Investigation of various antibiotic combinations using the E-Test method in multiresistant Pseudomonas aeruginosa strains

BACKGROUND: Antibiotic combinations are frequently used in order to obtain wide-spectrum effects in the treatment of serious infections such as septicemia and endocarditis, and also to produce an in vivo effect against strains which are defined as resistant to the known inhibiting or fatal dose of one antibiotic. The synergistic effects of combinations such as aminoglycoside + beta-lactam, aminoglycoside + quinolone and quinolone + beta-lactam on Pseudomonas aeruginosa have been revealed in different studies. The multiple resistance rate of nosocomial P. aeruginosa strains isolated from intensive care units (ICUs) has been reported as high in many studies. METHODS: In this study, the effects of various combinations of antibiotics (aminoglycoside + beta-lactam and aminoglycoside + quinolone) against 101 multiresistant P. aeruginosa strains which were isolated from the ICUs of three different hospitals in Istanbul were investigated using the E-test method. The combinations for which the highest synergistic effects were determined by the E-test method were also tested with the checkerboard method, i.e. in addition to the E-test method, in 19 of a total of 23 strains. RESULTS: When the synergistic results which were obtained with the combinations of aminoglycoside + beta-lactam were compared with those of the aminoglycoside + quinolone combinations, they were determined to be higher for the two aminoglycosides gentamicin (GM) and tobramycin (TM). We determined the synergistic rates to be 23, 21, 19, 18, 16, 14, 10 and 10% for GM + ceftriaxone (TX), GM + piperacillin (PP), GM + ceftazidime (TZ), TM + PP, TM + TX, TM + TZ, GM + ciprofloxacin (CI) and TM + CI, respectively. The GM + TX combination - for which the highest synergistic effects were determined with the E-test stripes - was also determined as synergistic with the checkerboard method in 19 of a total of 23 strains (23%), and the agreement rate between the two methods was 100% (kappa > 0.7). The highest synergistic effects against strains which were sensitive to both of the antibiotics which constitute the combinations were found for the GM + TX combination, as 50%, whereas for strains which were resistant to both of the antibiotics, this was found for the TM + PP combination, also as 50%. CONCLUSIONS: We consider that the minimal inhibitory concentration values of antibiotics are not sufficient alone in order to constitute a combination for multiresistant strains and it would be advisable to begin a treatment by applying a combination study. The E-test method has been evaluated as a good alternative for combination investigations because of its ease both of application and evaluation and also for its good agreement with the standard checkerboard method.     

Alveolar hemorrhage associated with warfarin therapy: a case report and literature review

A 75-year-old man was admitted to our clinic with the complaints of palpitation, fever, severe dyspnea, dizziness and bloody sputum associated with coughing. Chest radiographs revealed that the lungs were bilaterally infiltrated. A high resolution computed tomographic study of the thorax disclosed diffuse alveolar hemorrhage, of which presence was proved by histopathological study of bronchoalveolar lavage material. The hemorrhage occured at 8th day of 5 mg daily warfarin therapy, which was given for frequent atrial fibrillation attacks was controlled by fresh frozen plasma and vitamin K. Alveolar hemorrhage is difficult to diagnose and has high mortality if the treatment was not started as soon as possible. This is the first report of alveolar hemorrhage caused by 5 mg daily warfarin therapy. We propose that the patient's age, nutritional status, used drugs should be taken into consideration for true management of patients with atrial fibrillation.     

Fashioning regulatory dendritic cells: what is currently in vogue?

Dendritic cells (DCs) are uniquely well-equipped antigen-presenting cells with remarkable plasticity, whose differentiation and function can be manipulated in vitro and in vivo. With increased understanding of their immunoregulatory properties, strategies to enhance DC tolerogenicity have emerged. Carefully fashioned DCs, the result of biological, pharmacological or genetic modification, hold promise as new cell-based therapies of organ allograft rejection and autoimmune diseases.     

Use of middle hepatic vein in right lobe living donor liver transplantation

The harvesting of the middle hepatic vein (MHV) with the right lobe graft for living‐donor liver transplantation allows an optimal venous drainage for the recipient; however, it is an extensive operation for the donor. This is a prospective, nonrandomized study evaluating liver functions and early clinical outcome in donors undergoing right hepatectomy with or without MHV harvesting. From August 2005 to July 2007, a total of 100 donor right hepatectomies were performed with (n = 49) or without (n = 51) the inclusion of the MHV. The decision to take MHV was based on an algorithm that considers various donor and recipient factors. There was no donor mortality in donors in either group. Overall complication rate was higher in MHV (+) donor group, however when remnant liver volume was kept above 30%, complication rates were similar between the groups. The results of this study show that right hepatectomy including the MHV neither affects morbidity nor impairs early liver function in donors when remnant volume is kept above 30%. The decision, therefore, of the extent of right lobe donor hepatectomy should be tailored to the particular conditions considering the graft quality and metabolic demand of the recipient.     

Dual left lobe living donor liver transplantation using donors unacceptable for right lobe donation: a case report

Living donor liver transplantation (LDLT) has become a viable alternative for end-stage liver disease. The shortage of brain-dead donors has led to development of advanced surgical approaches. Dual lobe LDLT has been performed successfully in the recent years. The major indication for this complex procedure has been insufficient graft size from a single donor or insufficient remnant in the donor. We performed a dual left lobe LDLT using 2 donors who were unacceptable for right lobe donation.     

Finding help: Turkish-speaking refugees and migrants with a history of psychosis

There is a large population of Turkish-speaking migrants living in London, many of whom are refugees (Enneli, Modood, & Bradley, 2005). Primary care and secondary mental health services have consistently reported poor continuity of care among patients from this community. The aim of this study was to explore the possible interconnection of causal attributions and pathways into care among Turkish-speaking, mainly Kurdish, patients with a past history of psychosis. Narratives of illness were elicited from informants. Physical symptomatology was a prominent feature of presentation in this group. These patients did not discuss their health problems conceptualized as uniform ;models' of illness, but rather in an attributional style that emphasized the experience of traumatic life events, often related to the overarching problem of exile and settlement. Childhood and family issues of poverty and domestic violence were often raised by patients, but tended to be backgrounded as having little contributory significance. These patients sought intervention, serially or in combination, from a diverse range of practitioners, including private healthcare and traditional healers or hocas. Their explanatory models of illness were complex and fragmentary and the relationship between explanations and help seeking is seldom linear. The implications of these findings for health services are discussed.     

Type 1 neurofibromatosis and adult extremity sarcoma. A report of two cases

We report two cases of malignant soft-tissue tumours--one myxoid malignant fibrous histiocytoma and one pleomorphic rhabdomyosarcoma--which were diagnosed in two young adult patients with type 1 neurofibromatosis (NF 1). The patients were evaluated with criteria for Neurofibromatosis 1 and NF 1 gene analysis was performed. Four of seven criteria were found in both patients. The tumours were stage II and III respectively. Both patients were treated with radiotherapy or chemotherapy and surgical intervention. Diagnoses of myxoid malignant fibrous histiocytoma and pleomorphic rhabdomyosarcoma in adult NF 1 patients are exceedingly rare. Thus detection of subtypes of rhabdomyosarcoma and malignant fibrous histiocytoma with immunohistochemistry may be helpful for the management of these tumours among other pleomorphic sarcomas that may occur in type 1 Neurofibromatosis.