Developmental outcomes of children born through ICSI versus conventional IVF (cIVF) in couples with non-male factor infertility.

STUDY QUESTION: In non-male factor infertile couples, are there any differences in the developmental outcomes between children born through ICSI and conventional IVF (cIVF)? SUMMARY ANSWER: In this preliminary study, ICSI and cIVF seem to have a comparable effect on developmental outcomes after 12 months in children born to non-male factor infertile couples. WHAT IS KNOWN ALREADY: ICSI, an invasive technique, has raised concerns about potential developmental abnormalities in children. Limited data are available regarding the developmental outcomes of ICSI-conceived infants born to non-male factor infertile couples. STUDY DESIGN, SIZE, DURATION: This prospective cohort study involved a follow-up of all children aged 12 months or older who were born from pregnancies resulting from either ICSI or cIVF as part of a previous randomized controlled trial (RCT) (NCT03428919). PARTICIPANTS/MATERIALS, SETTING, METHODS: In the original RCT, 1064 women were randomly assigned to the ICSI or cIVF groups (532 women for each group). Follow-up was conducted with 155 couples (195 children) in the ICSI group and 141 couples (185 children) in the cIVF group. The Vietnamese version of the Ages & Stages Third Edition Questionnaires (ASQ-3) and the Development Red Flags questionnaires were completed by the participants. A total of 141 (90.1%) women (177 children) in the ICSI group and 113 (80.1%) women (145 children) in the cIVF group returned fully completed questionnaires. The primary outcomes were the developmental outcomes based on responses to the ASQ-3 and the Red Flags questionnaire. MAIN RESULTS AND THE ROLE OF CHANCE: The mean age of children at follow-up was 19.5 ± 5.0 months in the ICSI group and 19.3 ± 5.5 months in the cIVF group. The mean height and weight of children in both groups were similar. The overall proportion of children with any abnormal ASQ-3 score did not differ significantly between the ICSI and cIVF groups (16.9% vs 13.1%, P = 0.34). The proportion of children with Red Flag signs was also comparable between the two groups (6.2% vs 9.2%, P = 0.36, ICSI vs cIVF, respectively). LIMITATIONS, REASONS FOR CAUTION: Despite a reasonably high follow-up response rate, there is a potential risk of sampling bias, and overall, the number of children with developmental abnormalities was very small. The study relied solely on questionnaires as screening tools, rather than incorporating additional behavioral observations or physical developmental tests; this may have affected the statistical power and the significance of between-group comparisons. WIDER IMPLICATIONS OF THE FINDINGS: The current findings contribute to the existing evidence and support the comparative safety of ICSI and cIVF regarding early childhood development. However, more extensive and prolonged follow-up data for these children are needed to draw definitive conclusions. STUDY FUNDING/COMPETING INTEREST(S): No external funding was received for this study, and no authors reported conflicting interests. TRIAL REGISTRATION NUMBER: NCT04866524 (clinicaltrials.gov).

Development of children born to women with twin pregnancies treated with cervical pessary or vaginal progesterone: Follow-up of a randomized controlled trial.

INTRODUCTION: Preterm birth is the most common cause of neonatal morbidity and mortality. Women with twin pregnancies and a short cervical length are at high risk for preterm birth. Vaginal progesterone and cervical pessary have been proposed as potential strategies to reduce preterm birth in this high-risk population. Therefore, we aimed to compare the effectiveness of cervical pessary and vaginal progesterone in improving developmental outcomes of children born to women with twin pregnancies and mid-trimester short cervical length. MATERIAL AND METHODS: This was a follow-up study (NCT04295187) of all children at 24 months of age, born from women treated with cervical pessary or progesterone to prevent preterm birth in a randomized controlled trial (NCT02623881). We used a validated Vietnamese version of Ages & Stages Third Edition Questionnaires (ASQ-3) and a red flag questionnaire. In surviving children, we compared the mean ASQ-3 scores, abnormal ASQ-3 scores, the number of children with any abnormal ASQ-3 scores and red flag signs between the two groups. We reported the composite outcome of perinatal death or survival with any abnormal ASQ-3 score in offspring. These outcomes were also calculated in a subgroup of women with a cervical length ≤28 mm (<25th percentile). RESULTS: In the original randomized controlled trial, we randomized 300 women to pessary or progesterone. After counting the number of perinatal deaths and lost to follow-up, 82.8% parents in the pessary group and 82.5% parents in progesterone group returned the questionnaire. The mean ASQ-3 scores of the five skills and red flag signs did not differ significantly between the two groups. However, the percentage of children having abnormal ASQ-3 scores in fine motor skills was significantly lower in the progesterone group (6.1% vs 1.3%, P = 0.01). There were no significant differences in the composite outcome of perinatal death or survival with any abnormal ASQ-3 score in unselected women and in those with cervical length ≤28 mm. CONCLUSIONS: Cervical pessary and vaginal progesterone may have comparable effects on developmental outcomes in children at ≥24 months of age, born to women with twin pregnancies and short cervical length. However, this finding could be likely due to a lack of study power.

Release of a disordered domain enhances HspB1 chaperone activity toward tau.

Small heat shock proteins (sHSPs) are a class of ATP-independent molecular chaperones that play vital roles in maintaining protein solubility and preventing aberrant protein aggregation. They form highly dynamic, polydisperse oligomeric ensembles and contain long intrinsically disordered regions. Experimental challenges posed by these properties have greatly impeded our understanding of sHSP structure and mechanism of action. Here we characterize interactions between the human sHSP HspB1 (Hsp27) and microtubule-associated protein tau, which is implicated in multiple dementias, including Alzheimer's disease. We show that tau binds both to a well-known binding groove within the structured alpha-crystallin domain (ACD) and to sites within the enigmatic, disordered N-terminal region (NTR) of HspB1. However, only interactions involving the NTR lead to productive chaperone activity, whereas ACD binding is uncorrelated with chaperone function. The tau-binding groove in the ACD also binds short hydrophobic regions within HspB1 itself, and HspB1 mutations that disrupt these intrinsic ACD-NTR interactions greatly enhance chaperone activity toward tau. This leads to a mechanism in which the release of the disordered NTR from a binding groove on the ACD enhances chaperone activity toward tau. The study advances understanding of the mechanisms by which sHSPs achieve their chaperone activity against amyloid-forming clients and how cells defend against pathological tau aggregation. Furthermore, the resulting mechanistic model points to ways in which sHSP chaperone activity may be increased, either by native factors within the cell or by therapeutic intervention.

Contractility of the epididymal duct: function, regulation and potential drug effects

During their transit through the epididymis, spermatozoa mature and acquire motility and fertilizing capacity. The smooth muscle cells (SMCs) of the epididymal duct are thought to be responsible for the adequate transport of spermatozoa. Thus, precise regulation of SMC function also represents a prerequisite for sperm maturation thereby contributing to male fertility. In this review, we would like to highlight various aspects of epididymal SMC function and discuss several angles with respect to regulation of contraction and relaxation. Different to the vas deferens, where disturbed SMC pathways resulting in male infertility could be defined, comparable information is missing in the epididymis. We therefore include some vas deferens data which could also be useful for a better understanding of epididymal SMC function. Furthermore, we would like to draw attention to drugs used in clinical practice and their potential (side) effects on contractions in the epididymis.

Factors Associated with Receiving Late HIV Testing Among Women Delivering at Hung Vuong Hospital, Ho Chi Minh City, Vietnam, 2014.

HIV testing during pregnancy facilitates timely antiretroviral treatment for HIV-positive women. This study identifies reasons for late HIV testing among pregnant women delivering at a hospital in Ho Chi Minh City. We conducted a case-control study in which 160 cases were women who were tested for HIV late (i.e., at labor and delivery) and 160 controls were women who were tested during antenatal care (ANC). In multivariable logistic regression analysis, six variables were associated with late HIV testing: age less than 30 years, nine or fewer years of education, working as a homemaker or worker/farmer, living 20 km or more from the hospital, having received ANC at a private clinic/hospital only, and not believing that HIV testing is important during pregnancy. We recommend that national programs should provide additional effort for HIV testing during pregnancy to young women, less educated women, homemakers, and those receiving ANC at private clinics and hospitals.

Epididymitis: ascending infection restricted by segmental boundaries.

STUDY QUESTION: Is the regionalization of epididymitis related to epididymal segmentation? SUMMARY ANSWER: We show for the first time that luminal ascent of bacteria is strictly gated by epididymal segment boundaries, involving ductal constriction adjacent to the infected area. WHAT IS KNOWN ALREADY: The epididymal duct is a continuous, unbranched tube, coiled into segments that are divided by connective tissue septa. Sonographic analysis indicates that swelling associated with epididymitis is predominant in the cauda region. Epididymal segmentation has never been investigated in the context of pathological alterations. STUDY DESIGN, SIZE, AND DURATION: We analyzed segment-specific changes in the epididymal duct in a mouse model and in men. In the mouse epididymitis model (3 days post-infection, injection of bacteria into the lumen of the vas deferens), two Escherichia coli strains were tested: a uropathogenic strain CFT073 (UPEC, n = 7) and a fecal non-pathogenic strain NPEC470 (NPEC, n = 5). Two control groups: phosphate-buffered saline, sham-treated animals (n = 4) and untreated mice (n = 8). In addition, segmentation was verified by ex vivo injection of dye into the interstitial spaces of untreated mouse epididymides. Histological findings were compared with specimens from epididymitis patients (n = 10, age range 14-78, median 60 years) who underwent surgical intervention; control: samples from patients without epididymitis (n = 16, age range 38-87, median 73 years). PARTICIPANTS/MATERIALS, SETTING, AND METHODS: We investigated the ascending infections by detailed histological analysis in correlation with local infection status in a mouse epididymitis model. As a proof of concept, rare patient material from two archives was analyzed: epididymides from patients who underwent surgical intervention for persisting epididymitis, and for control, histologically normal epididymides from men who underwent orchiectomy for therapy of prostatic carcinoma. MAIN RESULTS AND THE ROLE OF CHANCE: Luminal ascent of E. coli in mice was strictly gated by epididymal segment boundaries. In the mouse model, both strains of E. coli were detected exclusively in the distal cauda segment associated with damage of the epithelium and muscle layer. Ductal constriction occurred in the non-infected upstream segments of infected area, putatively blocking further luminal ascent of bacteria in UPEC-infected animals. Corresponding histological and morphological changes were found in epididymitis patients. The caput region was found to be unaffected in patients and the mouse model. LIMITATIONS, REASONS FOR CAUTION: Patient samples represented advanced cases of epididymitis that made surgical intervention necessary. WIDER IMPLICATIONS OF THE FINDINGS: Our data demonstrate the impact of epididymal segmentation, presumably a protective response mechanism against infectious invasion and bacterial ascent, during epididymitis and affirm the importance of rapid intervention. STUDY FUNDING/COMPETING INTERESTS: This work was supported by grants from the State of Hessen (LOEWE-MIBIE) and the DFG (KFO 181). The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: No clinical trial involved.

Charcot neuroarthropathy versus osteomyelitis: a case series.

INTRODUCTION: Patients with diabetes and peripheral neuropathy have a 25% risk of developing a foot ulcer, and these can lead to soft tissue infections that worsen and result in osteomyelitis. While Charcot neuroarthropathy is not as common as osteomyelitis, it is often misdiagnosed as osteomyelitis. CASE REPORTS: Three patients presented with diabetes, neuropathy, and foot ulcers. They underwent prophylactic surgery but later developed swelling at the surgical sites. Radiographs showed fragmentations that caused concern about osteomyelitis. The authors maintained diagnoses of Charcot neuroarthropathy and treated the patients with immobilization and offloading. All patients resolved the fragmentations without antibiotics or surgery. CONCLUSION: While Charcot neuroarthropathy and osteomyelitis have similar signs and symptoms, understanding the similarities and differences between the conditions can aid providers in appropriate wound management.

'It's really important to be collaborating': Experiences of participatory research for Chinese and Vietnamese parents of autistic children.

Background and aims: Participatory research involves academic partners working together with the community that is affected by research to make decisions about that research. Such approaches often result in research that is more respectful of, and responsive to, community preferences - and is vital in the context of autism research with culturally and linguistically diverse (CALD) communities. Whilst participatory approaches are becoming more commonplace within CALD autism research, no studies have explored the experiences of being involved in autism research from the perspectives of CALD community partners over the course of a study. This paper intended to address this gap by reporting on the experiences of CALD parents of autistic children who were community partners in a 1-year Australian research project exploring home-school partnerships for CALD parents of autistic children. We aimed to: (1) report on how parents' involvement in the research process shaped the home-school partnerships study over time and (2) understand their experiences of being community partners on the home-school partnerships project. Methods: Using key principles of participatory approaches, we established Chinese and Vietnamese parent advisory groups to contribute to a project exploring home-school partnerships for parents of autistic children from CALD backgrounds in Australia. Advisory groups included parents of autistic children from Chinese/Vietnamese backgrounds, as well as interpreters, professionals and researchers. We documented how parents' participation as community partners shaped the home-school partnerships study over the course of the project. We also elicited parents' own views and experiences of being community partners through informal, open-ended questions at the beginning and end of the study. Results: We found that parents' input fundamentally shaped the broader home-school partnership study, from meaningful, accurate translation of interview schedules through to making decisions regarding community-specific recommendations and dissemination plans. Parents themselves reported being keen to collaborate and to hear and share opinions for the purpose of the home-school partnership study - although they noted how emotionally difficult sharing their stories could be. While they initially had some concerns about combining being involved as a community partner with their existing responsibilities, ultimately, parents were surprised by the scope of the home-school partnership study and their level of involvement as community partners. Through hearing others' stories and sharing their own in advisory group meetings, parents reported ancillary benefits of their involvement, including increased self-advocacy and well-being. Conclusions: These findings show how research that is conducted in partnership with diverse members of the autism community has the capacity to improve the quality of the research and benefit community partners. Implications: This study clearly documents the benefits and potential challenges of participatory approaches with CALD communities. These findings emphasise to researchers and funders the importance of including extra time and money within budgets in order to produce meaningful research that is respectful and responsive to communities.

Trypan blue: effect on retinal pigment epithelial and neurosensory retinal cells.

PURPOSE: To evaluate the toxicity of trypan blue on retinal cells in vitro. METHODS: Human retinal pigment epithelial cells (ARPE-19) and rat neurosensory retinal cells (R28) were grown in tissue culture and treated with four different concentrations of trypan blue (0.1%, 0.05%, 0.025%, and 0.0125%), in combination with surgical light exposure (0, 5, or 10 minutes). Cell viability, mitochondrial function, and DNA synthesis were measured by trypan blue dye-exclusion assay, mitochondrial dehydrogenase assay, and tritiated [3H] thymidine incorporation, respectively. RESULTS: ARPE-19 and R28 cells exposed to trypan blue with or without illumination did not show any significant decrease, either in cell viability by the dye-exclusion assay or in [3H] thymidine incorporation. R28 cells exposed to 0.1% trypan blue with and without light showed a significant reduction of mitochondrial dehydrogenase activity (P <0.05). ARPE-19 cells exposed to trypan blue, with or without light, did not show any significant decrease in mitochondrial dehydrogenase activity. CONCLUSIONS: This study suggests that rat neurosensory retina (R28) cells are more sensitive than human RPE (ARPE-19) cells to trypan blue. ARPE-19 cells showed no evidence of toxicity with any of the three assays, but R28 cells showed evidence of toxicity with the mitochondrial dehydrogenase assay at the higher doses and light-exposure times studied. Clinical studies must be conducted to determine the safety and efficacy of staining of the inner limiting membrane with trypan blue.

Toxicity of indocyanine green (ICG) in combination with light on retinal pigment epithelial cells and neurosensory retinal cells.

PURPOSE: To evaluate the toxicity of indocyanine green (ICG) in combination with light. METHODS: Human retinal pigment epithelial cells (ARPE-19) and rat neurosensory retinal cells (R28) were treated with four different concentrations of ICG in combination with light exposure. Cell viability, mitochondrial function, and DNA synthesis were measured. RESULTS: All concentrations of ICG with 10 min of light exposure caused a significant decrease in mitochondrial dehydrogenase activity in R28 and ARPE-19 cells. ICG without light exposure did not decrease mitochondrial dehydrogenase activity. In both cell lines, [(3)H]thymidine incorporation was increased when treated with ICG with or without light. R28 cells did not show any significant decrease in cell viability. CONCLUSIONS: The duration of light was a significant factor in ICG toxicity. ICG needs to be used with caution as it decreases the mitochondrial dehydrogenase activity and increases the DNA synthesis in retinal cells, markers for cell toxicity and dysfunction.

Mechanisms of the adjuvant effect of hemoglobin in experimental peritonitis. III. The influence of hemoglobin on phagocytosis and intracellular killing by human granulocytes.

The effect of hemoglobin on the ability of polymorphonuclear granulocytes (PMNs) to phagocytize and kill opsonized E. coli was measured. Results show that the addition of hemoglobin in a concentration of 0.1% inhibititis phagocytotic activity of PMNs from 68% to 13% after 30 minutes and from 73% to 45% after 60 minutes. The rate of intracellular killing after the addition of hemoglobin in the concentration of 0.5% declined from 63% to 21%. Though these experiments do not allow any conclusions as to the exact mechanism of action of hemoglobin in inhibition of phagocytosis, it seems likely from other data that the inhibitory activity resides in the heme part of the molecule. We conclude that hemoglobin inhibits phagocytotic activity and the ability to kill ingested bacteria of human polymorphonuclear granulocytes. This provides an additional mechanism for the adjuvant action of hemoglobin in intraperitoneal infections and supports the theory that hemoglobin acts directly on the granulocyte to impair the essential host defenses.

Mechanisms of the adjuvant effect of hemoglobin in experimental peritonitis. IV. The adjuvant effect of hemoglobin in granulocytopenic rats.

Intraperitoneal inocula of pure Escherichia coli do not produce lethal peritonitis unless adjuvant materials are present. We have previously presented evidence that hemoglobin acts as an adjuvant in experimental Escherichia coli peritonitis by interfering with antibacterial neutrophil function. The hypothesis was further tested in normal Sprague-Dawley rats and rats depleted of granulocytes by pretreatment with busulfan and cyclophosphamide. Hemoglobin increased the lethality of Escherichia coli peritonitis in both neutropenic and normal rats. Furthermore, the early clearance of bacteria from the peritoneal cavity was equally depressed by hemoglobin in neutropenic and normal rats. We conclude that hemoglobin has some effect on intraperitoneal infections beyond its suppression of granulocyte function. This additional effect may represent interference with bacterial lymphatic absorption or peritoneal or systemic macrophage function or may be a manifestation of a nutritional effect of hemoglobin on bacterial growth.

The effect of adenosine and allopurinol on the tolerance of the collapsed lung to warm ischemia.

The collapsed left lungs of dogs were subjected to 1 hour of normothermic ischemia in situ followed by immediate ligation of the contralateral pulmonary artery. Adenosine in a dose of 50 mg/kg prolonged the survival of the dogs significantly. In the survivors only transient changes in the chest x-ray were seen, and no changes in arterial oxygenation were observed. The pulmonary architecture was well preserved on histological studies 14 days after operation. Animals whose ischemic lungs were not protected by adenosine showed an immediate drop in arterial oxygenation and a massive infiltrate of the ischemic lung. Histological study of the lungs showed a complete breakdown of the capillary-alveolar barrier. Allopurinol alone was ineffective by itself and was not able to improve the survival achieved with adenosine further. We conclude that it is possible to prolong the tolerance of a deflated lung to normothermic ischemia by pretreatment with adenosine.

Prognostic factors of peritoneal infections in transplant patients.

Twenty-eight cases of peritoneal infections occurring in 686 transplant patients (4%) are reported. The mortality was 78.5% (22 of 28 patients) and accounted for 13.2% of all transplant deaths. Recipients of cadaver kidneys were more prone to develop intraperitoneal infection, whereas the age, the presence of diabetes, and the tissue typing had no influence on the likelihood to develop intraperitoneal infections. Sixteen patients developed intraperitoneal infection secondary to the transplantation or another operation, whereas the intraperitoneal infection was due to a disease process unrelated to previous surgery in 12 patients. Only 64% of the patients presented with abdominal symptoms, 24 presented with septic shock, and 11 with a wound infection without peritoneal signs. The uncharacteristic clinical findings resulted in a delay of 8.7 days between the onset of symptoms and the recognition of the peritoneal infection and made a preoperative diagnosis possible in only 22 patients. It became clear that patients with generalized peritonitis, concomitant distant infections, opportunistics organisms in the peritoneal cavity, and the infections caused by postoperative complications have a poorer prognosis than the remainder of the group. Early recognition of the problem, especially after operation, and vigorous treatment seem to be the keys for improved results in the treatment of this serious condition.

Evaluation of the mechanism of zymosan-induced resistance to experimental peritonitis.

Three injections of intraperiotoneal (IP) zymosan-induced profound resistance to E. coli peritonitis in Sprague-Dawley rats. IP zymosan had minimal effects on organ weights and systemic phagocytic clearance ability, suggesting that this mode of administration had few systemic reticuloendothelial system (RES) effects. Hemoglobin (a known inhibitor of local phagocytosis) reduced the protection induced by zymosan, giving further evidence that IP zymosan acts locally. IP zymosan stimulation results in an initial marked influx of polymorphonuclear cells followed by a greater percentage replacement of mononuclear cells by the third day. Examination of these cells via chemiluminescence studies demonstrated that the phagocytic capacity of zymosan-stimulated peritoneal cells was markedly greater than the control group on a cell-for-cell basis. IP zymosan also gave some protection against intravenous (IV) E. coli, but IV zymosan did not significanly protect against IP E. coli. Possible mechanisms of action are discussed. These findings suggest that a technique of local RES stimulation could have a place in preparation of certain high-risk patients for elective abdominal surgery where peritoneal contamination is likely.

Antibiotics fail to prevent abscess formation secondary to bacteria trapped in fibrin clots.

We inoculated 120 rats with 2 X 10(9) Escherichia coli or 2 X 10(9) Bacteroides fragilis suspended in normal saline solution or incorporated into fibrin clots. In the control group, all animals died after inoculation with E coli, but none died after the inoculation with B fragilis; both were suspended in normal saline solution. Escherichia coli entrapped in fibrin did not cause mortality but did result in abscess formation in all animals. Bacteroides fragilis incorporated into fibrin clots resulted in abscess formation in the majority of animals. Treatment with gentamicin sulfate, ampicillin sulfate, and cefoxitin sodium completely abolished the mortality secondary to E coli suspended in normal saline solution but did not influence the rate of abscess formation secondary to E coli incorporated into fibrin clots. Similarly, cefoxitin and clindamycin phosphate did not significantly change abscess formation secondary to B fragilis incorporated into fibrin clots. We conclude that systemic antibiotics are ineffective in the prevention of abscesses secondary to bacteria trapped in fibrin, either because they do not reach bactericidal levels in the fibrin clot, as in the case of gentamicin, ampicillin, and clindamycin, or, as in the case of cefoxitin, because of the inoculum effect caused by the high number of bacteria. Fibrinogen or fibrin itself do not afford any protection of bacteria against the action of antibiotics.

Role of surgical and percutaneous drainage in the treatment of abdominal abscesses.

Reviewing our experience with 32 surgically and 13 percutaneously drained abdominal abscesses, we propose the following criteria for computed tomography (CT)-assisted percutaneous drainage: (1) the absence of more than two abscess cavities or loculations; (2) drainage route not traversing bowel, uncontaminated organs, or uncontaminated peritoneal or pleural spaces; (3) the absence of a source of continuous contamination; and (4) the absence of fungi as causative organisms. Of nine abscesses that met these criteria, seven were successfully drained percutaneously. In all abscesses that did not meet the criteria, percutaneous drainage resulted in complications. Of the 32 surgical patients, six would have been candidates for percutaneous drainage according to these criteria. Two of those patients experienced technical complications that might have been prevented by the use of percutaneous drainage. Surgical intervention is the preferred treatment in the majority of patients; however, in properly selected patients, CT-assisted percutaneous drainage is highly successful and can prevent unnecessary morbidity and mortality.

Amebic liver abscess.

Amebic liver abscess was seen in 35 patients over a ten-year period at Cook County and the University of Illinois hospitals, Chicago; 32 had immigrated from an area of endemic amebiasis, but three were natives of Chicago. Typically they had right upper-quadrant abdominal pain and fever of short duration (nine days); on physical examination, upper abdominal tenderness and hepatomegaly were usually present. The diagnosis was confirmed by liver scan, serologic studies, aspiration of "anchovy paste" from the abscess, and/or a favorable response to specific antiamebic therapy. Most were solitary abscesses in the right lobe of the liver. Metronidazole treatment alone was adequate in 24 of 29 patients (83%). Nine patients underwent percutaneous or surgical drainage of the abscess owing to incorrect diagnosis (three), persistent pain and fever after medical treatment (three), expanding left lobe abscess (two), and for diagnosis (one). Mortality was 5.7% (two patients). Owing to current immigration patterns amebic liver abscess should be considered in the differential diagnosis of patients with right upper-quadrant pain and fever. The diagnosis should be confirmed with a liver scan and serologic study for amebiasis.

Planned relaparotomy vs relaparotomy on demand in the treatment of intra-abdominal infections. The Peritonitis Study Group of the Surgical Infection Society-Europe.

OBJECTIVE: To define the role of planned relaparotomy (PR) in the treatment of intraperitoneal infection, compared with that of relaparotomy on demand (RD). DESIGN: Case-control study on the basis of a prospective multicenter cohort analytic study. Statistical evaluation was done by the McNemar test for qualitative data and the Wilcoxon matched-pairs signed rank test for qualitative data. SETTING: Eighteen hospitals of different care levels in Austria, Germany, and Switzerland. PATIENTS: Thirty-eight of 42 patients with intra-abdominal infections who underwent PR were matched for APACHE II (Acute Physiology and Chronic Health Evaluation II) score, age, cause of infection, site of origin of peritonitis, and the ability of the surgeon to securely eliminate the source of infection with 38 patients taken from a cohort of 278 undergoing RD. INTERVENTIONS: Planned relaparotomy was defined as at least one relaparotomy decided on at the time of the first surgical intervention; RD, relaparotomy indicated by clinical findings. MAIN OUTCOME MEASURES: Mortality and incidence of postoperative multiple organ failure and infectious complications. RESULTS: There was no significant difference in mortality between patients treated with PR (21%) or RD (13%). Postoperative multiple organ failure as defined by a Goris score of more than 5 was more frequent in the group of patients undergoing PR (50%), compared with the group undergoing RD (24%) (P = .01), as were infectious complications (68% vs 39% [P = .01]). Infectious complications were due to more frequent suture leaks (16% vs 0% [P = .05]), recurrent intra-abdominal sepsis (16% vs 0% [P = .05]), and septecemia (45% vs 18% [P = .05]) in the PR vs the RD groups. The incidence of other complications was not different in the two groups. CONCLUSIONS: Until larger prospective studies are available, the indication for PR should be evaluated with caution.

Moxalactam vs tobramycin-clindamycin. A randomized trial in secondary peritonitis.

One hundred five patients with peritonitis were randomized to receive either tobramycin sulfate plus clindamycin phosphate or moxalactam alone before surgical intervention. Fifty-nine patients were evaluable. A mean of 3.1 (moxalactam) and 3.5 (tobramycin-clindamycin) pathogens per patient were identified. Overall success rate was 85% (tobramycin-clindamycin, 24/30; moxalactam, 26/29). When patients with appendicitis were excluded, there was an observed but not statistically significant advantage of moxalactam over tobramycin-clindamycin (85% vs 67%). There were five deaths (tobramycin-clindamycin, four; moxalactam, one). Other complications included hypoprothrombinemia (tobramycin-clindamycin, five; moxalactam, five), renal dysfunction (tobramycin-clindamycin, three; moxalactam, one), and superinfection (tobramycin-clindamycin, nine; moxalactam, six). More wound infections were noted in the group given tobramycin-clindamycin. These data suggest that moxalactam is as safe and efficacious as tobramycin plus clindamycin. The observed benefits of this agent warrant study in a larger sample to verify advantages of moxalactam over combination therapy.