirostris) admitted to a rehabilitation center along the central California coast, 1994-1995

In 2 yr of bacteriologic culturing of 297 California sea lions (Zalophus californianus), 154 harbor seals (Phoca vitulina), and 89 northern elephant seals (Mirounga angustirostris) stranded alive along the California coast, the most frequent isolates from inflammatory lesions in live animals were Escherichia coli, Streptococcus viridans, Listeria ivanovii, beta-hemolytic Streptococcus spp., and Enterococcus spp. This is the first report of L. ivanovii isolation from a marine mammal. The common isolates from lung and liver in animals dying during rehabilitation were E. coli, Salmonella spp., Klebsiella spp., Pseudomonas spp., Aeromonas spp., Proteus spp., and Staphylococcus aureus. The most common isolates from brain were Enterococcus spp., E. coli, Klebsiella spp., and Pseudomonas spp. Ocular lesions were seen most often in harbor seals and elephant seals, from which the isolates cultured included Pseudomonas spp., Enterococcus spp., Streptococcus viridans, E. coli, Staphylococcus aureus, Proteus spp., Morganella morganii, Moraxella spp., beta-hemolytic Streptococcus spp., and L. ivanovii. Nine different Salmonella serotypes were isolated from 49 animals; S. newport was the most common. These results should enable those working clinically with these species to make logical decisions in choosing initial antimicrobial therapy.

Long-term management of asthma: how to improve outcomes

Improved clinical outcomes in asthma patients have been demonstrated in several clinical trials that applied the National Institutes of Health (NIH) guidelines for the long-term management of asthma. Environmental control, objective monitoring, drug therapy, and partnership in patient education are the major components of optimal management. Inhaled antiinflammatory agents are of major importance for long-term control in patients with persistent asthma. Adequate patient education is absolutely essential for excellent, cost-effective care of patients with asthma. Improved outcomes in adults with asthma have been demonstrated at clinics initiated and managed by pharmacists. Further trials are needed with large numbers of patients in managed care organizations.

Acute respiratory distress syndrome in a community hospital ICU

OBJECTIVE

To estimate the incidence of the acute respiratory distress syndrome (ARDS) in an Australian urban community, and to describe the pattern of disease and outcomes in a community hospital intensive care unit (ICU).

SETTING

An eight-bed general ICU in a community hospital.

DESIGN

Retrospective chart review.

PATIENTS

32 patients identified over a 4-year period as having ARDS.

MEASUREMENTS AND RESULTS

The incidence of ARDS in an Australian urban community was estimated to be 7.3-9.3 cases/100,000 population per year. In-hospital mortality was 59%, while ICU mortality was 47%. Sepsis, pneumonia and aspiration were the main aetiological factors accounting for 94% of the patient population. There was no trauma. The Acute Physiology and Chronic Health Evaluation and Murray scores and values for the ratio of the partial pressure of oxygen in arterial blood and fractional inspired oxygen on admission to the ICU were similar between survivors and nonsurvivors, and none of these parameters were reliable predictors of outcome. Mean age, however, was different between survivors (56 +/- 16 years) and non-survivors (69 +/- 9 years) (p < or = 0.01). Mean daily fluid balance was also different between survivors (536 +/- 545 ml/day) and non-survivors (1576 +/- 1255 ml/day) (p < or = 0.02). Haemodynamic data were collected on 21 of the 32 patients within 72 h of the onset of ARDS. None of the haemodynamic parameters reached significance. There was, however, a trend for better cardiac function and oxygen consumption in the survivors.

CONCLUSIONS

These data show that for ARDS, at least, mortality outcome can be comparable in a community ICU to a tertiary referral institution. The pattern of disease in an urban Australian community hospital is different to that often reported from tertiary centres. The incidence of ARDS in an Australian urban community is comparable to the reported incidence in North America and Western Europe.

Gender differences in hostility among depressed and medical outpatients

We assessed possible gender differences in state and trait hostility in a large sample of depressed outpatients and in a group of medical outpatients. We administered the Cook and Medley Hostility Scale, measuring trait hostility and aggressiveness, and the Symptom Questionnaire, including a state measure of irritability and hostility, to 218 depressed outpatients and 51 medical outpatients. There was a statistically significant positive correlation between severity of depression and our state measure of hostility, and a weak, although statistically significant, relationship between severity of depression and total score of our trait measure of hostility. Among depressed outpatients, trait hostility was greater in men than in women, while no significant gender difference was observed in state hostility. Among medical outpatients, the state hostility scale scores were significantly higher in men than in women. These gender differences in both groups remained significant even after adjusting for severity of depression. Thus, it appears that men with depression tend to have higher scores than women on state and trait measures of hostility, suggesting that men may be at greater risk than women of developing patterns of pathologic aggression and hostile behavior.

Current trends in the management of acute spinal cord injury

Acute spinal cord injury is a traumatic event that affects more than 10,000 individuals each year. Rapid diagnosis and treatment are imperative. The critical care practitioner who can provide early intervention to prevent anticipated complications, as well as provide appropriate therapy, may significantly reduce the mortality and/or morbidity for these patients. This article describes the classification of, as well as current research regarding the pathophysiologic processes that occur during spinal cord injury. Furthermore, trends in the surgical and pharmacologic treatment, and therapies to prevent complications, are discussed. Finally, research horizons are articulated.

Acid-base regulation following acute acidosis in seawater-adapted rainbow trout, Salmo gairdneri: a possible role for catecholamines

A fall in blood pH was induced by intra-arterial infusion of HCl in seawater-adapted rainbow trout (Salmo gairdneri). The acute acidosis resulting from HCl infusion caused a short-lived decrease in plasma bicarbonate concentration ([HCO3-]) and an increase in arterial CO2 tension (PaCO2). Erythrocyte pH and bicarbonate concentrations were not significantly altered by the infusion of acid. Injection of acid did, however, stimulate a branchial net H+ efflux which could be primarily accounted for by a net uptake of bicarbonate equivalent ions from the environmental water. Acid infusion of animals pre-treated with the beta-adrenergic blocking agent, propranolol, induced a similar pattern of change in plasma acid-base status. However, the recovery of plasma pH and restoration of plasma [HCO3-] were slower than in animals infused with acid alone. Red cell pH fell significantly in the face of plasma acidosis in the beta-blocked animals. Erythrocyte [HCO3-] showed a similar pattern of change to that of erythrocyte pH. Branchial net H+ efflux increased to a lesser extent following acid infusion in animals treated with propranolol. We conclude that catecholamines released into the bloodstream during periods of acute acidosis may play an important role in facilitating branchial H+ efflux in seawater-adapted rainbow trout.

Aspergillus endophthalmitis in an intravenous drug user

A 27-year-old male drug user administered methamphetamine hydrochloride solution intravenously (IV) from a storage vial. Within two weeks he was admitted with a fungal endophthalmitis of the right eye. A diagnostic and therapeutic vitrectomy was performed. Aspergillus fumigatus was cultured from the drug storage vial and the vitreous biopsy specimen. The endophthalmitis was not controlled by IV and intravitreal amphotericin B. Pathological examination revealed fungal abscesses in the vitreous and subretinal space.

Remissions of diabetes mellitus after weight reduction by jejunoileal bypass

Limited weight loss following jejunoileal bypass in 24 diabetic persons who were still distinctly overweight five to ten months after a mean weight decrease of 78 lbs. was accompanied by a return of normal fasting glucose and insulin levels, normal insulin responses, and a decrease in glucose intolerance. The glucose disappearance rate had improved in the majority of the subjects, but only three had attained values in the normal range. Concomitants of the undue hyperglycemia and/or obesity included labile and, rarely, sustained hypertension and/or cardiomegaly. The blood pressure returned to normal but heart size did not change. Electrocardiographic abnormalities noted in about one-half of the patients persisted after the operation. Triglyceride and cholesterol levels decreased. No patients had diabetic retinopathy visible on funduscopy. Proteinuria did not change in three patients. Neuropathy consisting of absent ankle reflexes and/or decreased vibration perception noted in one-half of the subjects persisted despite the improvement in carbohydrate metabolism.

Endocrine abnormalities and myopathy in Bloom's syndrome

Abnormal endocrine indices and myopathy have been variably present in two brothers with Bloom's syndrome (congenital teleangiectatic erythema, hypersensitivity to light, and growth retardation). These consisted of: (1) growth retardation with height and weight below the third centiles; in the younger one at age 14, hypoglycaemia failed to elicit a rise in growth hormone but did so in the older one at age 17; (2) serum TSH was raised in the older one in whom serum FSH and LH were also above the normal range; and (3) myopathy characterised by pronounced dilatation of the sarcoplasmic reticulum was present in the younger one; distinct reduction of muscle strength was shown in his older brother with ultrastructural alteration of skeletal muscle of unknown significance.