Molecular characterization of Staphylococcus aureus isolates causing skin and soft tissue infections in patients from Malakand, Pakistan.

Comparatively few studies have been published describing Staphylococcus aureus/MRSA epidemiology in Central Asia including Pakistan. Here, we report the genotyping of Staphylococcus aureus strains (that include both methicillin-susceptible and methicillin-resistant Staphylococcus aureus) from community- and hospital-acquired skin and soft-tissue infections in a tertiary care hospital in the Malakand district of the Khyber Pakhtunkhwa Province of Pakistan. Forty-five isolates of Staphylococcus aureus were characterized by microarray hybridization. Twenty isolates (44 %) were MRSA, whereas 22 (49 %) were PVL-positive. Fourteen isolates (31 %) harboured both mecA and PVL genes. The dominant clones were CC121-MSSA (n = 15, 33 %) and the PVL-positive "Bengal Bay Clone" (ST772-MRSA-V; n = 13, 29 %). The PVL-positive CC8-MRSA-IV strain "USA300" was found once. The pandemic ST239-MRSA-III strain was absent, although it has previously been observed in Pakistan. These observations require a re-assessment of schemes for initial antibiotic therapy to cover MRSA and they emphasise the need for a rapid and non-molecular test for PVL.

Multiple cases of methicillin-resistant CC130 Staphylococcus aureus harboring mecC in milk and swab samples from a Bavarian dairy herd.

The discovery of a new mecA homolog, mecC, necessitates a modification of diagnostic procedures for the identification of methicillin-resistant Staphylococcus aureus (MRSA), as most assays used for the genotypic and phenotypic mecA detection cannot currently recognize mecC. Although the prevalence, distribution, and importance of mecC are not yet completely understood, an exchange of mecC-MRSA between humans and animals seems possible. All previously reported observations of mecC-positive strains have been sporadic. To the best of our knowledge, this is the first report about multiple cases of mecC-positive Staph. aureus in 1 dairy herd. Clonal complex 130 Staph. aureus harboring mecC were found in milk samples from 16 of 56 lactating cows kept in a herd in Bavaria, Germany. Almost all quarter milk samples positive for mecC-MRSA had the lowest possible California Mastitis Test score; composite somatic cell counts obtained from monthly milk recordings showed a mean of 51,600 cells/mL in mecC-MRSA affected cows. Additionally, mecC-positive clonal complex 130 Staph. aureus were detected in swab samples from the mammary skin and a teat lesion of 1 cow from this herd. This report suggests that mecC-carrying strains are able to spread among livestock, and that they have the ability to cause multiple cases in single herds. Therefore, future studies targeting MRSA in dairy cows need to consider mecC.

Hip lateralisation in children with bilateral spastic cerebral palsy treated with botulinum toxin type A: a 2-year follow-up.

We investigated the effect of BoNT/A injection on hip lateralisation in children with bilateral spastic cerebral palsy and bilateral adductor spasticity. Pelvic radiographs using Reimers' migration index (MI) were evaluated from 27 children (n=9 females, n=18 males; mean age 5.2 ± 1.96 years; range: 2-10 years; initial MI <50%) with bilateral spastic cerebral palsy over a time period of 2 years. All received injections of BoNT/A (Dysport) every 12 weeks with a dose of 30 Units per kilogram body weight into adductor and medial hamstring muscles on both sides. The MI was calculated before treatment and after 1 and 2 years. The mean MI increased from 25.5% (range: 0-48) to 26.7% (+1.2%, range: 0-79) on the right side and from 28.0% (range: 0-40) to 30.6% (+2.6%, range: 3-84) on the left side over 2 years, respectively. Hips of one patient dislocated bilaterally. The mean MI remained stable over 2 years. Although a specific BoNT/A effect cannot be proven because of the open design of this study, we provide strong evidence that the MI can be kept stable for a time period of 2 years under non-surgical management including therapy with BoNT/A even in CP patients with a high risk for hip dislocation.

[Airway complications following lung transplantation - clinic, diagnosis, and interventional management]. / Atemwegskomplikationen nach Lungentransplantation - Klinik, Diagnose und interventionelle Behandlung.

Tracheobronchial complications following lung transplantation are defined as local structural or infectious alterations of the airways, which occur early or several months after lung transplantation (LTx). They preferentially develop in the region of the bronchial anastomosis. The most frequently reported complications are bronchial stenosis, bronchial dehiscence, exophytic excessive granulation tissue formation, tracheo-bronchomalacia, bronchial fistulas, and endobronchial infections. Airway complications are mainly attributed to ischaemia of the donor bronchus during the immediate post-transplant period. The most relevant risk factors for the development of airway complications include local infections, surgical techniques, and the immunosuppressive regimen. Thus, management of post-transplant bronchial complications requires early interventional bronchoscopic procedures including balloon bronchoplasty, cryotherapy, laser photoresection, endobronchial brachytherapy, and bronchial stents. In addition, antibiotic treatment, or non-invasive positive-pressure ventilation may be necessary. The procedures required depend on the time of occurrence, the type, and clinical relevance of the airway complication. This review summarises clinical presentation, risk factors, the diagnostic methods as well as management options for the most common LTx-associated airway complications.

[Interferon-alpha as treatment option in severe persistent uncontrolled bronchial asthma: an open label study]. / Interferon-alpha als Therapieoption bei der Behandlung des schwergradig persistierenden, unkontrollierten Asthma bronchiale: Eine offene Studie.

BACKGROUND: The purpose of this study was to evaluate the long-term safety and therapeutic effects of IFN-alpha in patients with severe persistent uncontrolled asthma on long-term oral glucocorticoid (GC) treatment. PATIENTS AND METHODS: The study included 16 patients (2 male, 14 female; age 39 years [range: 24 - 63]) with severe persistent asthma. Diagnosis and severity classification of asthma were established according to the guidelines of the "Deutsche Atemwegsliga". Eight patients stopped the therapy within 7 months due to side effects (n = 3), costs not covered by health insurance (n = 2), non-compliance (n = 2), and change of residence (n = 1). 8 patients (8 female, age 49 years [range: 35 - 68], duration of disease 16 years [range: 5 - 24]) were treated for at least 12 months with IFN-alpha (9 microg) 3 times/week. All patients were on oral glucocorticoids (GCs) for more than 5 years (average dose 17.5 [range: 5.0 - 64.0] mg/d). Clinical signs, lung function, need for reliever medication, number of emergency visits and hospitalisations and diary were assessed prior to and after 12 months of treatment. Data are given as percent of normal or median [range]. RESULTS: IFN-alpha improved lung function after 12 months: FEV1 64 vs. 75 %; FEV1/IVC 76 vs. 89 %; RV 153 % vs. 129 %; Rtot 193 vs. 111 % and morning PEF by 50 - 190 L/min. IFN-alpha also significantly reduced the use of reliever medication (10 [2 - 20] vs. 1 [0 - 3] puffs/d), nocturnal awakening (11 [4 - 30] vs. 1 [0 - 5]/month), emergency visits (7 [2 - 15] vs. 0 [0 - 5]/month) and hospitalisations (4 [1 - 8] vs. 0 [0 - 5]/year). In 5 patients the asthma attacks and nightly disturbances disappeared completely. The improvements were achieved despite a tapering of the oral GCs in all patients from 17.5 (5.0 - 64.0) to 2 (0 - 16) mg/d. In 5 patients GC treatment could be discontinued. The number of blood eosinophils decreased from 0.46 to 0.28 Gpt/L. Adverse events were transient and usually decreased within 3 to 4 weeks. Two patients developed an autoimmune thyreoiditis. CONCLUSION: In severe persistent, uncontrolled, and GC-dependent asthma, treatment with IFN-alpha leads to sustained clinical improvement and allows the reduction or discontinuation of oral GCs. Severe side effects may occur in isolated cases.

Enhancing 18F-FDG-PET/CT analysis in lung cancer patients. Is CT-CT image fusion helpful in predicting pleural involvement? A pilot study.

AIM: To retrospectively evaluate the feasibility and value of CT-CT image fusion to assess the shift of peripheral lung cancers with/-out chest wall infiltration, comparing computed tomography acquisitions in shallow-breathing (SB-CT) and deep-inspiration breath-hold (DIBH-CT) in patients undergoing FDG-PET/CT for lung cancer staging. METHODS: Image fusion of SB-CT and DIBH-CT was performed with a multimodal workstation used for nuclear medicine fusion imaging. The distance of intrathoracic landmarks and the positional shift of tumours were measured using semi-transparent overlay of both CT series. Statistical analyses were adjusted for confounders of tumour infiltration. Cutoff levels were calculated for prediction of no-/infiltration. RESULTS: Lateral pleural recessus and diaphragm showed the largest respiratory excursions. Infiltrating lung cancers showed more limited respiratory shifts than non-infiltrating tumours. A large respiratory tumour-motility accurately predicted non-infiltration. However, the tumour shifts were limited and variable, limiting the accuracy of prediction. CONCLUSION: This pilot fusion study proved feasible and allowed a simple analysis of the respiratory shifts of peripheral lung tumours using CT-CT image fusion in a PET/CT setting. The calculated cutoffs were useful in predicting the exclusion of chest wall infiltration but did not accurately predict tumour infiltration. This method can provide additional qualitative information in patients with lung cancers with contact to the chest wall but unclear CT evidence of infiltration undergoing PET/CT without the need of additional investigations. Considering the small sample size investigated, further studies are necessary to verify the obtained results.

Sonography of lung and pleura in pulmonary embolism: sonomorphologic characterization and comparison with spiral CT scanning.

STUDY OBJECTIVES: Despite the widespread use of lung scanning and angiography, pulmonary embolisms (PEs) remain undiagnosed in the majority of patients, suggesting the need for alternative diagnostic approaches. The present study investigates the clinical utility of transthoracic sonography (TS) for the diagnosis of PE and compares the data obtained with the technique to those obtained by spiral CT (sCT) scanning. DESIGN: This prospective study was performed using 69 patients with suspected PEs. TS was performed in all patients. In addition, sCT scanning was carried out in 62 patients. Other diagnostic procedures included the estimation of d-dimers, echocardiography, venous duplex sonography of the legs, pulmonary angiography, and ventilation/perfusion scanning. The diagnosis of PE was accepted when there was a conclusive result of these investigations or when an embolus could be visualized on a CT scan. SETTING: The Department of Pneumology in Friedrich-Schiller-University Hospital (Jena, Germany). PATIENTS: Sixty-nine patients (27 women and 42 men) with suspected PEs. RESULTS: A diagnosis of PE was established in 44 patients. Ninety-one peripheral parenchymal lesions (mean, 2.6 lesions per patient; range 1 to 9 lesions per patient) that are associated with PE were detected by TS in 35 patients (80%). Multiple, triangular, hypoechoic, and pleural-based parenchymal lesions with a localized and/or basal effusion were typical of the PEs as shown by TS. In nine patients with central PEs that had been diagnosed by CT scanning, no peripheral lesions could be detected by sonography. One patient with sonographic signs of PEs had a diffuse bronchogenic adenocarcinoma that was diagnosed at autopsy. In another patient with parenchymal lesions, pneumonia was diagnosed by CT scanning. The sensitivity of TS for detecting PEs was 80% (sensitivity of CT scanning, 82%), and the specificity of TS for detecting pulmonary lesions was 92% (specificity of CT scanning, 100%). The positive and negative predictive values of TS for the detection of PEs were 95% and 72%, respectively (positive predictive value for CT scanning, 100%; negative predictive value for CT scanning, 77%). The accuracy of TS was 84% (accuracy of CT scanning, 89%). CONCLUSIONS: TS is a noninvasive technique that is used for diagnosing parenchymal alterations, and it may serve as an additional method in the strategy for diagnosing PE.

[Improvement of the image quality of MSCT of the pelvis with a raw data-based, multidimensional filter]. / Verbesserung der Bildqualität in der MSCT des Beckens durch ein rohdaten-basiertes mehrdimensionales Filter.

PURPOSE: To evaluate the potential of raw data-based multidimensional adaptive filtering (MAF) by determining its effects on image noise and image quality in multi-slice spiral CT (MSCT) of the pelvis. MATERIALS AND METHODS: Fifty patients with rectal and bladder cancer were examined with MSCT using a high-resolution protocol. Reconstructions were performed with dedicated reconstruction software and a standard algorithm, both without and with MAF, with four different modification fractions selected from 5 % to 20 %. The noise was measured at six anatomic sites of the pelvis. Image quality and image noise were rated on a 5-point-scale. RESULTS: Modification fractions of 15 % (15 % MAF) and 20 % (20 % MAF) significantly reduced the noise level at all measurement points in comparison with lower modification fractions (p < 0.05). Overall quality of the reconstructed images was rated better with 15 % MAF and 20 % MAF than with other modification fractions (p < 0.05). No further improvement of the image quality was observed by changing from 15 % MAF to 20 % MAF (p > 0.05). 15 % MAF achieved a mean noise reduction of 33 %. All examinations showed an improved visualization of the rectal wall and perirectal lymph nodes. CONCLUSIONS: MAF improves the image quality by reducing the noise level and by removing noise structures. This technique offers new perspectives to radiation dose reduction in CT.

[Asthma therapy for adults]. / Therapie des Asthma bronchiale im Erwachsenenalter.

The goal of asthma management is to achieve control of the condition. This essentially requires environmental control measures (allergen avoidance) and patient training and education. Drug treatment comprises anti-inflammatory (corticosteroids), and bronchodilatory controller therapy (long-acting beta 2-sympathomimetics, leukotriene receptor antagonists, retarded theophylline) as well as bronchodilatory medication as required (short-acting beta 2-sympathomimetics). The number and frequency of pharmacologic therapy relates to the severity of the clinical presentation. The combination of certain controller drugs (corticosteroids with long-acting beta 2-agonists, corticosteroids with leukotriene receptor antagonists, and beta 2-agonists with leukotriene receptor antagonists) yields a synergistic therapeutic effect as well as a compliance advantage.

Early detection of disease progression after palliative chemotherapy in NSCLC patients by (18)F-FDG-PET.

AIM: We investigated whether 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is capable of detecting renewed disease progression earlier than computed tomography (CT) in patients with inoperable non-small cell lung cancer (NSCLC) who have undergone chemotherapy as part of a palliative treatment plan. PATIENTS, METHODS: 18 patients were studied retrospectively. Three FDG-PET/CT scans for initial and follow-up diagnostic purposes were evaluated. Palliative chemotherapy was administered between the first FDG-PET/CT scan (t0) and the second (t1), followed by a treatment-free interval between the second FDG-PET/CT scan (t1) and the third (t2). Maximum standardized uptake values (SUVmax) and largest diameters of lesions were determined for PET scans and the corresponding CTs. Lesion-based and patient-based assessments were performed, as were assessments according to RECIST/PERCIST. RESULTS: 82 lesions were identified in 18 patients. In interval t1-t2, the increase in diameter in the lesion-based evaluation was 5.0% (non-significant), while the patient-based evaluation showed a non-significant reduction of 2.8%. Considering PET, both the lesion-based and patient-based evaluations found a significant increase in SUVmax by a median of 30.4 % and 45.8 %, respectively. PERCIST criteria at time point t2 identified ten more patients with progression than did RECIST. CONCLUSION: In patients with NSCLC, renewed progression during the treatment-free interval after palliative chemotherapy can be detected earlier with PET than with CT. Thus, FDG-PET appears to be a useful diagnostic imaging procedure regarding this aspect. Its clinical relevance should be investigated in further studies.

[Diagnosis and therapy of pulmonary embolism prior to death]. / Prämortale Diagnostik und Therapie autoptisch bestätigter Lungenarterienembolien.

BACKGROUND: The study was conducted to assess the rate of suspected pulmonary embolism (PE) prior to death and the diagnostic and therapeutic procedures performed. METHODS: Patients with autopsy-confirmed PE between 1998 and 2002 were included. Autopsy register and medical records were reviewed for history, diagnosis and therapy of PE. Patients were categorised into fatal and non-fatal PE according to the autopsy findings. RESULTS: 102 patients with fatal and 247 patients with non-fatal PE were eligible for analysis (median age 68 years; 24-95). In 58.8% with fatal and in 32% with non-fatal PE, disease was suspected pre-mortal. Clinical suspicion of PE was significantly enhanced in venous thrombosis (Odds Ratio [OR] = 12.17, p=0.004) and significantly decreased for chronic vascular disease (OR = 0.30, p=0.002). Recurrent PE was demonstrated in 31.4% fatal and in 4.5% non-fatal PE (OR = 9.81, p=0.001). 7% of all PE were localised centrally, 19% centrally and peripherally and 74% peripherally. Dyspnoea and tachycardia were the most frequent symptoms in fatal PE. About half of all patients suffered from malignancies. Suspicion of PE decreased after day 14 of hospitalisation (OR = 0.33, p=0.021). CONCLUSION: PE often is not diagnosed pre-mortally. Patients with chronic vascular disease and tumours as well as those hospitalised for over 14 days are at particular risk for PE.

[Sonographic diagnosis of post-interventional pneumothorax and hydropneumothorax--prospective study of 100 patients]. / Sonographische Diagnostik des post-interventionellen Pneumothorax und Seropneu- mothorax--Prospektive Studie an 100 Patienten.

In order to answer the question, if transthoracic sonography may replace chest radiographs in diagnosing post-interventional pneumothorax/hydropneumothorax, this prospective study was conducted. A total of 100 patients (38 females, 62 males; median age 63 years), biopsy and 37 had an ultrasound-guided tube thoracostomy, were enrolled in the study. Transthoracic sonography was performed three hours after the intervention, followed by postero-anterior chest radiograph. One (1%) of the 100 patients developed a pneumothorax after transbronchial biopsy. Eight of 37 patients suffered from hydropneumothorax due to tube thoracostomy detected by sonography. In one patient, hydropneumothorax was missed by posteroanterior chest radiography. Sensitivity, specificity and accuracy of transthoracic sonography were 100%. Transthoracic sonography is a safe bed-side-method, allowing an immediate exclusion/diagnosis of postinterventional pneumothorax/hydropneumothorax. The results suggest that chest radiography may only be required in patients with pneumothorax diagnosed by transthoracic sonography so as to assess its extension, if full sonographic assessment is not possible or if any discrepancy exists between TS-results and clinical presentation.

[Therapeutic approaches to acute pulmonary embolism]. / Therapeutisches Vorgehen bei akuter Lungenembolie.

The diagnosis of pulmonary embolism (PE) remains a considerable challenge to any physician. Irrespective of the diagnostic progress, the prevalence of fatal PE in autopsy studies is still about one third. Introducing sufficient anticoagulant therapy, mortality due to PE can be decreased from about 30% to 2-8%. Therefore, immediate anticoagulant therapy should be given, if PE is clinically suspected. Initial anticoagulation by low-molecular-weight heparins is as effective as unfractionated heparin in non-massive PE. In patients suffering from massive PE, thrombolytic treatment is indicated. Whether patients with submassive PE and/or elevated cardial troponins should also receive thrombolytic treatment, is still under debate. After PE has been established, vitamin-k-antagonists are the current standard of secondary prophylaxis.

[Diagnosis of pulmonary embolism by transthoracic sonography. Sono-morphologic characterization of pulmonary lesions and comparison with spiral computed tomography]. / Diagnostik der Lungenembolie mittels transthorakaler Sonographie. Sonomorphologische Charakterisierung pulmonaler Läsionen und Vergleich mit der Spiral-Computertomographie.

BACKGROUND AND OBJECTIVE: Pulmonary embolism often extends to pleural surfaces, resulting in pleural-based parenchymal lesions. This study was carried out in order to evaluate the clinical value of transthoracic sonography (TS) for the diagnosis of pulmonary embolism. PATIENTS AND METHODS: A prospective study was performed in 45 patients (27 men, 18 women; mean age: 63.4 years; range: 24-88 years) with suspected pulmonary embolism. Transthoracic sonography was performed in all patients. In addition, helical computed tomography (CT) was carried out in 40 patients. Other diagnostic procedures included the estimation of D-dimeres, echocardiography, venous duplex sonography of the legs and ventilation/perfusion scanning. The diagnosis of pulmonary embolism was accepted when an embolus was detected on CT or as a conclusive result of the other investigations. RESULTS: Pulmonary embolism was established in 33 patients. Peripheral parenchymal lesions suspicious of pulmonary embolism were detected by transthoracic sonography in 26 patients (79%). In seven patients with central pulmonary embolism diagnosed by CT, no peripheral lesions could be detected by sonography. One patient with sonographic signs of pulmonary embolism had a diffuse bronchogenic adenocarcinoma which was diagnosed on autopsy. The sensitivity of transthoracic sonography (computed tomography) for pulmonary embolism was 79% (76%) and the specificity 92% (100%). The positive and negative predictive values of transthoracic sonography for the detection of pulmonary embolism were 96% and 61% (100% and 61%), respectively. The accuracy was 82% (82%). CONCLUSIONS: A substantial number of pulmonary emboli involve the peripheral lung areas. Transthoracic sonography is a non-invasive technique for diagnosing such parenchymal alterations and may serve as an alternative method in the diagnosis of pulmonary embolism.

[Interferon-alpha treatment of the Churg-Strauss syndrome]. / Behandlung des Churg-Strauss-Syndromes mit Interferon-alpha.

HISTORY: Two patients, 60 (pat. 1; female) and 30 years of age (pat. 2; male), respectively, suffering from a histologically confirmed Churg-Strauss-syndrome and receiving immunosuppressive therapy were treated with Interferon-alpha. INVESTIGATIONS: Clinical complaints, disease activity, blood eosinophil counts, and lung function were monitored. In patient 1 the differential cell counts and immunocytology of bronchoalveolar lavage cells were assessed using flow cytometry. TREATMENT AND COURSE: Both patients were treated with interferon-alpha in dosages of 3 million units of IFN-alpha 2b or an equivalent dosage of interferon-acon thrice weekly subcutaneously. The patients were observed for a period of up to 24 months. Interferon-alpha induced remission of disease and allowed discontinuation of oral glucocorticoid therapy in both patients. Treatment also improved the peripheral polyneuropathia in patient 1 as well as the hemorrhagic cystitis and reduction of the Cushing syndrome (weight reduction of 19 kg) in patient 2. In addition, blood eosinophil counts normalised. After 12 months of treatment, the number of bronchoalveolar eosinophils decreased from 61,5% (5.7 x 106 cells/ml) to 7% (1.1 x 106 cells/ml). In addition, the proportion of CD4+ T-lymphocytes and B-cells increased, while CD8+ T-cells and NK cells decreased (pat. 1). CONCLUSION: Interferon-alpha may represent an effective alternative to the current treatment of Churg-Strauss syndrome consisting of corticosteroids and immunosuppressives.