Gangrene of the perineum

Fournier's gangrene, an anaerobic necrotizing cellulitis of the infradiaphragmatic soft tissues, is a serious pathologic entity with an unpredictable course. From 1978 to 1991, a total of 24 men (mean age, 57 years; range 27 to 90) were treated for this entity at our institution. Diagnosis prompted immediate institution of multimodal treatment combining triple antibiotics, surgical dissection, debridement, and repeated surgical drainage. Fecal diversion (16 patients), hyperbaric oxygenation, and standard intensive care procedures were widely indicated and performed quasi-systematically. The mean interval between initial symptoms and diagnosis was 7.4 days. Lesions were limited to the perineum in 11 patients but extended to the abdomen, thighs, or loins in the remaining 13. The pathogens were identified in 19 patients, and hemoculture results were positive in 5. A coloproctologic origin was identified in 12 patients and a urogenital origin in 4. In 2 patients, perineal gangrene occurred postoperatively, and no etiology was determined for 6. Six patients died, and 18 patients recovered, without any sequelae. The prognosis is better when the patient is young (less than 60 years old), has clinically localized disease, without systemic involvement, and sterile hemocultures and is managed with a colostomy. A thorough workup is mandatory to determine the etiology (locoregional lesion, malignancy, hemopathy, arteritis).     

意大利的耐多药结核病管理

地点：SMIRA（意大利抗结核药品耐药性研究）网络,包括意大利全国46个主要临床单位和22个实验室.目的：确定1995年1月至1999年12月登记的耐多药结核病人（MDR-TB）的特点、对WHO指南的依从性以及治疗结果.设计：根据WHO的建议,先作耐药水平测试,然后进行观察性研究.结果分为治疗方案适当和治疗方案不合理（少于三种有效药物）.根据治疗的合理程度分析治疗结果.用单变量和多变量分析法分析危险因素和治疗结果预报因素（显著性水平P＜0.0结果：共诊断127个耐多药病人.总的治疗成功率低（39%）.70%的病人至少使用过3种有效药物.治疗成功的预报因素有,新治MDR-TB病人（OR=3.45;95%CI：1.22-9.87;P＜0.05）和治疗≥12个月（OR=5.03;95%CI：1.65-15.31;P＜0.05）.在新治MDR-TB病人中,移民和艾滋病病毒感染是主要的危险因素.结论：应该给所有新诊断MDR-TB病人提供现有的最好治疗,避免使用不适宜的治疗方案.MDR-TB病人应该被转诊到专业机构诊治.     

Morphological variation of layer III pyramidal neurones in the occipitotemporal pathway of the macaque monkey visual cortex

We compared the morphological characteristics of layer III pyramidal neurones in different visual areas of the occipitotemporal cortical 'stream', which processes information related to object recognition in the visual field (including shape, colour and texture). Pyramidal cells were intracellularly injected with Lucifer Yellow in cortical slices cut tangential to the cortical layers, allowing quantitative comparisons of dendritic field morphology, spine density and cell body size between the blobs and interblobs of the primary visual area (V1), the interstripe compartments of the second visual area (V2), the fourth visual area (V4) and cytoarchitectonic area TEO. We found that the tangential dimension of basal dendritic fields of layer III pyramidal neurones increases from caudal to rostral visual areas in the occipitotemporal pathway, such that TEO cells have, on average, dendritic fields spanning an area 5-6 times larger than V1 cells. In addition, the data indicate that V1 cells located within blobs have significantly larger dendritic fields than those of interblob cells. Sholl analysis of dendritic fields demonstrated that pyramidal cells in V4 and TEO are more complex (i.e. exhibit a larger number of branches at comparable distances from the cell body) than cells in V1 or V2. Moreover, this analysis demonstrated that the dendrites of many cells in V1 cluster along specific axes, while this tendency is less marked in extrastriate areas. Most notably, there is a relatively large proportion of neurones with 'morphologically orientation-biased' dendritic fields (i.e. branches tend to cluster along two diametrically opposed directions from the cell body) in the interblobs in V1, as compared with the blobs in V1 and extrastriate areas. Finally, counts of dendritic spines along the length of basal dendrites revealed similar peak spine densities in the blobs and the interblobs of V1 and in the V2 interstripes, but markedly higher spine densities in V4 and TEO. Estimates of the number of dendritic spines on the basal dendritic fields of layer III pyramidal cells indicate that cells in V2 have on average twice as many spines as V1 cells, that V4 cells have 3.8 times as many spines as V1 cells, and that TEO cells have 7.5 times as many spines as V1 cells. These findings suggest the possibility that the complex response properties of neurones in rostral stations in the occipitotemporal pathway may, in part, be attributed to their larger and more complex basal dendritic fields, and to the increase in both number and density of spines on their basal dendrites.      

Cost-effectiveness analysis of tuberculosis control policies in Ivanovo Oblast, Russian Federation. Ivanovo Tuberculosis Project Study Group.

Many of the current tuberculosis control programmes in the Russian Federation are based on costly strategies which are underfunded and use long, individualized treatment regimens. This article compares, using a cost-effectiveness analysis, the new WHO strategy implemented in the Ivanovo Oblast (case-finding among symptomatic patients (SCF) and shorter regimens) and the old strategy (active screening of the asymptomatic population (ACF) and longer regimens). The cost per case cured was calculated at different levels of cure rate (45-95%) using three scenarios to describe the new WHO strategy (use of WHO-recommended regimens and three options at increasing rates of admission) and a fourth scenario to describe the old strategy (all patients admitted for the whole treatment and longer regimens). The cost per case detected was determined by calculating the following: yield of the new and old strategy (number of examinations necessary to diagnose one case); cost of the diagnostic process; multiplying yield per cost according to the three scenarios describing the new WHO strategy and a fourth scenario describing the old strategy. In the Ivanovo Oblast the cost per case cured, at 85% cure rate level, ranged from US$ 1197 (new strategy, scenario 1 without food) to US$ 6293 (old strategy, scenario 4) the cost per case detected ranged from US$ 1581 (new strategy, scenario 1) to US$ 4000 (old strategy, scenario 4). Significant savings can result from shifting towards the new WHO strategy. Decision-makers and health administrators should be responsible for re-investing the financial and human resources mobilized by the adoption of cost-effective strategies within the TB control programme.