Evaluation of postpartum blood loss after misoprostol-induced labour

Objective  To objectively evaluate postpartum blood loss after successful misoprostol induction and compare it with blood loss after oxytocin induction of labour.
Design  Prospective randomised study.
Setting  Labour ward in university maternity hospital.
Population  A total of 150 women up to third parity with completed 40 weeks of singleton normal pregnancy, average size cephalic fetus.
Methods  Cases were randomised between oxytocin induction and misoprostol induction. Blood was collected in suction set and measured in the delivery room starting after delivery of the fetus and was evaluated by pad weighing in the following 6 hours. Pre- and postdelivery haematocrit were measured and difference between the two values was assessed and analysed.
Main outcome measures  Success of induction, induction delivery interval, postpartum blood loss, and difference between pre- and postdelivery haematocrit.
Results  Induced labour was significantly faster with misoprostol induction ( P < 0.001). Blood loss and haematocrit difference was significantly greater in the misoprostol group than in oxytocin group ( P < 0.02 and 0.001, respectively). Blood loss in both groups was significantly correlated with higher initial Bishop score ( P < 0.001 and 0.024, respectively) and short labour duration ( P < 0.0002 and 0.0001, respectively).
Conclusions  Misoprostol induction is associated with increased blood loss especially when used in women with high Bishop score; therefore, it is better reserved for cases requiring cervical ripening.     

Unpredictable Effects of Rifampin as an Adjunctive Agent in Elimination of Rifampin-Susceptible and -Resistant Staphylococcus aureus Strains Grown in Biofilms

The use of rifampin as an adjunct in biofilm-associated infections is based on the ability to penetrate into biofilms and a presumed activity against dormant bacteria. Yet, its efficacy remains contradictory, and rifampin-resistant strains frequently emerge during therapy. Therefore, the efficacy against rifampin-susceptible and isogenic rifampin-resistant methicillin-susceptible Staphylococcus aureus (MSSA) strains was evaluated. Biofilms were generated under static conditions using MSSA with various genetic backgrounds. Oxacillin alone or with rifampin at various concentrations was subsequently added, and after 24 h biomass and viable cell counts were determined. Upon rifampin addition, interstrain variations in viable count change, ranging from a tendency toward antagonism to synergy, were observed among all strains tested, irrespective of the genetic background of the strain. Similar variations were observed in changes in biomass. The decrease in viable count upon rifampin addition was negatively correlated to formation of large amounts of biomass, since strains embedded by more biomass showed a diminished reduction in viable count. Rifampin (1 μg/ml) as adjunct to oxacillin achieved greater reductions in biomass produced by most rifampin-susceptible isolates, ranging from 17 to 54%, compared to 4% for oxacillin alone. In contrast, rifampin had no additional value in reduction of biomass of isogenic rifampin-resistant mutants. At subinhibitory concentrations of rifampin (0.008 μg/ml), none of the strains tested yielded an extra reduction in biomass that was ≥40%. In conclusion, the effects of rifampin as adjunct on biomass and viable count were unpredictable, and the use of rifampin against biofilm containing rifampin-resistant strains seems unwarranted.Bacteria embedded in biofilm are often hard to eradicate, which will often result in failure of antibiotic therapy. A biofilm can appear and persist on implanted or indwelling devices. Adherence to bone or natural tissue can also occur. As a consequence of biofilm formation, foreign body infections are a risk factor for persistent bacteremia (12).Staphylococcus aureus biofilm-infected devices often require removal in combination with antimicrobial therapy (6). Even if an infection seems to be cured, a subset of bacteria can survive within the partly unremoved biofilm and the infection can remanifest after several years. These are the so-called low-grade infections (30). The ideal antibiotic should be able to diffuse properly into biofilms, eradicate dormant bacteria, and kill phagocytized S. aureus, since foreign body infections are associated with intracellular S. aureus (16, 18). Rifampin meets these criteria partially (28). Rifampin penetrates biofilms adequately (38) and improves the diffusion of a companion agent through the biofilm (8). It also reduces the adherence of bacteria to surfaces (28). Furthermore, rifampin addition eliminates intrinsic rifampin-resistant Pseudomonas aeruginosa (MIC, 32 μg/ml) from biofilms (11). Therefore, it could be hypothesized that the presence of rifampin leads to biofilm matrix disintegration. However, rifampin cannot be used alone due to the rapid emergence of resistance (37), and it is not as effective as presumed against slow-growing bacteria (21, 38). An alternative approach for S. aureus biofilm-associated infections is the addition of rifampin to a companion drug. In clinical practice, rifampin addition has been occasionally demonstrated as beneficial in terms of clinical or bacteriological cure rates (39), especially for prosthetic device-related infections (10, 18, 22). However, its effect remains poorly defined, since the number of supporting human studies is limited and most of them have been underpowered (10, 18, 22, 29). Moreover, recently performed in vitro studies have demonstrated antagonistic effects after addition of rifampin in experimental foreign body infection and endocarditis models (15, 17).Exposure to combination therapy including rifampin frequently results in the emergence of rifampin-resistant subpopulations, which might hinder clearance of the infection (25). This is probably due to the fact that the pharmacokinetics of the companion drug were different from that of rifampin. Preferably, the companion drug needs to penetrate easily through diverse layers of a biofilm to prevent the development of rifampin resistance. But, although some antibiotics penetrate adequately through biofilms, bacteria may be protected from killing by thickening of the cell wall (38). A high bacterial load is another cause of rapid resistance development (33). To overcome the emergence of resistance it is recommended that rifampin be initiated after the companion drug has been administered for 2 to 5 days, to reduce the high density of the initial burden (1), or at least until a substantial reduction in bacterial load has been achieved (4, 25).Since interstrain variability in response to rifampin addition might be responsible for the contradictory results obtained by various authors, the aim of the present study was to elucidate whether this variability does exist for strains between and within the S. aureus genetic backgrounds associated with multilocus sequence types (MLSTs) CC5, CC8, and CC30. Furthermore, since rifampin-resistant mutants emerge during therapy and rifampin is used for hypothesized destruction of the biofilm matrix, we evaluated whether continuation of exposure to rifampin is useful against biofilms containing rifampin-resistant methicillin-susceptible S. aureus (MSSA). In addition, we examined whether a potential effect was also present at a subinhibitory concentration.     

Infectious complications and antibiotic use in renal transplant recipients during a 1-year follow-up

Objective   To evaluate infectious complications and antibiotic use in 192 renal transplant recipients.
Methods   Infectious complications and antibiotic use were monitored in all patients receiving renal transplantation at our center from 1992 to 1997. Risk factors for infectious complications were evaluated. Transplants and patient survival were monitored. The follow-up period was 1 year.
Results   One-hundred and ninety-two patients received renal transplants during the study period. The mean duration of urethral catheterisation after transplantation was 10.5 days (SD = 5). Seventy-one per cent ( n  = 137) of patients had at least one infectious episode. In all, 284 infectious episodes were monitored. The most frequent infections were: urinary tract infections 61%, respiratory tract infections 8%, intra-abdominal infections 7%, and cytomegalovirus infection 8%. Escherichia coli and Enterococcus faecalis were the most frequently isolated microorganisms. Seventy-four per cent ( n  = 142) of patients received 314 antimicrobial courses (284 for therapy, and 30 for prophylaxis). Female gender and duration of urethral catheterisation were risk factors for urinary tract infection. Cytomegalovirus reactivation was associated with acute graft rejection and additional immunosuppressive therapy. Overall mortality was 4%. Infection-related mortality was 2.6%. Mortality was associated with Enterobacteriaceae in three patients, with Pseudomonas aeroginosa in one patient and with Enterococcus faecali s in one patient.
Conclusions   The incidence of infectious complications remains high in renal transplant recipients. Most cases of mortality were associated with infections. Early removal of the urethral catheter to reduce the risk of urinary tract infections is recommended.     

Is MSH2 a breast cancer susceptibility gene?

Mutations in the DNA mismatch repair gene MSH2 lead to increased replication error and microsatellite instability and account for a substantial proportion of hereditary non-polyposis colorectal cancer (Lynch syndrome). A recent international collaborative genome-wide linkage scan (GWS) for breast cancer susceptibility loci found some evidence for there being a breast cancer susceptibility gene in a genomic region on chromosome 2p close to MSH2. We sought to investigate the possibility that mutations in MSH2 might explain the multiple cases of breast cancer in some families that were included in the international GWS. DNA samples from the affected probands of 59 multiple-case breast cancer families, many of whom gave LOD scores >0.5 in the MSH2 region, were screened for large genomic alterations in MSH2 via the Multiplex Ligation-dependant Probe Amplification (MLPA) assay and for coding region mutations via exonic sequencing. Several of the families also contained cases of colorectal cancer in addition to breast cancer and had been included in the GWS that had identified a positive LOD score on chromosome 2p. Using MLPA, c.1236C > T was identified in one proband but this variant was not predicted to create an alternate acceptor/donor site within exon 7 MSH2 using in silico analyses. A c.1734T > C was identified in a second proband via exonic sequencing but testing of the variant in other family members did not support segregation of this variant with disease. Extensive screening of 59 multiple-case breast cancer families did not identify any coding region mutations or larger genomic alterations in MSH2 that might implicate MSH2 as a breast cancer susceptibility gene.     

Meningitis due toFusobacterium necrophorum subspeciesnecrophorum. Case report and review of the literature

Summary This paper reports a case of fatal meningitis caused byFusobacterium necrophorum subsp.necrophorum in a previously healthy five-year-old child. The organism was isolated in pure culture from the cerebrospinal fluid and from intracranial pus obtained at autopsy. The role ofF. necrophorum in the development of meningitis is reaffirmed and its isolation and identification are discussed. The clinical presentation of the present case resembles the previously published reports and highlights the poor prognosis in spite of appropriate antibiotic treatment.

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Meningitis durch Fusobacterium necrophorum Subspecies necrophorum. Fallbeschreibung und Literaturübersicht

Zusammenfassung In der vorliegenden Arbeit wird der Fall eines vorher gesunden fünfjährigen Kindes beschrieben, das an einer Meningitis, verursacht durchFusobacterium necrophorum Subspeciesnecrophorum, verstorben ist. Der Keim wurde aus Liquor und autoptisch entnommenem intrakranialem Eiter in Reinkultur isoliert. Die Rolle vonFusobacterium necrophorum als Meningitiserreger und die Techniken zur Isolierung und Identifikation des Keimes werden diskutiert. Der vorgestellte Fall ähnelt früher publizierten Beschreibungen und verdeutlicht die schlechte Prognose der Infektion auch bei adäquater Antibiotika-Therapie.

     

Intraoperative ultrasound examination of the brain

In a preliminary demonstration of cranial intraoperative real-time ultrasound, both supratentorial and posterior fossa scans displayed the pertinent anatomy. A grade III astrocytoma was visualized on the supratentorial scan as well. Ultrasound may be valuable for surgical planning and biopsy procedures because of its reliable depiction of intracranial anatomy and ease of use.     

Risk factors associated with having psoriatic arthritis in patients with cutaneous psoriasis

The aim of this study was to determine if the following characteristics were associated with the presence of psoriatic arthritis in a sample of psoriasis patients: race, family history of psoriasis and psoriatic arthritis, age of onset of psoriasis, smoking, alcohol consumption and the maximum body surface area (BSA) affected by psoriasis. This was a case–control study involving 400 psoriasis patients who attended the Psoriasis and Photo‐medicine clinic in the National Skin Center of Singapore over a 1‐year period. Cases were psoriasis patients with psoriatic arthritis while controls were psoriasis patients without psoriatic arthritis. The diagnosis of psoriatic arthritis was made by rheumatologists and participants completed a self‐administered standardized questionnaire. The maximum BSA involved was determined from the case notes. Psoriatic arthritis was not significantly associated with sex, race, age of onset of psoriasis, a family history of psoriasis, smoking and alcohol consumption but was significantly associated with a family history of psoriatic arthritis (P < 0.001) and the maximum body surface involved (P = 0.05). Using multivariate analysis to control for variables, the presence of psoriatic arthritis was significantly associated with a family history of psoriatic arthritis (odds ratio [OR] = 20.5; 95% confidence interval [CI] = 2.49–169.10) and the maximum BSA involved (OR = 2.52; 95% CI = 1.33–4.75). Indian psoriatic patients were more likely to have psoriatic arthritis compared to the other races. A family history of psoriatic arthritis and a greater maximum body surface involved may be associated with having psoriatic arthritis in this study population of psoriasis patients.     

Nosocomial respiratory syncytial virus infection in Canadian pediatric hospitals: a Pediatric Investigators Collaborative Network on Infections in Canada Study

OBJECTIVE: To determine nosocomial transmission of respiratory syncytial virus (RSV) in Canadian pediatric hospitals, outcomes associated with nosocomial disease, and infection control practices. DESIGN: A prospective cohort study in the 1992 to 1994 winter respiratory seasons. SETTING: Nine Canadian pediatric university-affiliated hospitals. PARTICIPANTS: Hospitalized children with symptoms of lower respiratory tract infection (at least one of cough, wheezing, dyspnea, tachypnea, and apnea) and RSV antigen identified in a nasopharyngeal aspirate. RESULTS: Of 1516 children, 91 (6%) had nosocomial RSV (NRSV), defined as symptoms of lower respiratory tract infection and RSV antigen beginning >72 hours after admission. The nosocomial ratio (NRSV/[com-munity-acquired RSV {CARSV})] + NRSV) varied by site from 2.8% to 13%. The median length of stay attributable to RSV for community-acquired illness was 5 days, but 10 days for nosocomial illness. Four children with NRSV (4. 4%) died within 2 weeks of infection, compared with 6 (0.42%) with CARSV (relative risk = 10.4, 95% confidence interval: 3.0, 36.4). All sites isolated RSV-positive patients in single rooms or cohorted them. In a multivariate model, no particular isolation policy was associated with decreased nosocomial ratio, but gowning to enter the room was associated with increased risk of RSV transmission (incidence rate ratio 2.81; confidence interval: 1.65, 4.77). CONCLUSIONS: RSV transmission risk in Canadian pediatric hospitals is generally low. Although use of barrier methods varies, all sites cohort or isolate RSV-positive patients in single rooms. Children with risk factors for severe disease who acquire infection nosocomially have prolonged stays and excess mortality.     

The prevalence of antibiotic-resistant faecalEscherichia coli in healthy volunteers in Venezuela

Summary  Faecal samples were collected from healthy volunteers in two regions in Venezuela, the village of Grulla (n=195) and the city of Mérida (n=181), and analysed for the prevalence of antibiotic resistant faecalEscherichia coli as well as the antibiotic susceptibility of the strains isolated. The highest prevalences of resistance were observed for amoxicillin, oxytetracycline, sulfamethoxazole and trimethoprim. The percentages found for Grulla were 46, 38, 44 and 30%, respectively; for Mérida 39, 65, 56 and 36%, respectively. In Mérida, a significantly higher prevalence of resistance for oxytetracycline was found (P<0.05). Significant differences in the distribution of the MIC values between Grulla and Mérida were observed for amoxicillin, chloramphenicol and oxytetracycline (P<0.05). In Grulla, the most frequent pattern was resistance to amoxicillin only and in Mérida to oxytetracycline only. Amoxicillin resistance was due to production of TEM1 β-lactamase.     

Inducing capacity and selection of resistant variants of cefpirome (HR 810) in comparison with other beta-lactam compounds

The inducing capacity of cefpirome (HR 810) and the ability of the compound to select for stable derepressed mutants was determined and compared with those of cefodizime (HR 221), cefotaxime, ceftazidime and cefamandol. Variations in both characteristics between and within species was observed. Overall, cefodizime showed the lowest, cefamandol the highest inducing capacity. Antibiotic resistant variants were isolated from all strains tested at a frequency of around 10(-9). A stable increased enzyme production was found in Pseudomonas aeruginosa after exposure to ceftazidime as well as in the resistant mutants from Enterobacter cloacae after selection with cefpirome, ceftazidime, cefotaxime and cefamandol. In the other resistant mutants the resistance was probably due to changes in permeability. All resistant variants remained relatively susceptible to cefpirome.