Prevalence of extended spectrum beta-lactamase producing Escherichia coli and Klebsiella isolates in a large community teaching hospital in Connecticut

The prevalence of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (ESC) and Klebsiella (KS) among consecutive non-urine isolates were evaluated. Twenty-four of 392 isolates produced ESBLs. Among these half were from respiratory sites and all were susceptible to meropenem. Pulse field-gel electrophoresis (PFGE) showed 12 clonally distinct ESBLs and iso-electric focusing (IEF) revealed that most (83%) produced multiple enzymes.     

The role of gender in the long-term prognosis of patients with myocardial infarction submitted to fibrinolytic treatment

PURPOSE: To determine the role of gender in short- and long-term survival after a thrombolytic-treated myocardial infarction. METHODS: A total of 686 consecutive patients with ST-elevation acute myocardial infarction, admitted to a single center and treated with intravenous streptokinase, were studied prospectively and consecutively. Assessment of clinical and in-hospital variables permitted comparison of baseline characteristics and both in-hospital and long-term survival between men and women. RESULTS: A significantly (odds ratio=0.48, P=0.009) lower 14-day mortality rate for males (8.5%) relative to females (16%) was noted. However, this difference became non-significant after adjustment for age (odds-ratio male/female=0.62, P=0.097) or age and other variables (odds ratio=0.71, P=0.17). At the end of the follow-up (up to 12 years), survival rates for the whole population were 59.6% and 54.4% for men and women, respectively (chi-square=1.4, P=0.24); excluding in-hospital deaths, the rates were 65.1% and 64.8%, respectively (chi-square=0.21, P=0.65). CONCLUSIONS: In the short-term follow-up, women have a significantly higher mortality relative to men in an unadjusted analysis. This difference became non-significant after adjusting for age, or age and other variables. In the long-term follow-up, sex was not correlated with prognosis.     

Pharmacodynamics of meropenem and imipenem against Enterobacteriaceae, Acinetobacter baumannii, and Pseudomonas aeruginosa

STUDY OBJECTIVE: To compare the pharmacodynamics of meropenem and imipenem, both administered as 500 mg every 6 hours, against populations of Enterobacteriaceae, Acinetobacter baumannii, and Pseudomonas aeruginosa. DESIGN: Ten thousand-subject Monte Carlo simulation. INTERVENTION: Variability in total body clearance (ClT), volume of distribution as calculated by the terminal elimination rate (Vdbeta), and minimum inhibitory concentration (MIC) distributions (Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, A. baumannii, P. aeruginosa) were derived from the literature for both meropenem and imipenem. For the free drug concentrations, the percentage of the dosing interval that the drug concentrations remain above the MIC (%T>MIC) for each carbapenem-bacteria combination was calculated for 10,000 iterations, substituting a different ClT, Vdbeta, fraction of unbound drug, and MIC into the equation each time based on the probability distribution for each parameter. Probabilities of attaining targets of 30%, 50%, and 100% T>MIC were calculated. MEASUREMENTS AND MAIN RESULTS: Meropenem free drug %T>MIC exposure was significantly greater than that of imipenem against Enterobacteriaceae and P. aeruginosa, whereas imipenem exposure was greater for A. baumannii. For both agents, free drug %T>MIC exposure was greatest against Enterobacteriaceae and less for A. baumannii and P. aeruginosa. Probabilities of target attainment for 30% and 50% T>MIC were similar between drugs for most bacteria. At 100% T>MIC, meropenem target attainments were greater than those of imipenem against Enterobacteriaceae and P. aeruginosa, and imipenem attainment was higher for A. baumannii. CONCLUSION: The probability of attaining lower pharmacodynamic targets for most gram-negative bacteria is similar for these carbapenems; however, differences become apparent as the pharmacodynamic requirement increases. Further study of the benefits of achieving this pharmacodynamic breakpoint with a higher probability of attaining targets is necessary.     

Inhibition of multidrug resistance by immunisation with synthetic P-glycoprotein-derived peptides

Overexpression of the membrane glycoprotein (P170) represents the most common multidrug resistance (MDR) mechanism in cancer therapy. Specific auto-antibodies to extracellular loops 1, 2 and 4 of murine P170 were elicited in mice using palmitoylated synthetic peptides reconstituted in liposomes, with or without Lipid A, and resuspended in alum. IgM antibodies were detected 14 days following the first injection and IgG1 became predominant after the third challenge. Animals did not show any auto-immune symptoms or induced toxicity up to 18 months after the immunisation. Previous immunisations of mice using liposomes with MDR1 peptides increases the efficacy of chemotherapy treatments with doxorubicin and vinblastine against P388 R cells with increase of 77% in the survival half time in the immunised group. Sera from the immunised mice were also effective in reducing cellular resistance to vinblastine and doxorubicin in vitro. Taken together, these data suggest that this immunisation approach might have potential clinical applications.     

Results of a feasibility study for a psycho-educational intervention in head and neck cancer

BACKGROUND: With survival rates for people with head and neck (H&N) cancers static during the past 30 years and the enormous burden of psychosocial impacts they suffer well documented, the testing of psychosocial interventions in this group is a priority. OBJECTIVE: To test the feasibility of providing a psycho-educational intervention for people with H&N cancer. METHODOLOGY: A prospective non-randomised design was used. Subjects were patients with H&N cancer. They were offered the Nucare coping strategies program in one of three formats: small group and one-to-one formats with therapists; and a home format, with material for home use, without a therapist. Outcomes measures (quality of life (QOL) and anxiety and depression) were collected at baseline and following the intervention. Analyses were performed using non-parametric statistics. RESULTS: Of 128 people invited to participate, 66 agreed, 59 completed the intervention and 50 had outcomes data. Following the intervention, there were significant improvements in physical and social functioning and global QOL, and reduced fatigue, sleep disturbance and depressive symptoms. CONCLUSIONS: These data suggest that the intervention is desired by the target group, feasible to deliver after cancer therapy and may have some beneficial effects, although an appropriately designed study is required to confirm this.     

Accuracy of sonography with a hydration test in differentiating between excretory renal obstruction and renal sinus cysts

PURPOSE: The aim of this prospective study was to determine whether sonography with a hydration test to induce diuresis can be used to reliably differentiate between excretory renal obstruction and renal sinus cysts. METHODS: We performed sonographic examination of all patients diagnosed with minimal or moderate obstruction of the intrarenal collecting system or renal sinus cysts on the basis of excretory urography, CT, or both between September 1, 1998, and October 31, 1999. The largest fluid-filled structures in the renal sinus were sonographically measured before and after each patient ingested 1.5 l of water. Cases in which the maximum diameters of the largest anechoic structures increased by at least 10% after hydration were diagnosed with excretory renal obstruction. The sonographic diagnoses were compared with the final diagnoses on excretory urography, CT, or both. RESULTS: Both kidneys were affected in 16 of the 36 patients examined, for a total of 52 kidneys. The sonographic diagnosis was consistent with the results of urography or CT in 48 (92%) of the 52 kidneys. The sonographic approach had a specificity of 92% and a sensitivity of 93% for the diagnosis of excretory renal obstruction, with only 1 false-negative and 3 false-positive results. CONCLUSIONS: When used with the stimulated diuresis test, sonography can reliably distinguish between excretory renal obstruction and renal sinus cysts and can be used as an alternative to other imaging techniques such as urography.     

Laparoscopic radical cystoprostatectomy: a technique illustrated step by step

OBJECTIVES: Laparoscopic surgery is expanding among urologists as a minimally invasive treatment and may now be applied to treat neoplasms of the pelvic organs. Laparoscopic cystoprostatectomy has still not been well codified and illustrated. We describe a technique of laparoscopic radical cystoprostatectomy that we have developed in 10 patients after practicing in laparoscopic radical prostatectomy. METHODS: Between June 2001 and July 2002, 10 men with bladder cancer underwent laparoscopic cystoprostatectomy with urinary diversion. This report details step by step our 5-port transperitoneal technique with primary access to the seminal vesicles and Denonvillier's fascia, ureters detection after umbilical arteries incision, endopelvic fascia incision and dorsal vein complex control before division of the vesical and prostatic fibrovascular pedicles with a harmonic scalpel. RESULTS: We performed 6 orthotopic ileal neobladders, 2 sigmoid ureterostomies and 2 cutaneous ureterostomies. In all cases no conversion to open surgery was necessary. The mean time to perform the laparoscopic radical cystoprostatectomy, including the lymph node dissection, was 166 minutes (range 150-180). Mean estimated blood loss was 310 ml (range 220-440). Mean hospital stay was 8.1 days (range 7-9) for ileal orthotopic neobladder, 8 days (range 7-9) for sigmoid ureterostomy and 5 days for cutaneous ureterostomy. The mean follow up is 12.3 months (range 5-18). Two patients respectively with stage T2bN0 G2-3 and stage pT1N0 (plus carcinoma in situ) G3 transitional cell carcinoma and surgical margins tumor free had diffusive metastatic disease after 6 months. The other 8 patients are free from disease. CONCLUSIONS: Laparoscopic radical cystectomy is still an operation for pioneers but this procedure may be not strictly relegated to a few academic centers. In our opinion laparoscopic cystoprostatectomy is a feasible, fast, safe and easy procedure and urinary diversion may be performed with a laparoscopic, open or combined approach without reducing the advantages of laparoscopy.     

Advantages and disadvantages of planned staged relaparotomy using the zipper technique in surgical treatment of necrotizing pancreatitis

The rationale of surgical intervention during acute necrotizing pancreatitis is to remove necrotic tissue preserving healthy glandular parenchyma and other adjacent structures, thus limiting severe complications. Necrosectomy and debridement are the crucial in surgical management, further treatment of pancreatic bed and peripancreatic tissue are still a matter of debate among pancreatic surgeons. Zipper technique is one of the three recognized methods [table: see text] for the surgical management of necrotizing pancreatitis. The aim this study was to review the literature data about treatment using this technique, as well to compare the results of treatment with other techniques, in order to present the advantage and disadvantage of zipper technique. The main advantage of this technique is a high level of control of intraabdominal infection and other septic complications associated with necrotizing pancreatitis and its surgical management. Increased risk of development of gastrointestinal and pancreatic fistulas as well of intraabdominal bleeding is probably the main disadvantage. A flexible approach focused on the individual patients is a reasonable solution in the surgical management of the necrotizing pancreatitis.     

Production and resolution of cantharidin-induced inflammatory blisters

While inflammatory blisters have long been utilized as a means of evaluating antimicrobial disposition to aid in the development of new treatments for skin and skin structure infections, sparse data are available regarding the healing of the blisters once the experiment has been completed. We report the blister induction technique and resolution time in ten volunteers enrolled in a pharmacokinetic study using the cantharidin-induced inflammatory blister technique.