Modelling Tumor Treating Fields for the treatment of lung-based tumors.

Tumor Treating Fields (TTFields), low-intensity electric fields in the frequency range of 100-500 kHz, exhibit antimitotic activity in cancer cells. TTFields were approved by the U. S. Food and Drug Administration for the treatment of recurrent glioblastoma in 2011. Preclinical evidence and pilot studies suggest that TTFields could be effective for treating certain types of lung cancer, and that treatment efficacy depends on the electric field intensity. To optimize TTFields delivery to the lungs, it is important to understand how TTFields distribute within the chest. Here we present simulations showing how TTFields are distributed in the thorax and torso, and demonstrate how the electric field distribution within the body can be controlled by personalizing the layout of the arrays used to deliver the field.

Distribution of fluconazole-resistant Candida bloodstream isolates among hospitals and inpatient services in Israel.

The emergence of fluconazole-resistant Candida (FRC) is worrisome, but little is known about susceptibility patterns in different nosocomial settings. We prospectively analysed Candida bloodstream isolates in 18 medical centres in Israel (six tertiary-care and 12 community hospitals). The study included 444 episodes of candidaemia (450 patient-specific isolates, 8.5% fluconazole-resistant). Institutional FRC bloodstream infection rates correlated with annual inpatient days, and were strongly associated with the presence and activity of haematology/oncology services. Infection with Candida krusei and fluconazole-resistant Candida glabrata occurred exclusively in hospitals with >600 beds. These findings suggest that empirical antifungal strategies should be tailored to the nosocomial setting.

Macular findings on optical coherence tomography in cat-scratch disease neuroretinitis.

PURPOSE: To describe the macular findings on optical coherence tomography (OCT) in patients with cat-scratch disease (CSD) neuroretinitis. METHODS: Medical records of all patients diagnosed with CSD neuroretinitis at the Tel Aviv Medical Center between April 2006 and May 2010 were retrospectively reviewed. All patients underwent Stratus OCT macular examination. RESULTS: Eight eyes of seven patients with confirmed CSD neuroretinitis, (mean age 33 ± 9.9 years, range 6-48 years) were included in the study. All patients presented clinically with optic nerve swelling and macular edema or macular exudates. OCT demonstrated flattening of the foveal contour, thickening of the neurosensory retina, and accumulation of subretinal fluid (SRF) in all studied eyes. Retinal exudates appeared as multiple hyper-reflective foci in the outer plexiform layer. The average central macular thickness was 460 µm (range 170-906 µm) and the average maximal retinal thickness was 613 µm (range 387-1103 µm), at presentation. The macula appeared normal on repeated exams during follow-up. CONCLUSION: Similar OCT findings were demonstrated in patients with CSD neuroretinitis. SRF was found in all eyes, although was not visible on clinical examination or fluorescein angiography. OCT may be used as an adjunct imaging tool in the diagnosis and follow-up of patients with CSD neuroretinitis.

A retrospective six-year national survey of P. multocida infections in Israel.

Pasteurella multocida is the commonest organism infecting pet bites. Anecdotal reports tend to overemphasize dramatic outcomes. We aimed to study a large database of P. multocida infections. This retrospective survey of P. multocida infections in Israeli hospitals refers to the y 2000-2005. Clinical microbiologists were contacted by email and asked to perform a back-search of their hospital's records for isolates of P. multocida. The charts of patients growing P. multocida were abstracted into a structured questionnaire. 77 cases were identified in 12 hospitals, yielding an annual incidence of 0.19/100,000. The mean age was 49.2+/-26.5 y and the mortality rate was 2.6%. Those who died were >65 y of age, had diabetes mellitus or cirrhosis and were bacteraemic. One-third of the cases occurred in people aged > or =65 y. Cats caused most of these infections (54%). Surgery for debridement was common (53.7%), but no-one required amputation; a second- and third-look operation was necessary for these patients. Bacteraemia was found in 32.5% of patients and was significantly more common among those aged >60 y (p =0.044). Hospitalized patients with P. multocida have a favourable prognosis, apart from elderly and bacteraemic patients with comorbidities. Surgery and reoperations may be required in about half of the patients.

"All-in-one-plate" E-test and disk diffusion susceptibility co-testing for multiresistant Acinetobacter baumannii.

Multiresistant Acinetobacter baumannii requires ancillary manual susceptibility testing with the E-test and disk diffusion when tested with the VITEK-2 system (bioMérieux, Marcy l'Etoile, France). In the study presented here, the E-test and disk diffusion were combined in a single plate, and the method was verified by comparing categorical agreement of combined and control plates. There were no very major, major or minor errors, and similar results were obtained for all ten representative bacterial strains used as controls. Co-testing is thus feasible, accurate and reproducible, and it merits evaluation with other bacterial species.

Influx of extended-spectrum beta-lactamase-producing enterobacteriaceae into the hospital.

BACKGROUND: The prevalence of infections caused by extended-spectrum beta -lactamase (ESBL)-producing Enterobacteriaceae is increasing worldwide. The influx of these bacteria into hospitals has major implications for infection-control and empirical treatment strategies. METHODS: Isolates from 2 patient cohorts--patients with gram-negative bacteremia within 2 days after admission and patients screened for fecal colonization at admission--were assessed for ESBL production. ESBL phenotype was confirmed according to Clinical and Laboratory Standards Institute guidelines. Predictors of ESBL phenotype were examined by univariate and multivariate analyses. RESULTS: Of 80 Enterobacteriaceae isolates from blood samples obtained at admission to the hospital, 13.7% produced ESBL. Thirty-eight patients with ESBL-positive isolates and 72 with ESBL-negative isolates were included in a case-control study. Predictors of ESBL production were male sex and nursing home residence (area under receiver operator characteristic curve, 0.7). Of 241 persons screened at admission, 26 (10.8%) had fecal carriage of ESBL-producing Enterobacteriaceae. Predictors of fecal carriage were poor functional status, antibiotic use, chronic renal insufficiency, liver disease, and use of histamine2 blockers (area under receiver operator characteristic curve, 0.8). Four (15.4%) of the 26 individuals with fecal carriage had subsequent bacteremia with ceftazidime-resistant Enterobacteriaceae, compared with 1 (0.5%) noncarrier (odds ratio, 38.9; P<.001). Of 80 ESBL-producing Enterobacteriaceae isolates obtained at admission, 65 were health care associated, and 15 were community acquired. The 15 community-acquired ESBL-producing Enterobacteriaceae belonged to diverse clones. The most prevalent ESBL gene among these isolates was CTX-M-2 (found in 53.3% of the isolates). CONCLUSIONS: We report high rates of bacteremia and colonization with ESBL-producing Enterobacteriaceae at admission to our institution, which may undermine infection-control measures and complicate the selection of empirical treatment.

Enzyme immunoassay for the diagnosis of cat-scratch disease defined by polymerase chain reaction.

Whole-cell immunofluorescent antibody (IFA) tests for detection of anti-Bartonella henselae immunoglobulin (Ig) G are commonly used to diagnose cat-scratch disease (CSD). The need to cultivate B. henselae in Vero cells for antigen preparation and the absence of routinely applied IFA assays for IgM constitute the major disadvantages of this form of test. We describe the results of an enzyme immunoassay (EIA) for IgM and IgG that used N-lauroyl-sarcosine-insoluble outer membrane antigens from agar-grown B. henselae performed in 84 patients with definite CSD (regional lymphadenitis, cat contact, and > or =1 confirmatory test: polymerase chain reaction, skin test, or B. henselae culture). Although this method has been used as a diagnostic tool in several case reports, it has not previously been evaluated in a large study of definitively proven CSD cases. Results of this study indicate that the EIA described herein can play an important role in the serodiagnosis of CSD, although improvement of the sensitivity, particularly that of the IgM, would be desirable.

West Nile fever outbreak, Israel, 2000: epidemiologic aspects.

From August 1 to October 31, 2000, 417 cases of West Nile (WN) fever were serologically confirmed throughout Israel; 326 (78%) were hospitalized patients. Cases were distributed throughout the country; the highest incidence was in central Israel, the most populated part. Men and women were equally affected, and their mean age was 54+/-23.8 years (range 6 months to 95 years). Incidence per 1,000 population increased from 0.01 in the 1st decade of life to 0.87 in the 9th decade. There were 35 deaths (case-fatality rate 8.4%), all in patients >50 years of age. Age-specific case-fatality rate increased with age. Central nervous system involvement occurred in 170 (73%) of 233 hospitalized patients. The countrywide spread, number of hospitalizations, severity of the disease, and high death rate contrast with previously reported outbreaks in Israel.

Clinical characteristics of the West Nile fever outbreak, Israel, 2000.

West Nile (WN) virus is endemic in Israel. The last reported outbreak had occurred in 1981. From August to October 2000, a large-scale epidemic of WN fever occurred in Israel; 417 cases were confirmed, with 326 hospitalizations. The main clinical presentations were encephalitis (57.9%), febrile disease (24.4%), and meningitis (15.9%). Within the study group, 33 (14.1%) hospitalized patients died. Mortality was higher among patients >70 years (29.3%). On multivariate regressional analysis, independent predictors of death were age >70 years (odds ratio [OR] 7.7), change in level of consciousness (OR 9.0), and anemia (OR 2.7). In contrast to prior reports, WN fever appears to be a severe illness with high rate of central nervous system involvement and a particularly grim outcome in the elderly.

West Nile encephalitis in Israel, 1999: the New York connection.

We describe two cases of West Nile (WN) encephalitis in a married couple in Tel Aviv, Israel, in 1999. Reverse transcription-polymerase chain reaction performed on a brain specimen from the husband detected a WN viral strain nearly identical to avian strains recovered in Israel in 1998 (99.9% genomic sequence homology) and in New York in 1999 (99.8%). This result supports the hypothesis that the 1999 WN virus epidemic in the United States originated from the introduction of a strain that had been circulating in Israel.

DNA amplification for the diagnosis of cat-scratch disease in small-quantity clinical specimens.

Diagnosis of cat-scratch disease (CSD) by polymerase chain reaction (PCR) of lymph node fineneedle aspiration (FNA) and primary lesion specimens can be difficult owing to the minute amount of available material. A PCR assay specifically suited to test these specimens was developed. First, small-quantity (10 microL) samples were prepared from 17 CSD-positive and 16 CSD-negative specimens, and DNA extraction and amplification from these samples were compared using 3 methods. Sensitivity and specificity of PCR were 100% using material collected on glass microscope slides and by using Qiagen (Hilden, Germany) columns for DNA extraction. Then, this method was used to test 11 archival glass microscope slides of FNA (7 malignant neoplasms, 4 undiagnosed lymphadenitis) and 2 primary lesion specimens. Two of the 4 lymphadenitis samples and the 2 primary lesion specimens were PCR positive. The technique presented could facilitate CSD diagnosis from a wider range of clinical samples.

Abdominal recovery after laparotomy and omental transposition into a grossly contaminated median sternotomy wound.

Grossly contaminated median sternotomy wounds are frequently treated with transposed omental flaps. A laparotomy adjacent to such an infected wound carries the risk of peritonitis. It has been suggested that this risk may increase when the omentum, which has anti-infective properties, is removed from the abdominal cavity and is transposed to the chest. The authors evaluated abdominal recovery after laparotomy and omental transposition into an adjacent, grossly contaminated median sternotomy wound. The study group included 15 patients who had sternal wound reconstruction with an omental flap between 1990 and 1998. All patients underwent median sternotomy reconstruction according to a "two-compartment" operative sequence protocol, which included division of the surgical field into an upper (thoracic) contaminated zone and a lower (abdominal) clean zone. The control group was comprised of 15 patients who underwent elective laparotomy for splenectomy during the same time period. The effect of the surgical procedure on the abdomen was compared between the two groups. The timing of the reappearance of peristalsis and regular bowel function, and the incidence of bowel obstruction and postoperative peritonitis were similar in the two groups. The findings indicate that laparotomy and omental transposition in the presence of a grossly contaminated median sternotomy wound is a safe procedure, and is associated with a low rate of abdominal complications.

Unusual eruption as a presenting symptom of cat scratch disease.

Cat scratch disease (CSD) is a common infectious cause of subacute regional lymphadenopathy. Bartonella henselae is the principal etiologic agent. About 10% of CSD patients experience atypical manifestations, including rashes. The most common cutaneous manifestation of CSD is a papule at the inoculation site. We report a case of CSD presenting with an eruption on the upper trunk, reminiscent of Sweet's syndrome, accompanied by lymphadenopathy, arthralgia, and fever. Response to systemic corticosteroids was remarkable. Histopathologic findings refuted the diagnosis of Sweet's syndrome. Identification of anti-B henselae antibodies and B henselae DNA in the affected lymph node confirmed the diagnosis of CSD. This is a first report of extensive papuloedematous eruption as a cutaneous manifestation of CSD. Accurate diagnosis is possible due to the availability of serological tests and DNA amplification techniques.

Prevention of stress fractures using custom biomechanical shoe orthoses.

In a prospective study of stress fractures the hypothesis that training with custom made biomechanical shoe orthoses could lessen the incidence of stress fractures in infantry recruits was tested. Recruits were assigned randomly to groups and given soft biomechanical orthoses or semirigid biomechanical orthoses and compared with a control group that did not train in biomechanical orthoses. All recruits wore infantry boots with soles designed like those of basketball shoes. Recruits were examined biweekly during 14 weeks of basic training. The incidence of stress fractures was 15.7% for the recruits with the semirigid biomechanical orthoses, 10.7% for the recruits with the soft biomechanical orthoses, and 27% for the control group. The soft biomechanical orthoses were tolerated better by the recruits than were the semirigid devices. Among trainees at high risk for stress fractures, prophylactic use of custom made biomechanical orthoses may be warranted.

Hemophilus influenzae biotype III cellulitis in an adult.

The case of a patient with systemic lupus erythematosus presenting with severe leg cellulitis caused by Hemophilus influenzae non-B biotype III is reported. Skin infections caused by H. influenzae in general, and of the extremities in particular, seem to be rare in adults. This is the first reported case of cellulitis caused by H. influenzae biotype III. The infection was treated successfully with antibiotics. This case highlights the importance of blood cultures and prompt antimicrobial treatment in febrile adults with cellulitis, especially immunocompromised patients.

Pseudomonas aeruginosa bacteremia: an analysis of 123 episodes, with particular emphasis on the effect of antibiotic therapy.

OBJECTIVES: To review current experience with Pseudomonas aeruginosa bacteremia and compare outcome of patients treated with single-drug, versus combination therapy. METHODS: The charts of all patients with P. aeruginosa bacteremia between 1990 and 1992 were reviewed, and pertinent demographic, clinical, and bacteriologic data were retrieved. In addition, similar data were collected from a series of patients with P. aeruginosa bacteremia from the literature of the past 20 years. RESULTS: One hundred and twenty-three episodes of P. aeruginosa bacteremia in 121 patients were identified. Most patients were older than 70 years, had at least one underlying condition, and had acquired the infection in the hospital. Attributable mortality was 34%. After exclusion for early mortality and inappropriate therapy, 57 patients remained eligible for comparison of outcome according to therapy protocol. Mortality from infection was equal between the group of 42 patients who received monotherapy and the 15 patients who received combination therapy (14% and 13%, respectively). The literature review revealed eight articles describing 21 to 410 episodes of Pseudomonas bacteremia. The clinical characteristics of these series did not differ significantly from those of the present series. CONCLUSIONS: Incidence, epidemiology, clinical characteristics, and outcome of pseudomonas sepsis did not change significantly over the past 2 decades. Appropriate monotherapy was as effective as combination drug therapy for individuals with pseudomonas bacteremia surviving the first 2 days of infection.