Levofloxacin does not decrease mortality in Staphylococcus aureus bacteraemia when added to the standard treatment: a prospective and randomized clinical trial of 381 patients

OBJECTIVES: To study whether levofloxacin, added to standard treatment, could reduce the high mortality and complication rates in Staphylococcus aureus bacteraemia. DESIGN: A prospective randomized multicentre trial from January 2000 to August 2002. SETTING: Thirteen tertiary care or university hospitals in Finland. SUBJECTS: Three hundred and eighty-one adult patients with S. aureus bacteraemia. Patients with meningitis, and those with fluoroquinolone- or methicillin-resistant S. aureus were excluded. INTERVENTIONS: Standard treatment (mostly semisynthetic penicillin) (n = 190) or that combined with levofloxacin (n = 191). Supplementary rifampicin was recommended if deep infection was suspected. MAIN OUTCOME MEASURES: Primary end-points were mortality at 28 days and at 3 months. Clinical and laboratory parameters were analysed as secondary end-points. RESULTS: Adding levofloxacin to the standard treatment offered no survival benefit. Case fatality rates were 14% in both groups at 28 days, and 21% in the standard treatment and 18% in the levofloxacin group at 3 months. Levofloxacin combination did not differ from the standard treatment in the number of complications, time to defervescence, decrease in serum C-reactive protein concentration or length of antibiotic treatment. Deep infection was found in 84% of patients within 1 week following randomization with no difference between the treatment groups. At 3 months, the case fatality rate for patients with deep infection was 17% amongst those who received rifampicin versus 38% for those without rifampicin (P < 0.001, odds ratio = 3.06, 95% confidence intervals = 1.69-5.54). CONCLUSIONS: Levofloxacin combined with standard treatment in S. aureus bacteraemia did not decrease mortality or the incidence of deep infections, nor did it speed up recovery. Interestingly, deep infections in S. aureus bacteraemia appeared to be more common than previously reported.     

Aseptic spondylitis as the initial manifestation of the SAPHO syndrome

We describe the case of a 61-year-old female patient who presented with spondylitis of the lumbar spine. Although the microbiological cultures of the bone biopsy specimens obtained during laminotomy remained negative, the patient was treated with broad-spectrum antimicrobials for 2 months. Eight months later she started to suffer from pain and tenderness in her sternum and the medial portion of her left clavicle. The findings of computed tomography and gallium-labelled isotope scan were indicative of sternoclavicular arthritis. Again, all surgically obtained biopsy specimens yielded negative results in microbiological studies. The diagnosis of the SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteomyelitis) syndrome was then made based on the clinical presentation with recurrent sterile osteitis in two characteristic locations, and the patient was started on immunosuppressive therapy. This case is a reminder that SAPHO may sometimes occur without any skin manifestations. Since this type of patient may be admitted to an orthopedic ward, it is important that orthopedic surgeons are familiar with the syndrome.     

Spinal epidural abscess: an unusual cause of sciatica

Summary A previously healthy patient was admitted to our hospital because of low back pain and sciatica. For 4 weeks preceding the admission, he had been treated with nonsteroidal antiinflammatory analgetics and bed rest with a clinical diagnosis of lumbar disc herniation. On admission, the patient was subfebrile but developed general symptoms of septic infection by the next day. Computed tomography and magnetic resonance imaging of the lumbar spine revealed a spinal epidural abscess and spondylodiscitis at the L5-S1 level. During an emergency laminotomy, gross pus in abundance was evacuated from the epidural space; microbiological cultures from the pus and blood yielded Staphylococcus aureus. The unique clinical presentation of our patient combined with merely indolent symptoms of infection delayed the correct diagnosis. We are not aware of any similar reports of patients with lower spinal epidural abscess whose primary presentation was sciatic pain.     

Intraosseous fat necrosis simulating septic arthritis and osteomyelitis in a patient with chronic pancreatitis

A woman with a 20-year history of alcohol abuse and chronic pancreatitis developed an osteoarticular involvement of her right ankle in association with subcutaneous nodules. Histopathological examination of the tissue samples obtained during surgical revision of the ankle showed necrotic fat and connective tissue. Microbiological cultures remained negative. The patient was administered long-term antimicrobial treatment without any apparent benefit. Four months later, she died of pancreatic insufficiency and pneumonia. Postmortem examination showed numerous foci of intra-abdominal fat necrosis. Histopathological examination of the bone samples from the right ankle showed fat necrosis with lipophages. Based on these findings, we consider that the osteoarticular involvement in this patient was caused by intraosseous fat necrosis. This case reminds us of the importance of considering the possibility of this condition whenever a patient with chronic pancreatic disease develops sterile osteoarthritis. Received: 4 August 1997     

Positron emission tomography as an aid in the diagnosis and follow-up of Riedel's thyroiditis

We describe the usage of positron emission tomography (PET) as an aid in the initial diagnosis and follow-up of Riedel's thyroiditis. A 41-year-old patient was admitted for an enlarged and tender thyroid gland in association with severe systemic symptoms of inflammation. Imaging with fluorine-18 fluorodeoxyglucose (FDG) and PET demonstrated an intensive uptake of FDG in both lobes of the thyroid gland as an indication of severe inflammation. The diagnosis of Riedel's thyroiditis was confirmed by the histological findings of biopsy specimens taken during a palliative thyroid resection. The inflammatory symptoms and local pain dramatically disappeared after commencement of high-dose corticosteroid therapy. A follow-up PET scan after 2 weeks of corticosteroid treatment showed a 60% decrease in the uptake of FDG in the thyroid. This indicates that FDG metabolic activity can also be used to assess a patient's response to therapy in Riedel's thyroiditis.     

Lamotrigine in treatment-resistant schizophrenia: a randomized placebo-controlled crossover trial.

BACKGROUND: There is no evidence from randomized, controlled trials that demonstrate effectiveness for any pharmacological treatment in clozapine-resistant schizophrenia. Since the introduction of chlorpromazine, all antipsychotics with proven efficacy on positive symptoms have been dopamine antagonists, but recent experimental data suggest that ketamine-induced positive schizophreniform symptoms in healthy subjects can be controlled by a glutamate antagonist lamotrigine. The hypothesis tested was that lamotrigine is more effective than placebo in the treatment of positive schizophrenic symptoms when combined with clozapine. METHODS: Thirty-four hospitalized treatment-resistant patients having chronic schizophrenia participated in a double-blind, placebo-controlled, 14-week, crossover trial where 200 mg/day lamotrigine was gradually added to their ongoing clozapine treatment. Clinical assessments were made by the Positive and Negative Syndrome Scale at the beginning and end of each treatment period. RESULTS: In intention-to-treat analysis, lamotrigine treatment was more effective in reducing positive (effect size.7, p =.009) and general psychopathological (effect size.6, p =.030) symptoms, whereas no improvement was observed in negative symptoms. CONCLUSIONS: These results provide the first evidence from a randomized controlled trial of an effective pharmacological treatment with an anticonvulsant agent in treatment-resistant schizophrenia and indicate that both positive and general psychopathological symptoms in patients with schizophrenia can be controlled by a drug that is not a dopamine antagonist. The results are in line with previous experimental data suggesting that excessive glutamate neurotransmission contributes to the positive symptoms of schizophrenia.     

Microsurgical treatment of lumbar disc herniation: Follow-up of 237 patients

Summary We have reviewed retrospectively the results of 237 consecutive patients who underwent microsurgical discectomy for a virgin lumbar disc herniation. Included were 128 (54%) men and 109 (46%) women, with the mean age of 42 years. Intra-operatively, protrusion was found in 60 (25%) patients, prolapse in 127 (54%) patients and sequestration in 50 (21%) patients. The median post-operative follow-up time was 2 years.During the observation period, sciatic pain had completely recovered or markedly diminished in 218 (92%) patients, and 187 (79%) patients had returned to work. The mean duration of preoperative sciatica was 3.8 months in those patients who finally returned to work. In contrast, it was as long as 6.3 months in those patients who lost their working capacity as a consequence of low back pain. The patients operated on for a prolapse or a sequestrum recovered better than those who underwent surgery for a protrusion. Of the patients operated on for a protrusion, 68% returned to work, while 76% of those operated on for a sequestrum and 85% of those operated on for a prolapse returned to work during the follow-up. Difference was seen also in the occupational outcome: only 37% of the patients operated on for a protrusion reported to manage their work well, while 47% of those with a prolapse and 58% of those with a sequestrum managed well. Surgical complications were in-frequent in this study. Dural tear appeared in 10 (4%) patients and post-operative discitis in 4 (1.7%) patients. Of all patients, 9 (4%) required re-operation for a true recurrent disc.     

Percutaneous nucleotomy in the treatment of cervical disc herniation: report of three cases and review.

We describe here three patients with cervical disc herniation who were treated at our department with manual percutaneous nucleotomy. These patients had suffered from cervical pain radiating into an upper extremity, with the duration of the conservative treatment varying between three and six months before the operation. After a follow-up of three years, radiating pain into the upper extremity was totally recovered in one patient, markedly diminished in one and remained unchanged in one. All patients were continuously working. The outcome of patients who underwent percutaneous nucleotomy for cervical disc herniation has been evaluated in only three previous papers, all focusing on automated cervical nucleotomy. We review the literature on cervical percutaneous nucleotomy and discuss the usefulness of this methodology.     

Comparison of amplitude-modulated (direct) and frequency-modulated ambulatory techniques for recording ischemic electrocardiographic changes

Continuous ambulatory electrocardiographic monitoring of ST-segment configuration has become a useful technique for evaluation of myocardial ischemia. Concern that direct or amplitude-modulated (AM) recording and playback systems have inherent limitations that cause inaccurate ST-segment recordings has led to preference for frequency-modulated (FM) devices. To determine the accuracy of AM and FM ambulatory electrocardiographic systems, the signal was compared from the same set of 2 bipolar leads simultaneously recorded by standard electrocardiography and AM and FM recorders in 14 patients during treadmill exercise. Also, simultaneous AM and FM recorders were compared in 9 ambulatory patients in 16 monitoring sessions. The AM recording system accurately reproduced ST segments recorded during treadmill exercise (range 4.0 mm of ST-segment depression to 2.0 mm of ST elevation) when measured at the J point (r = 0.91, p less than 0.0001), and 0.08 second after the J point (r = 0.95, p less than 0.0001). FM recording was equally accurate (r = 0.89 and 0.95, respectively, p less than 0.0001). Similarly, during ambulatory recording, the AM technique accurately recorded maximal ST depression in each episode as recorded by the FM device (28 episodes, range 0 to 3 mm of ST depression, r = 0.85, p less than 0.0001). Both AM and FM ambulatory electrocardiographic systems can accurately reproduce ST-segment deviation associated with ischemia and can be used to monitor transient ST-segment changes in patients with coronary artery disease.