Enhanced antimicrobial stewardship based on rapid phenotypic antimicrobial susceptibility testing for bacteraemia in patients with haematological malignancies: a randomized controlled trial.

OBJECTIVES: Recently, rapid phenotypic antimicrobial susceptibility testing (AST) based on microscopic imaging analysis has been developed. The aim of this study was to determine whether implementation of antimicrobial stewardship programmes (ASP) based on rapid phenotypic AST can increase the proportion of patients with haematological malignancies who receive optimal targeted antibiotics during early periods of bacteraemia. METHODS: This randomized controlled trial enrolled patients with haematological malignancies and at least one positive blood culture. Patients were randomly assigned 1:1 to conventional (n = 60) or rapid phenotypic (n = 56) AST. The primary outcome was the proportion of patients receiving optimal targeted antibiotics 72 hr after blood collection for culture. RESULTS: The percentage receiving optimal targeted antibiotics at 72 hr was significantly higher in the rapid phenotypic AST group (45/56, 80.4%) than in conventional AST group (34/60, 56.7%) (relative risk (RR) 1.42, 95% confidence interval (CI) 1.09-1.83). The percentage receiving unnecessary broad-spectrum antibiotics at 72 hr was significantly lower (7/26, 12.5% vs 18/60, 30.0%; RR 0.42, 95% CI 0.19-0.92) and the mean time to optimal targeted antibiotic treatment was significantly shorter (38.1, standard deviation (SD) 38.2 vs 72.8, SD 93.0 hr; p < 0.001) in the rapid phenotypic AST group. The mean time from blood collection to the AST result was significantly shorter in the rapid phenotypic AST group (48.3, SD 17.6 vs 83.1, SD 22.2 hr). DISCUSSION: ASP based on rapid phenotypic AST can rapidly optimize antibiotic treatment for bacteraemia in patients with haematological malignancy. Rapid phenotypic AST can improve antimicrobial stewardship in immunocompromised patients.

Deafferentation-disconnection neglect induced by posterior cerebral artery infarction.

OBJECTIVE: To investigate patients with posterior cerebral artery (PCA) infarctions to learn whether hemispatial neglect is more frequent and severe after right than left PCA infarction; whether visual field defects (VFDs) influence the presence or severity of hemispatial neglect; and the anatomic loci of lesions that are associated with hemispatial neglect. METHODS: The authors recruited 45 patients with PCA infarction that involved only the occipital lobe or the occipital lobe plus other areas served by the PCA. All subjects received seven neglect tests within 2 months after onset. RESULTS: Overall, the frequency of hemispatial neglect was 42.2%. The frequency did not significantly differ between the right (48.0%) and left (35.0%) PCA groups, but the severity of hemispatial neglect was significantly greater in the right group. VFD alone did not influence the frequency or severity of neglect after controlling other variables. Isolated occipital lesions were rarely associated with hemispatial neglect, and it was only the occipital plus splenial lesion that significantly influenced the frequency and severity of neglect. CONCLUSIONS: This study suggests that after excluding such confounding factors as aphasia or hemiplegia, neglect frequency does not differ between the right and left posterior cerebral artery (PCA) groups, but the severity of neglect is greater after right PCA infarctions; even in the acute stage of PCA infarction; visual field defect from an isolated occipital lesion does not cause hemispatial neglect; and the injury to both the occipital lobe and the splenium of the corpus callosum is important for producing hemispatial neglect with PCA infarction.

Phase II study of high-dose lovastatin in patients with advanced gastric adenocarcinoma.

Lovastatin, an inhibitor of mevalonate synthesis, demonstrated in vitro antitumor activity against a variety of human cancer cells, especially in gastric adenocarcinoma cells at pharmacologically achievable concentrations. To determine the antitumor activity of this drug in advanced measurable gastric adenocarcinoma as well as to assess the toxicities and the pharmacokinetic features, we carried out a phase II study of high-dose lovastatin. Patients received lovastatin 35 mg/kg/day for 7 consecutive days, with ubiquinone (60 mg qid p.o.) to prevent rhabdomyolysis. The treatment was repeated every 28 days. From March 1996 to January 1997, 16 patients (median age, 57 years; range, 34-68) were entered into the study, 14 of whom were evaluated for response and toxicity. No patient achieved a response. A total of 28 cycles were administered. The median number of cycles was 2 (range, 1 to 4). Anorexia was the most common toxicity (64%), but decreased oral intake was observed only in 3 cycles. Two patients developed myalgia with elevated muscle enzyme. When used in this dosage and schedule, lovastatin does not appear to be effective for patients with advanced gastric adenocarcinoma.

Perspectives of stroke in persons living in Seoul, South Korea. A survey of 1000 subjects.

BACKGROUND AND PURPOSE: The aim of the present study was to investigate the perspectives of stroke in persons who live in Seoul, South Korea, a country which is unique in that the social and political status of traditional (herbal) medicine is equal to that of western (modern) medicine. METHODS: We randomly selected 1000 persons living in Seoul, South Korea, and performed open-ended telephone interviews regarding stroke risk factors, symptoms, and the choice of treatment for stroke. We also asked whether the subjects would prefer to visit western-medicine doctors or traditional-medicine doctors if they developed stroke. RESULTS: Twenty-nine percent of the interviewees responded correctly that the most important risk factor for stroke is hypertension. However, other major factors, such as cigarette smoking, diabetes mellitus, and heart disease, were greatly underappreciated, while less important risk factors such as hyperlipidemia/obesity, stress, and exposure to coldness were overappreciated. Also, although 65% of the subjects correctly identified paresis as the most important symptom of stroke, tremor was indicated incorrectly as an important symptom of stroke. Regarding the choice of treatment, only 46% responded that visiting a hospital is the most important method of treatment, whereas a significant percentage of the subjects responded that they would prefer herbal medicine and other traditional methods of treatment. Generally, the older and less educated the subjects, the more they prefer to depend on traditional medicine. CONCLUSIONS: These data show that perspectives of stroke are heavily influenced by the presence of traditional medicine in Korea, especially in older and less educated persons. This perspective significantly deviates from the scientific concept regarding the etiology, symptoms, and treatment of stroke. Current science-based health education is urgently needed in this country.

Multifocal hypointense cerebral lesions on gradient-echo MR are associated with chronic hypertension.

PURPOSE: To investigate the basis for multifocal hypointense lesions within the brain as identified on T2*-weighted gradient-echo MR imaging in patients with no known or presumed cause of these lesions. METHODS: In the first of a two-part study design, we retrospectively reviewed a case series of 38 patients whose gradient-echo MR images showed multiple hypointense lesions within the brain parenchyma. Thirty-one cases in which the cause was known or presumed (eg, head trauma or cavernous angioma) were excluded from further review. The MR studies and clinical findings of the remaining seven cases were reexamined. In the second part, using a cohort study design with respect to hypertension, we prospectively reviewed the gradient-echo images from MR studies of 65 patients and control subjects enrolled in two ongoing clinical studies, one on "possible vascular dementia" (n = 33) and the other on "possible motor neuron disorder" (n = 32). RESULTS: In the first part of the study, we found seven cases with a pattern of multiple hypointense lesions involving the deep gray matter nuclei, especially the basal ganglia (n = 6) and thalamus (n = 5). In addition, involvement of the corona radiata (n = 5), brain stem (n = 4), and cerebellum (n = 3) was seen. Clinical review revealed a history of chronic hypertension in all seven patients. In the cohort study, we found three of 65 persons who had two or more focal hypointense lesions that involved the basal ganglia or thalami. Review of the clinical data showed that all three patients were being treated for hypertension; also, all three were patients from the "possible vascular dementia" group. CONCLUSIONS: The MR imaging pattern of multifocal hypointense lesions within the basal ganglia, thalamus, and other deep cerebral structures is more commonly found among patients with a history of chronic hypertension than in patients without chronic hypertension.