A Prediction Model for Bacterial Etiology in Acute Exacerbations of COPD

Abstract Objectives: Bacteria play a leading role in acute exacerbations of chronic obstructive pulmonary disease (COPD), but we lack predictors of bacterial etiology. We developed a prediction model for infection with gram-negative enteric bacteria (GNEB) and Pseudomonas aeruginosa. Methods: Clinical presentation, sputum characteristics, microbial sputum patterns, lung function and previous and concomitant medication were prospectively recorded in patients with moderate to severe exacerbation of COPD. Risk factors for a specific bacterial etiology were c alculated and a prediction model developed. Results: A total of 193 patients with acute exacerbation were included. In 121 (62.6%) of them a microbial etiology could be identified, most frequently Haemophilus influenzae (32 strains), Streptococcus pneumoniae (22 strains) and P. aeruginosa (12 strains). Multivariate analysis identified severe airflow obstruction and use of systemic steroids as predictors for exacerbation due to gram-negative enteric bacilli and P. aeruginosa. A prediction model including FEV1 < 35% of predicted value, systemic steroid use and prior antibiotic therapy within preceeding 3 months had a negative predictive of 89%, being a helpful tool in excluding patients at risk of exacerbation due to gram-negative enteric bacilli and P. aeruginosa when all criteria are absent. Conclusion: A simple prediction model based on three factors may identify COPD patients at low risk for exacerbations with gram-negative enteric bacilli and P. aeruginosa. Bacterial Etiology in COPD Exacerbations.     

The effects of mild maternal stress during pregnancy on the behavior of rat pups

Mild maternal stress in the form of chronic daily subcutaneous injections of saline or the vehicle for diazepam to pregnant rats was shown to result in some long term, subtle but reliable, changes in the behavior of the offspring. The same vehicle given for the same period of time in the dam's drinking water, without injection had no effect on the development of later behavior of rat pups. Chronic prenatal injections of saline or vehicle for diazepam, used in many experiments as controls for the evaluation of drug effects were shown to have some long lasting behavioral effects in the offspring of the treated dams. The series of experiments reported here compared the offspring of saline or vehicle injected dams to those of uninjected dams on a variety of developmental measurements, an open field behaviour and on learning performance in a complex brightness discrimination maze.     

Lateral ankle fracture with missed proximal tibiofibular joint instability (Maisonneuve injury)

We present a case of a soccer player who sustained a lateral ankle fracture and the associated proximal anterolateral tibiofibular joint instability (Maisonneuve injury) was overlooked. After a non-contact injury the (incomplete) diagnosis of a lateral malleolar fracture (type Weber B, AO 44-B1) was made and the patient was surgically treated with open reduction and internal fixation including a distal syndesmosis screw. After removal of the syndesmosis screw (six weeks after surgery) the patient suffered from activity-related pain around the fibular head. After thorough clinical and radiologic examination, temporary screw transfixation of the fibular head and capsular repair under meticulous fluoroscopic control of fibular rotation helped to restore patient’s sport activity level. This case report emphasizes the importance of precise clinical examination for detection of a proximal tibiofibular joint instability. Restoration of a well functioning and stable proximal tibiofibular joint may be difficult to achieve in previously operated and missed instabilities. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Combined haemoperfusion,haemofiltration and haemodialysis for systemic detoxification in locoregional 5-fluorouracil therapy

Summary Combined haemoperfusion, haemofiltration and haemodialysis (HPFD) was examined for its systemic effect on 5-fluorouracil (5-FU) kinetics after locoregional application to one female patient with liver metastases of a colon carcinoma. During each HPFD treatment, which lasted 4 h, 5-FU was given via a port-a-cath system into the hepatic artery on 4 separate days. The HPFD extraction rate was 99%. Extracorporal 5-FU clearance (89 ml/min) was 9% of total body clearance (1094 ml/min). The fraction eliminated within 4 h was only 6% of the applied dose (3500–4000 mg 5-FU). Sufficient extracorporal detoxification during combined HPFD can thus not be guaranteed in locoregional chemotherapy with a high dose of 5-FU.     

Report from the Rockefellar Foundation Sponsored International Workshop on reducing mortality and improving quality of life in long-term survivors of Hodgkin's disease: July 9-16, 2003, Bellagio, Italy

A workshop, sponsored by the Rockefellar Foundation, was held between 9 to 16 July, 2003 to devise strategies to reduce mortality and improve quality of life of long-term survivors of Hodgkin's disease. Participants were selected for their clinical and research background on late effects after Hodgkin's disease therapy. Experts from both developed and developing nations were represented in the workshop, and efforts were made to ensure that the proposed strategies would be globally applicable whenever possible. The types of late complications, magnitude of the problem, contributing risk factors, methodology to assess the risk, and challenges faced by developing countries were presented. The main areas of late effects of Hodgkin's disease discussed were as follows: second malignancy, cardiac disease, infection, pulmonary dysfunction, endocrine abnormalities, and quality of life. This report summarizes the findings of the workshop, recommendations, and proposed research priorities in each of the above areas.     

The impact of biologic agents on health-related quality of life outcomes in patients with psoriasis

Introduction: Psoriasis is a common, immune-mediated skin disease often associated with significant physical and psychosocial impairment. Antipsoriatic biologic agents offer patients unparalleled treatment potential in regard to greater skin clearance and overall improved quality of life. Evaluation of the therapeutic efficacy of biologic agents on the full psoriasis disease burden must account for their impact on both physical symptoms, as well as patient-reported, health-related quality of life (HRQoL) measurements.

Areas covered: Results from numerous clinical trials demonstrate the significant clinical efficacy of biological agents targeting tumor necrosis factor-α (TNF-α) and the interleukin (IL)-12/23 and IL-17 immune pathways. However, relatively limited data is available evaluating their full effect on quality of life outcomes. This review will discuss the most relevant and up-to-date clinical data on HRQoL measurements related to treatment with these aforementioned biologic agents.

Expert commentary: Patient-reported outcomes (i.e. Dermatology Life Quality Index) are being used with increasing frequency in clinical trials, and provide valuable information on the impact of psoriasis on numerous aspects of day-to-day living. These outcomes must also be incorporated in clinical practice, in addition to physical assessment of disease severity, treatment decisions, and therapeutic response in the psoriasis patient population.     

Desired lifetime and end-of-life desires across adulthood from 20 to 90: a dual-source information model

How long do people want to live, and how does scientific research on aging affect such desires? A dual-source information model proposes that aging expectations and desires are informed differently by two sources: personal experiences on the one hand, and scientific and societal influences on the other. Two studies with independent German national samples explored desires regarding length of life and end of life among adults between the ages of 20 and 90. FINDINGS ARE: First, desired lifetime is consistent at around 85 years with few age differences. Second, experimental induction of good or bad news from research on aging has little effect in Study 1. Third, interest in science has moderating effects on desired lifetime in Study 2. Fourth, there is a high prevalence of a strong desire to control the "when and how" of one's death, although only 11% of the individuals completed a living will. Findings are consistent with the dual-source information model.     

Therapeutic and diagnostic role of electrical devices in acute heart failure

Electrical devices, Cardiac Resynchronization Therapy (CRT) pacemakers, the Implantable Cardiac Defibrillator (ICD) and a combination of both, constitute an important line of treatment in the therapy of moderate to severe chronic heart failure. The effectiveness of these devices in the treatment of acute decompensated heart failure has yet to be systematically evaluated. However, the beneficial clinical effects of CRT translate into a marked reduction of heart failure-related hospitalization. Devices also offer unique diagnostic applications by continuous measurement of clinically useful physiological parameters over time. Of particular interest, monitoring of intrathoracic impedance and right ventricular pressures allows to detect changes in volume load in an early stage prior to the development of clinical symptoms. This information could be helpful to stop further progression to acute cardiac decompensation and to avoid hospitalization and acute clinical events. Using modern telecommunication technology, patients can also be remotely monitored in their daily living environment. In consequence, the incorporation of device technology into heart failure management programs calls for a close cooperation between heart failure specialists and electrophysiologists. This review addresses therapeutic and diagnostic aspects of device therapies in the context of acute heart failure. Disclosure information: the author of this review article receives research funding from Medtronic and St-Jude Medical, serves as a consultant to Medtronic and has received speakers honoraria from various device companies.     

Chemoimmunotherapy for cutaneous melanoma with dacarbazine and epifocal contact sensitizers: results of a nationwide survey of the German Dermatologic Co-operative Oncology Group

Purpose To scrutinize published data from small mono-centric studies and case reports which implicated high response rates and promising survival times for a combination therapy consisting of epifocal dinitrochlorobenzene (DNCB) and dacarbazine (DTIC) for metastasized melanoma. This therapy merges the effects of an allergic contact dermatitis elicited at the site of a cutaneous metastasis, and systemic chemotherapy. Methods We performed a retrospective survey with nine German centers and evaluated 72 patients treated from 1993 to 2005. Results The objective response rate in stage III melanoma (n = 39) was 62%. In contrast, only 9% objective responses were observed in 33 stage IV patients. Interestingly, more than half of patients with objective remissions remained progression-free for more than 1 year irrespective of the stage of disease. Conclusions Epifocal DNCB combined with DTIC is effective in patients with regionally metastasized melanoma not amenable to surgery or isolated limb perfusion, whereas in stage IV disease in spite of few durable remissions the addition of DNCB does not improve the therapeutic efficacy of DTIC.