Impact of antibiotic administration on blood culture positivity at the beginning of sepsis: a prospective clinical cohort study.

OBJECTIVES: Sepsis guidelines recommend obtaining blood cultures before starting anti-infective therapy in patients with sepsis. However, little is known of how antibiotic treatment before sampling affects bacterial growth. The aim of this study was to compare the results of blood cultures drawn before and during antibiotic therapy. METHODS: Prospective clinical cohort study of septic patients. Adult intensive care unit patients with two or three blood culture sets at the beginning of sepsis between 2010 and 2017 were included. Patients with blood culture samples obtained before antibiotic therapy were compared with patients with samples taken during antibiotic therapy. Blood culture positivity, defined as presence of a microbiological pathogen, was compared between the groups. Logistic regression was performed to adjust the impact of different factors with respect to blood culture positivity. RESULTS: In total, 559 patients with 1364 blood culture sets at the beginning of sepsis were analysed. Blood culture positivity was 50.6% (78/154) among patients with sepsis who did not receive antibiotics and only 27.7% (112/405) in those who were already receiving antibiotics (p <0.001). Logistic regression revealed antibiotic therapy as an independent factor for less pathogen identification (odds ratio 0.4; 95% CI 0.3-0.6). Gram-positive pathogens (28.3% (111/392) versus 11.9% (116/972); p <0.001) and also Gram-negative pathogens (16.3% (64/392) versus 9.3% (90/972); p <0.001) were more frequent in blood culture sets drawn before antibiotic therapy compared with sets obtained during antibiotic therapy. CONCLUSIONS: Obtaining blood cultures during antibiotic therapy is associated with a significant loss of pathogen detection. This strongly emphasizes the current recommendation to obtain blood cultures before antibiotic administration in patients with sepsis.

First report of the visceral leishmaniasis vector Phlebotomus martini (Diptera: Psychodidae) in Tanzania.

Phlebotomus martini is a known vector of visceral leishmaniasis caused by Leishmania donovani in sub-Saharan Africa. The disease is known to be endemic in areas of north and south Sudan, Kenya, Ethiopia, Uganda, and Somalia but has not been reported from Tanzania. In this report we present the first documented collection of P. martini and P. vansomerenae in Tanzania. Sand flies were collected using standard dry-ice baited CDC light traps (John W. Hock Company, Gainesville, FL) from five sampling sites in the Arusha and Kilimanjaro regions from 14 to 20 July 2010. Phlebotomus martini was collected from all sites and represented 6.6% of the total identified sand flies. Phlebotomus martini ranged from 4.5 to 9.4% of the total identified catch from the four sites in the Kilimanjaro region and 17.9% of the total identified catch at the one collection site in the Arusha region. In addition, one male specimen of the sibling species, Phlebotomus vansomerenae, was found at Chemka Springs in the Kilimanjaro region. These data indicate the presence of an established population(s) of P. martini in northern Tanzania that could support L. donovani transmission in an area with no prior case history of visceral leishmaniasis.

Combined surgery in pelvic organ prolapse is safe and effective.

OBJECTIVE: In women, rectal prolapse is often accompanied by other signs of generalized pelvic floor weakness including uterine and bladder prolapse. The purpose of this study was to compare whether there are differences in outcomes of rectal prolapse surgery between women having combined pelvic organ prolapse (POP) surgery with a urologist or urogynecologist (CS) vs those having abdominal rectal prolapse surgery alone (RP). METHOD: Charts were reviewed to collect perioperative data on those having surgery from 1995 to 2001. Phone surveys were conducted to obtain Cleveland Clinic Foundation (CCF) Incontinence score, Knowles-Eccersley-Scott-Symptom (KESS) Constipation Score, Short Form 36 (SF-36) quality of life score and recurrence rate. Appropriate statistical analysis was performed. RESULTS: Ninety-four operations were performed (23 CS and 71 RP). Forty-six (49%) could be contacted by phone. Mean follow-up was similar in both groups (CS 4.1 vs RP 3.6 years; P = 0.796). There were no significant differences between both groups regarding age, American Society of Anesthesiology classification Score, complications, length of hospital stay, CCF Incontinence score, KESS Constipation Score, SF-36 Score and recurrence rate of rectal prolapse. The operative time (CS 226 vs RP 122 min; P < 0.001) and blood loss (CS 377 vs RP 183 ml; P < 0.001) were significantly increased in the CS group. CONCLUSION: Combined surgery for POP is safe and effective when considering outcomes of rectal prolapse surgery. Therefore surgeons should not hesitate to address all pelvic floor issues during the same operation by working in partnership with the anterior pelvic floor colleagues.

Female bowel function: the real story.

PURPOSE: There has been minimal research done on normal female bowel habits. Because we do not know what is normal, this affects counseling of patients and research. The aim of this study was to conduct a survey of females with no bowel pathology to obtain a baseline of normal bowel function and examine any normal changes that occur during a woman's lifetime. METHODS: Females accompanying patients to our hospital and clinic were invited to fill out an IRB-approved questionnaire after excluding those with current bowel pathology, depression, a stoma, or were wheelchair bound. RESULTS: Four hundred twenty-five of 528 questionnaires of females who reported they had normal bowel habits were evaluated. The age range was from 18 to 80 years and comparison was according to age, race, and parity. Fifty-one percent had one bowel movement daily while 30 percent reported fewer. Overall, 15 percent reported constipation, which was higher in African-American females (26 percent) vs. Caucasian females (14 percent), P = 0.08. The average time for a bowel movement was 5-6 minutes, which was longer in African-American females (7.7 min) vs. Caucasian (5.0 min), P = 0.002. Younger females had changes in their bowel pattern reported as soft stool usually associated with their menstrual cycle; this was seen mostly in single females. Menopause did not affect bowels. Thirty-six percent of parous females reported occasional stool incontinence. Flatal incontinence was seen occasionally in over 50 percent of females, more frequently in those over 35 years old. Seventy-four percent of parous females reported incontinence to gas. One-third of females read on the toilet, with a majority doing so to relax or to be distracted and with African-American females reading more (54 percent) vs. Caucasian (32 percent), P = 0.004. Interestingly, Caucasian females read to conserve time (26 percent) vs. African-Americans (4 percent), P = 0.02. Fiber as a supplement was taken by only 8 percent. Foods affected bowel function in all age groups, while travel and exercise did not. Stress affected a change in 35 percent in the 18 to 50-year group. CONCLUSION: There is a vast diversity in what is considered normal female bowel habits. One daily bowel movement is not the norm. Normal older females and those who have had children report more flatal incontinence. One-third experience some element of fecal incontinence. Foods most commonly caused a change in bowel pattern, followed by menstruation, stress, and childbirth. A vast majority do not take fiber as a supplement.

Multimedia article. Success of episioproctotomy for cloaca and rectovaginal fistula.

PURPOSE: Surgical repair of rectovaginal fistula with an advancement flap has had suboptimal results. The existing literature documenting episioproctotomy as a surgical option in females with rectovaginal fistula or cloaca is limited. This study was designed to examine our experience with episioproctotomy in this group. Additionally we were interested in risk factors, which might predict failure. METHODS: All females who had repair of a rectovaginal fistula or cloaca with episioproctotomy from 1998 to 2004 were studied. Data were collected from chart review and telephone contact. This included demographics, body mass index, tobacco use, Crohn's disease, previous surgery, and diverting stoma. RESULTS: Data were obtained from 42 females (mean age, 39.2 (range, 25-70) years). The mean follow-up was 37 (range, 2-84) months. Nine females had a cloaca and the rest had a rectovaginal fistula with an anterior sphincter defect. Eleven (all with anterior tissue) had recurrence of fistula. None with cloaca had recurrence. Eight of 11 recurrences occurred in females who had failed at least one previous repair. No variables that were studied significantly affected recurrence. Median (25th, 75th percentiles) postoperative Wexner incontinence scores for those with and without recurrence were 8 (7, 12) and 5 (2, 6) respectively. CONCLUSIONS: Episioproctotomy is a successful technique for repair of rectovaginal fistula and cloaca. Incontinence score postoperatively were acceptable. It should be considered a first line of surgical treatment in those with a fistula that includes compromise of the anterior sphincter complex.

Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study.

BACKGROUND: Laparoscopic repair (LR) of rectal prolapse is potentially associated with earlier recovery and lower perioperative morbidity, as compared with open transabdominal repair (OR). Data on the long-term recurrence rate and functional outcome are limited. METHODS: Perioperative data on rectal prolapse in relation to all LRs performed between December 1991 and April 2004 were prospectively collected. The LR patients were matched by age, gender, and procedure type with OR patients who underwent surgery during the same period. Patients with previous complex abdominal surgery or a body mass index exceeding 40 were excluded from the study. Data on recurrence rate, bowel habits, continence, and satisfaction scores were collected using a telephone survey. RESULTS: A total of 111 patients (age, 56.8 +/- 18.1 years; female, 87%) underwent attempted LR. An operative complication deferred repair in two cases. Among the 111 patients, 42 had posterior mesh fixation, and 67 had sutured rectopexy (32 patients with sigmoid colectomy for constipation). Eight patients (7.2%) had conversion to laparotomy. Matching was established for 86 patients. The LR patients had a shorter hospital stay (mean, 3.9 vs 6.0 days; p < 0.0001). The 30-day reoperation and readmission rates were similar for the two groups. The rates for recurrence requiring surgery were 9.3% for LR and 4.7% for OR (p = 0.39) during a mean follow-up period of 59 months. An additional seven patients in each group reported possible recurrence by telephone. Postoperatively, 35% of the LR patients and 53% of the OR patients experienced constipation (p = 0.09). Constipation was improved in 74% of the LR patients and 54% of the OR patients, and worsened, respectively, in 3% and 17% (p = 0.037). The postoperative incontinence rates were 30% for LR and 33% for OR (p = 0.83). Continence was improved in 48% of the LR patients and 35% of the OR patients, and worsened, respectively, in 9% and 18% (p = 0.22). The mean satisfaction rates for surgery (on a scale of 0 to 10) were 7.3 for the LR patients and 8.1 for the OR patients (p = 0.17). CONCLUSIONS: The hospital stay is shorter for LR than for OR. Both functional results and recurrent full-thickness rectal prolapse were similar for LR and OR during a mean follow-up period of 5 years.

Mucosectomy vs. stapled ileal pouch-anal anastomosis in patients with familial adenomatous polyposis: functional outcome and neoplasia control.

PURPOSE: The tradeoff of neoplasia control for better function represented by a stapled ileal pouch-anal anastomosis is still controversial in patients with familial adenomatous polyposis. We compared outcomes after mucosectomy and hand-sewn ileal pouch-anal anastomosis with those after stapled ileal pouch-anal anastomosis in 119 patients with familial adenomatous polyposis who underwent surgery since 1983. METHODS: Age, gender, length of follow-up, complications, quality of life, incontinence, urgency, nighttime and daytime seepage, pad usage, necessity of ileostomy, and incidence of adenomas developing in pouch and anal transitional zone were recorded. RESULTS: There were 42 mucosectomy and 77 stapled patients who were followed up for an average of 5.8 and 3.6 years, respectively, with endoscopic surveillance. There was one postoperative death in the stapled group that prohibited long-term follow-up. Nine of 42 mucosectomy patients developed pouch adenomas vs. 8 of 76 in the stapled group. Six of 42 patients developed adenomas in the mucosectomized anal transitional zone in the mucosectomy group. Twenty-one of 76 patients developed adenomas in the anal transitional zone in the stapled group. All were managed with local procedures or further surveillance. One of 76 patients developed cancer in the residual low rectum; this required further resection. Patients with stapled anastomosis had better outcomes in every category. Differences in incontinence, daytime and nighttime seepage, pad usage, and avoidance of ileostomy were statistically significant. All patients with mucosectomy required ileostomy vs. only 40 of 77 patients with stapled anastomosis. CONCLUSION: Familial adenomatous polyposis patients with stapled ileal pouch-anal anastomosis have better functional outcome and can avoid temporary diversion. This should be balanced against a 28 percent incidence of adenomas in the anal transitional zone.

Influence of Ca(2+)-activated K(+) channels on rat renal arteriolar responses to depolarizing agonists.

Experiments were performed to evaluate the hypothesis that opening of Ca(2+)-activated K(+) channels (BK(Ca) channels) promotes juxtamedullary arteriolar dilation and curtails constrictor responses to depolarizing agonists. Under baseline conditions, afferent and efferent arteriolar lumen diameters averaged 23.4 +/- 0.9 (n = 36) and 22.8 +/- 1.1 (n = 13) microm, respectively. The synthetic BK(Ca) channel opener NS-1619 evoked concentration-dependent afferent arteriolar dilation. BK(Ca) channel blockade (1 mM tetraethylammonium; TEA) decreased afferent diameter by 15 +/- 3% and prevented the dilator response to 30 microM NS-1619. ANG II (10 nM) decreased afferent arteriolar diameter by 44 +/- 4%, a response that was reduced by 30% during NS-1619 treatment; however, TEA failed to alter afferent constrictor responses to either ANG II or arginine vasopressin. Neither NS-1619 nor TEA altered agonist-induced constriction of the efferent arteriole. Thus, although the BK(Ca) channel agonist was able to curtail afferent (but not efferent) arteriolar constrictor responses to ANG II, BK(Ca) channel blockade did not allow exaggerated agonist-induced arteriolar constriction. These observations suggest that the BK(Ca) channels evident in afferent arteriolar smooth muscle do not provide a prominent physiological brake on agonist-induced constriction under our experimental conditions.

Analyzing the development of individual differences in terms of Matthew effects in reading: results from a Dutch Longitudinal study.

The Matthew effect hypothesis provides a theoretical framework to describe the development of individual differences in reading ability. The model predicts an increase of individual differences in reading. Reciprocal relationships between reading and other factors seem to cause these increasing differences. This longitudinal study of 3 years was concerned with uncovering the existence and causes of increasing individual differences in reading in the early elementary grades. Data were analyzed within a structural equation modeling framework. The results clearly indicate increasing individual differences for word recognition skills. For reading comprehension, no such effects could be established for this limited time period. More important, some evidence for interactive relationships between reading and other cognitive skills, behaviors, and motivational factors, hypothesized to cause increasing differences between readers, was found.

Mathew Effects in Reading: A Comparison of Latent Growth Curve Models and Simplex Models with Structured Means.

The Matthew effect hypothesis in reading predicts that the gap between good and poor readers increases with time. Although, intuitively appealing, the Matthew effect has hardly been empirically studied in longitudinal studies of reading. Two competing longitudinal models were used to represent the Matthew effect hypothesis: the Latent Growth Curve model and the Simplex model with structured means. It is argued that on the basis of theoretical and empirical arguments the Simplex model should be preferred to represent and analyze the Matthew effect hypothesis. However, the results of the Simplex models imply that conceptual refinement and clarification of Matthew effects in reading are needed.

Lesions in the preoptic area suppressed sexual receptivity in ovariectomized rats with estrogen implants in the ventromedial hypothalamus.

The objective of the experiment was to determine if electrolytic ablation of a portion of the preoptic area (POA) influenced the activation of female lordosis behavior by implants of estradiol benzoate in the ventromedial hypothalamus (VMH) of ovariectomized (OVX) rats. Two weeks after ovariectomy, rats received either bilateral electrolytic lesions (2 mA for 10 sec in Experiment 1, or 1 mA for 5 sec in Experiment 2) in the POA, or sham lesions (all procedures except passage of current). On the same day (day 0 of the experiment) thirty-gauge stainless steel cannulae containing crystalline estradiol benzoate were stereotaxically placed bilaterally into the VMH of all the rats. Subsequently, females were tested for the lordosis response to stud males on days 2, 4, 6, 8, and 10 in Experiment 1 or on days 7, 14 and 15 in Experiment 2. All rats received 0.5 mg progesterone (SC) only before the last test. A female was considered sexually receptive if she exhibited a lordosis quotient (LQ) greater than or equal to 10 (LQ = No. lordosis responses/10 mounts by male X 100). The frequencies for sexual receptivity in females with POA lesions were significantly lower than those for control females without lesions in both experiments. Additionally the degree of receptivity (lordosis quotient) was significantly lower on each test day for rats with POA lesions than that for rats without POA lesions. The results imply that the maintenance of the integrity of the POA under this experimental condition was important for the expression of the facilitative influence of the VMH on lordotic responsiveness.

Cycloheximide activation of the lordotic response in low-dose, estrogen-treated ovariectomized rats: evidence for modulating inhibitory influences of the limbic system on sexual behavior.

This study tested the effect on intracranially injected cycloheximide (CHX), an inhibitor of protein synthesis, on facilitation of sexual receptivity in ovariectomized rats. The rats received 0.5 microgram estradiol benzoate (EB), s.c. once daily on days 8 through 12 after ovariectomy (OVX). Either CHX (in 0.5 microliter saline) or 0.5 microliter saline was injected into the lateral septum (LS), cortical nucleus (ACO) or medial nucleus of the amygdala or medial preoptic area on day 11 after OVX. The dose of EB was insufficient to facilitate lordotic behavior on day 10 or day 12 after OVX unless CHX was injected into the LS or ACO. Injection of saline did not influence lordosis.

Failure of a synthetic, anti-inflammatory compound to alter the efficiency of the IUD.

Holtzman, female rats with a plastic or copper IUD were maintained on either a dexamethasone solution (9.4 or 28 micrograms/rat/day) in the drinking water or on water alone. Animals were caged with males of proven fertility and subsequently killed at day 14 of pregnancy and the number of implantation sites counted. Both types of IUDs were effective in preventing implantation. Implantation sites were not increased in dexamethasone-treated animals. In addition, proestrous gonadotropin levels and follicular development did not differ between treated and nontreated animals. Thus, the data demonstrate that the efficacy of the IUD is not decreased with the use of anti-inflammatory drugs.

Hypothalamic injection of cycloheximide in the 4-day cyclic rat. Acute suppression of lordotic behavior and ovulation.

The results of serveral studies imply that estrogen can act upon the central nervous system via a protein synthetic step. Our objective was to determine if the intrahypothalamic (preoptic area, POA) injection of cycloheximide (CHX), an inhibitor of protein synthesis, at 17.00 h on diestrus II of the 4-day cycle altered lordotic behavior and (or) ovulation in the intact rat (sexual receptivity to males normally begins on the evening of proestrus as herein defined; ovulation occurs on estrus of the cycle). CHX-treated females were tested for lordotic behavior at 23.00 h on proestrus, then killed at 17.00 h on the following day. None of the CHX-POA rats were receptive to the males and 90% of these rats did not ovulate. Thus, CHX significantly suppressed sex behavior and ovulation in the cyclic rat.