Shifting trends in bacterial keratitis in south Florida and emerging resistance to fluoroquinolones

OBJECTIVE: To study the distribution, current trends, and patterns of resistance to antimicrobial agents of bacterial keratitis isolates in South Florida. DESIGN: Retrospective, observational, case series. PARTICIPANTS: The microbiology records of all patients with bacterial keratitis seeking treatment at the Bascom Palmer Eye Institute from January 1, 1990 through December 31, 1998 were reviewed. MAIN OUTCOME MEASURES: In vitro laboratory minimum inhibitory concentration testing of the corneal isolates to the fluoroquinolones (ofloxacin and ciprofloxacin) and to the aminoglycosides (tobramycin and gentamicin) was performed using the Vitek (Automatic Microbial System Biomerieux Vitek, Inc., Hazelwood, Missouri) method. RESULTS: During this 9-year period, 2920 consecutive corneal cultures were obtained, and a pathogen was recovered in 1468 cultures (50%). The number of corneal ulcers scraped, positive cultures, recovered bacterial isolates, and ratio of gram-positive to gram-negative isolates per year remained approximately equal throughout the study period. Staphylococcus aureus and Pseudomonas aeruginosa represented 19.4% and 25.7%, respectively, of the total bacterial isolates during this period. However, we documented a gradual increase in the number of S. aureus keratitis isolates (29% of gram-positive organisms in 1990 versus 48% in 1998, P = 0.01) coupled with a decrease in the number of P. aeruginosa isolates (54% of gram-negative organisms in 1990 versus 46% in 1998). A decrease in the incidence of contact lens-associated keratitis and P. aeruginosa isolates in this group of patients was documented. Serratia marcescens and P. aeruginosa were most commonly isolated in contact lens-associated keratitis (18% each). There was increasing laboratory resistance of S. aureus keratitis isolates to the fluoroquinolones (11% in 1990 to 28% in 1998), but resistance patterns to the aminoglycosides remained unchanged. There was a three-fold increase in the percentage of resistant S. aureus isolates to fluoroquinolones between 1990 and 1994 and between 1995 and 1998. Both fluoroquinolones and aminoglycosides exhibited low in vitro effectiveness against P. aeruginosa throughout the study period. CONCLUSIONS: The increased recovery of S. aureus keratitis isolates and decreased laboratory effectiveness against fluoroquinolones to these pathogens present an important therapeutic challenge.     

Is endosonography an effective method for detection and local staging of the ampullary carcinoma? A prospective study

Background  

The relatively rare carcinoma of the ampulla of Vater is a neoplasia with a good prognosis compared to pancreatic cancer. Preoperative staging is important in planning the most suitable surgical intervention.     

Percutaneous Cholangioscopy in the Management of Biliary Disease: Experience in 25 Patients

Purpose: To present our experience performing percutaneous cholangioscopy in the management of 25 patients with biliary disease. Methods: During the last 3 years, 26 percutaneous cholangioscopies were performed in 25 patients with common bile duct disease (n = 16), intrahepatic ducts disease (n = 6), and gallbladder disease (n = 4). Our patient population group included seven with common bile duct stones, three with intrahepatic lithiasis, and eight with benign strictures (six iatrogenic and two postinflammatory). In four patients malignancy was to be excluded, in two the tumor extent was to be evaluated, whereas in one case the correct placement of a metallic stent needed to be controlled. A 9.9 Fr flexible endoscope URF-P (Olympus, 1.2 mm working channel, 70-cm length) was used. Results: In total, percutaneous cholangioscopy answered 30 diagnostic questions, was technically helpful in 19 cases (performing lithotripsy or biopsy or guiding a wire), and of therapeutic help in 12 (performing stone retrieval). In 24 of 26 cases the therapeutic decision and the patient management changed because of the findings or because of the help of the method. In two cases biliary intervention failed to treat the cause of the disease. No major complication due to the use of the endoscopy was noted. Conclusions: Percutaneous cholangioscopy is a very useful tool in the management of patients with biliary disease. The method can help in diagnosis, in performing complex interventional procedures, and in making or changing therapeutic decisions.     

Cardiac abnormalities in end stage renal failure and anaemia

Thirteen anaemic children on dialysis were assessed to determine the incidence of cardiac changes in end stage renal failure. Nine children had an increased cardiothoracic ratio on radiography. The electrocardiogram was abnormal in every case but no child had left ventricular hypertrophy as assessed by voltage criteria. However, left ventricular hypertrophy, often gross, was found on echocardiography in 12 children and affected the interventricular septum disproportionately. Cardiac index was increased in 10 patients as a result of an increased left ventricular stroke volume rather than heart rate. Left ventricular hypertrophy was significantly greater in those on treatment for hypertension and in those with the highest cardiac index. Abnormal diastolic ventricular function was found in 6/11 children. Children with end stage renal failure have significant cardiac abnormalities that are likely to contribute to the high cardiovascular mortality in this group. Anaemia and hypertension, or its treatment, probably contribute to these changes. Voltage criteria on electrocardiogram are of no value in detecting left ventricular hypertrophy. Echocardiography must be performed, with the results corrected for age and surface area, in order to detect and follow these abnormalities.     

Rotator cuff tear: clinical experience with sonographic detection

Between June 1986 and April 1988, 86 sonographic examinations of the shoulder were performed on patients suspected of having rotator cuff tears. Major sonographic diagnostic criteria included (a) a well-defined discontinuity usually visible as a hypoechoic focus within the cuff, (b) nonvisualization of the cuff and (c) an echogenic focus within the cuff. Seventy-five patients underwent both sonography and arthrography. Compared with arthrography alone, ultrasound examinations enabled detection of 92% of rotator cuff tears (24 of 26 tears), with a specificity of 84% and a negative predictive value of 95%. Correlation was obtained in 30 of these patients who underwent surgery for rotator cuff tear or other soft-tissue abnormality. In this group, the sensitivity of sonography for detection of a tear was 93%, with a specificity of 73%, while for arthrography sensitivity was 87% and specificity was 100%. These data indicate that sonography is a useful, noninvasive screening procedure for patients suspected of having rotator cuff injury.     

Ki-67 proliferation index: correlation with prognostic parameters and outcome in multiple myeloma

The nuclear protein Ki-67 is a proliferation index, as it is expressed only by dividing cells. In this study, we investigated the clinical significance of Ki-67 determination on bone marrow biopsies of 35 patients with newly diagnosed multiple myeloma (MM). We examined the correlation of Ki-67 with other MM proliferation-related factors: interleukin-6 (IL-6), IL-10, bone marrow infiltration by plasma cells, serum lactate dehydrogenase (LDH), and beta 2 microglobulin (b2M). Ki-67 expression was also correlated with the survival rate of the patients. The results showed that Ki-67 expression increases with increasing stage of disease according to Durie-Salmon (classification stage III vs. I and II, p < 0.001). Furthermore, infiltration, IL-6, LDH, and b2M increase significantly with advancing stage of disease (p < 0.004). All parameters studied were significantly higher in patients versus controls. Ki-67 correlated with IL-6 (r: 0.422, p < 0.01), LDH (r: 0.437, p < 0.01), and b2M (r: 0.478, p < 0.004). There was a marked difference in survival between patients with MM with Ki-67 greater than 8% and patients with Ki-67 less than 8%, in favor of the latter (p < 0.07). We conclude that Ki-67 determination during routine pathological analysis of bone marrow in newly diagnosed MM could provide useful information about the proliferative activity and prognosis of the disease.     

Anti-inflammatory actions of flavonoids and structural requirements for new design

Flavonoids are low molecular weight compounds rich in seeds, citrus fruits, olive oil, tea and red wine, with potent antioxidant, cytoprotective and antiinflammatory activities. Flavonoids are composed of a three-ring structure (A,B and C) with various substitutions; they can be subdivided according to the presence of an oxy group at position 4, a double bond between carbon atoms 2 and 3 or a hydroxyl group in position 3 of the C (middle) ring. Particular hydroxylation patterns of the B ring of the flavones permit them to inhibit histamine, tryptase, interleukin-6 and interleukin-8 release from human umbilical-cord derived cultured mast cells, as well as from macrophages. The catechol (o-dihydroxy) group in the B ring as in quercetin confers potent inhibitory ability, while a pyrogallol (trihydroxy) group, as in myricetin, produces even higher activity. However, addition of one hydroxyl group on position 2′ of the B ring, as in the flavonol morin, renders this compound inactive. The C2-C3 double bond of the C ring appears to increase scavenger activity because it confers stability to the phenoxy-radicals produced, while the 4-oxo (keto double bond at position 4 of the C ring) increases free radical scavenger activity by delocalizing electrons from the B ring. The 3-OH group on the C ring appears tobe critical for anti-inflammatory activity. Inhibition of mast cell secretion was shown to be mediated by a 78-kD phosphoprotein which has been cloned and serves as a bridge between the cell surface and the cytoskeleton. Phosphorylation at particular sites in the C-terminus unfolds the three dimensional structure of this protein making actin binding sites accessible; crosslinking with actin in the cytoskeleton prevents secretion of inflammatory mediators. These properties present unique opportunities for the synthesis of new compounds for the treatment of inflammatory and possibly proliferative disorders.     

Obstetric and nonmalignant gynecologic bleeding: treatment with angiographic embolization

Eight patients (seven post partum, one post abortion) with massive pelvic hemorrhage related to pregnancy and one patient with uncontrollable bleeding following a cervical biopsy underwent angiography to facilitate the identification and treatment of bleeding sites. In all nine patients pelvic hemorrhage was successfully controlled with embolization under angiographic guidance. Angiographic embolization allowed preservation of the uterus in six patients referred prior to hysterectomy, and one patient subsequently became pregnant. When conservative measures and minor surgical repairs have failed, embolization should be the next step in the treatment of postpartum hemorrhage to avoid major surgery in an unstable patient and to maintain reproductive function.