Co-colonization by Streptococcus pneumoniae and Staphylococcus aureus in the throat during acute respiratory illnesses.

Pneumonia due to either Streptococcus pneumoniae (Sp) or Staphylococcus aureus (Sa) accounts for most mortality after influenza and acute respiratory illness (ARI). Because carriage precedes infection, we estimated Sp and Sa carriage to examine the co-colonization dynamics between Sp, Sa and respiratory viruses in the presence of ARI in the oropharynx. We tested oropharyngeal specimens of community subjects (aged ⩾2 years) with ARI for the presence of influenza A and B, 11 other common respiratory viruses, Sp and Sa, using real-time PCR. A total of 338 participants reported 519 ARI episodes of which 119 (35%) carried Sp, 52 (13%) carried Sa and 25 (7%) carried both. Thirty-five subjects tested positive for influenza, of which 14 (40%) carried Sp and six (17%) carried Sa, significantly more than in the influenza-negative group (P = 0·03 and P = 0·04, respectively). In subjects infected by any virus compared to those with no virus, Sp carriage (39·2% vs. 27·9%, P = 0·03) but not Sa carriage (11·6% vs. 14%, P = 0·6) was more frequent. For children, when Sa was present, Sp carriage tended to be less frequent than expected given the presence of viral infection, but not significantly [observed relative risk 1·14, 95% confidence interval (CI) 0·4-3·1; with a relative excess risk due to interaction of -0·11]. Independent of age, Sp carriers were more likely to return that season with subsequent ARI (odds ratio 2·14, 95% CI 1·1-4·3, P = 0·03). Both Sp and Sa carriage rates in the oropharynx increase during influenza infection in children. However, no negative interaction between Sp and Sa was observed. Sp carriers are more likely to suffer subsequent ARI episodes than non-carriers.

Impact of perioperative enteral synbiotics in hepatic and pancreatic surgery: design and rationale of a single blind placebo controlled prospective randomised control trial.

BACKGROUND: Prebiotics and probiotics influence all pathogenic mechanisms of bacterial translocation. Used in combination, they are called synbiotics. Postoperative infective complications in patients undergoing hepatic and pancreatic surgery lead to a significant prolongation of hospital stay and increased costs. While synbiotics are considered to have beneficial effects on human health, their clinical value in surgical patients, especially in South Asia remains unclear given a paucity of applicable clinical studies. In this study we aim to assess their clinical usefulness in patients who undergo hepatic and pancreatic surgery. METHODS: A prospective monocentric randomised single blind controlled trial is being conducted in patients undergoing major pancreatic resections (Whipple procedure, distal pancreatectomy, Frey procedure) and hepatic resections. Group A received a specific synbiotic composition, 5 days prior and 10 days after the surgery. Group B received a placebo. Primary study end point was the occurrence of postoperative infection during the first 30 days. Secondary outcome measures were mortality, first bowel movement, days in intensive care unit, length of hospital stay, and duration of antibiotic therapy. Side effects of probiotics were evaluated. From previous studies we assumed that perioperative synbiotics reduce the proportion of patients with infectious complications from 50% to 12%, with α of 0.05 and power 80%, the calculated sample size was 35 patients for each group with a dropout rate of 10%. CONCLUSIONS: This study is intended at determining the impact of perioperative synbiotic therapy on postoperative infectious complications, morbidity and mortality in patients undergoing major pancreatic and hepatic surgery. CLINICAL TRIAL: The Clinical Trials Registry of India (CTRI/2013/06/003737).

Percutaneous ultrasound-guided fine-needle aspiration of portal vein thrombi as a diagnostic and staging technique for hepatocellular carcinoma.

BACKGROUND: Detection of portal vein tumor invasion in hepatocellular carcinoma (HCC) is important in determining therapy and prognosis. Patients with portal vein thrombus (PVT) due to tumor are considered to have advanced disease and are only offered palliative therapy. Therefore, every possible attempt should be made to accurately differentiate benign from malignant PVT. METHODS: In this study, 20 patients presenting to the out-patient department with a PVT and a diagnosis/diagnostic suspicion of HCC were subjected to FNAC of PVT. Clinical, cytological, and histopathological data for these patients were analyzed. RESULTS: The patients had a median age of 58 years, with majority being cirrhotic (80%) and males (80%). Thirteen patients had a prior radiological diagnosis of HCC at the time of FNAC. In three patients without any mass on imaging, FNAC made the initial diagnosis and staged the disease simultaneously. 50% of the thrombi were limited to 1st-order portal vein branches (vp3). Sixteen of the aspirates were positive for malignancy with 50% of the tumors being moderately differentiated. On histologic follow-up, three of the patients with negative aspirates had bland thrombi in their portal veins. No complications resulted from the procedure. CONCLUSIONS: FNAC of PVT is a simple, safe, effective, well-tolerated, and economical method for staging of patients with HCC. When used as the initial diagnostic procedure, in selected patients, it can provide the diagnosis and staging information simultaneously.

Hemosuccus Pancreaticus: 15-Year Experience from a Tertiary Care GI Bleed Centre.

Background. Hemosuccus pancreaticus (HP) is a very rare and obscure cause of upper gastrointestinal bleeding. Due to its rarity, the diagnostic and therapeutic strategy for the management of this potentially life threatening problem remains undefined. The objective of our study is to highlight the challenges in the diagnosis and management of HP and to formulate a protocol to effectively and safely manage this condition. Methods. We retrospectively reviewed the records of all patients who presented with HP over the last 15 years at our institution between January 1997 and December 2011. Results. There were a total of 51 patients with a mean age of 32 years. Nineteen patients had chronic alcoholic pancreatitis; twenty-six, five, and one patient had tropical pancreatitis, acute pancreatitis, and idiopathic pancreatitis, respectively. Six patients were managed conservatively. Selective arterial embolization was attempted in 40 of 45 (89%) patients and was successful in 29 of the 40 (72.5%). 16 of 51 (31.4%) patients required surgery. Overall mortality was 7.8%. Length of followup ranged from 6 months to 15 years. Conclusions. Upper gastrointestinal bleeding in a patient with a history of chronic pancreatitis could be caused by HP. All hemodynamically stable patients with HP should undergo prompt initial angiographic evaluation, and if possible, embolization. Hemodynamically unstable patients and those following unsuccessful embolization should undergo emergency haemostatic surgery. Centralization of GI bleed services along with a multidisciplinary team approach and a well-defined management protocol is essential to reduce the mortality and morbidity of this condition.

Emerging fluoroquinolone resistance in Streptococcus agalactiae in South Korea.

The goal of this study was to determine the prevalence of fluoroquinolone resistance in Streptococcus agalactiae and the serotype distribution of this resistant bacterium. S. agalactiae strains collected from 221 asymptomatic pregnant women (35-37 weeks of gestation) and 838 patients with S. agalactiae infection in Korea, from 2006 to 2008, were tested for susceptibility to four fluoroquinolones. Rates of resistance of S. agalactiae to ciprofloxacin, levofloxacin, and moxifloxacin were 9.3 %, 9.5 %, and 0.8 %, respectively; greater than 94 % of S. agalactiae strains were resistant to norfloxacin. Resistance to ciprofloxacin and levofloxacin increased between 2006 and 2008. All strains were susceptible to penicillin. Resistance to ciprofloxacin and levofloxacin was higher in the clinical strains of S. agalactiae isolated from infections than in colonizing strains isolated from pregnant women. Mutations in the quinolone resistance-determining regions of gyrase and topoisomerase genes were detected in strains resistant to ciprofloxacin, levofloxacin, and moxifloxacin; no such mutations were found in strains resistant only to norfloxacin. There was a strong correlation between the minimum inhibitory concentrations and the presence of mutations in gyrase and topoisomerase genes. In conclusion, the prevalence of fluoroquinolone resistance was unexpectedly high. Strain serotypes were not associated with susceptibility to fluoroquinolones.

Caries resistance as a function of age in an initially caries-free population.

Using data from the Center for Oral Health Research in Appalachia Study, we examined variability in susceptibility to dental caries among children and adolescents in rural Appalachia. Among 210 participants who were caries-free at the initial visit, age at the baseline visit can be used as a proxy for the degree of caries resistance; probability of caries development at the tooth level decreased as age at the baseline visit increased. Participants who stayed caries-free for a longer period during childhood and adolescence experienced less extensive caries, as measured by the number of carious teeth. However, the probability of becoming caries-positive did not correlate with age at the baseline visit. For children between 1 and 18 years of age, there was not a "threshold age" after which a caries-free child's risk of caries onset is significantly reduced.

Inflammatory pseudotumour secondary to spilled intra-abdominal gallstones.

INTRODUCTION: Spillage of calculi in the abdomen is frequent during Laparoscopic Cholecystectomy (LC). Though uncommon, these stones may lead to early or late complications. We describe a rare case of spilled gallstone presenting four years after the index procedure, with a mass in the parietal wall mimicking a neoplastic lesion. PRESENTATION OF CASE: A 50 year old male presented with a mass in the right upper quadrant for the past 2 years. His past surgical history included a LC done four years ago. Intraoperative procedural details of the surgery were not available. A Computed Tomography (CT) scan showed an extrahepatic mass in the subdiaphragmatic space extending onto the soft tissues of the parietal wall. He underwent laparoscopic piecemeal excision of this organized mass. His post operative period was uneventful and he was pain-free on follow up. DISCUSSION: Gallbladder perforation can occur due to excessive traction during retraction or during dissection from the liver bed. It can also occur during extraction from the abdomen. Infected bile, pigment gallstones, male gender, advanced age, perihepatic location of spilled gallstones, more than 15 gallstones and an average size greater than 1.5cm have been identified as risk factors for complications. Definitive treatment is surgery with excision of the organized inflammatory mass and extraction of gallstones to avoid future recurrence. CONCLUSION: Spilled gallstones can be a diagnostic challenge and can cause significant morbidity to the patient. Clear documentation of spillage and explanation to the patient is of utmost importance, as this will enable prompt recognition and treatment of any complications. Prevention of spillage is the best policy.

Comparative whole-genome analysis of Streptococcus mutans isolates within and among individuals of different caries status.

INTRODUCTION: Genotypic analyses of Streptococcus mutans using fingerprinting methods depend on a few genetic loci being different but do not reveal the underlying genome-wide differences between strains. METHODS: We used comparative genomic hybridization (CGH) with 70-mer oligonucleotide microarrays containing open reading frames (ORFs) from S. mutans strain UA159 to examine the genetic diversity of 44 isolates from nine children selected from a local study population in Eastern Iowa. RESULTS: Unique strains (clones) within each child initially identified by arbitrary-priming polymerase chain reaction were confirmed by CGH. There was a wide range of variation in the hybridization patterns of the 1948 ORFs among the test isolates examined. Between 87 and 237 ORFs failed to give a positive signal among individual isolates. A total of 323 of the UA159 ORFs were absent from one or more of the test strains. These 323 variable genes seemed to be distributed across the entire UA159 genome and across all the predicted functional categories. CONCLUSION: This set of very close geographically and temporally collected S. mutans isolates had a degree of gene content variation as high as a previously examined global set of strains. Comparing the frequency of these variable genes, the majority of which have unknown function, among strains of different origins (i.e. different caries status) could help to determine their relevance in S. mutans cariogenicity.

Streptococcus agalactiae pulsed-field gel electrophoresis patterns cross capsular types.

Streptococcus agalactiae is a genetically diverse organism; when typed by pulsed-field gel electrophoresis (PFGE), multiple types appear within a single serotype. We tested whether S. agalactiae PFGE types correspond to a specific serotype within individuals, and different individuals from the same geographic area. A total of 872 S. agalactiae isolates from 152 healthy individuals were classified by PFGE and capsular serotype. Serotype V was the most homogeneous (Simpson's diversity index 0.54); and types III, II and Ib were mostly heterogeneous (Simpson's diversity index 0.90). Within an individual, isolates with the same PFGE patterns had identical capsular types, but across individuals the same PFGE types sometimes occurred in different serotypes. Capsular type alone is insufficient to define epidemiological relatedness. Although PFGE types appear to be a valid surrogate for capsular typing of isolates from the same individual, it is not a valid surrogate for serotype in isolates from different individuals.

Partial median corpectomy for C2-C3 intradural arachnoid cyst: case report and review of the literature.

Anterior cervical location of arachnoid cyst is a rare and only 22 cases have been reported in the literature. The surgical approach was quite varied and mostly these cysts were accessed via dorsal laminectomy, with few patients developing postoperative neurological deficit. We report a 51-year-old male with a cervical arachnoid cyst extending from the dens to the inferior border of the C3 body, which was successfully decompressed via an anterior cervical approach through the partial corpectomy of C2. This is probably the first case report demonstrating the safety of anterior partial median corpectomy of the C2 body with micro discectomy of C2-C3 space for excision of the anterior cervical archnoid cyst. The additional advantage of this procedure is that it may not result in spinal instability.

Intracranial aspergilloma in immunocompetent patients successfully treated with radical surgical intervention and antifungal therapy: case series.

INTRODUCTION: Aspergillosis of the central nervous system is an uncommon infection, mainly occurring in immunocompromised patients with a high mortality. Surgical excision of the intracranial lesion combined with oral voriconazole has been proposed to improve the outcome in immunocompromised patients. Itraconazole has been considered not to be effective because of poor penetration into the brain tissue. We report the long-term outcome of 3 cases of intracranial aspergilloma in immunocompetent patients who were successfully treated with radical surgery combined with oral itraconazole. MATERIALS AND METHODS: This is a retrospective study in which chronic invasive intracranial aspergilloma was successfully treated in 3 apparently immunocompetent patients and followed-up for more than 5 years. RESULTS: Near complete or radical surgical removal of this localised chronic invasive intracranial aspergilloma whenever possible is the definitive treatment. When combined with the oral antifungal drug itraconazole, the management regimen is effective in achieving near complete long-term cure of more than 5 years. Oral itraconazole 200 mg twice daily should be given for a prolonged period of at least 6 months. CONCLUSION: In chronic invasive intracranial aspergilloma in an immunocompetent patient, it was suggested that radical excision of the intracranial aspergilloma combined with oral antifungal drug belonging to triazole group that can be either itraconazole or voriconazole given for a period of 6 months was likely to improve the long-term outcome.

The debt of nations and the distribution of ecological impacts from human activities.

As human impacts to the environment accelerate, disparities in the distribution of damages between rich and poor nations mount. Globally, environmental change is dramatically affecting the flow of ecosystem services, but the distribution of ecological damages and their driving forces has not been estimated. Here, we conservatively estimate the environmental costs of human activities over 1961-2000 in six major categories (climate change, stratospheric ozone depletion, agricultural intensification and expansion, deforestation, overfishing, and mangrove conversion), quantitatively connecting costs borne by poor, middle-income, and rich nations to specific activities by each of these groups. Adjusting impact valuations for different standards of living across the groups as commonly practiced, we find striking imbalances. Climate change and ozone depletion impacts predicted for low-income nations have been overwhelmingly driven by emissions from the other two groups, a pattern also observed for overfishing damages indirectly driven by the consumption of fishery products. Indeed, through disproportionate emissions of greenhouse gases alone, the rich group may have imposed climate damages on the poor group greater than the latter's current foreign debt. Our analysis provides prima facie evidence for an uneven distribution pattern of damages across income groups. Moreover, our estimates of each group's share in various damaging activities are independent from controversies in environmental valuation methods. In a world increasingly connected ecologically and economically, our analysis is thus an early step toward reframing issues of environmental responsibility, development, and globalization in accordance with ecological costs.

Response of complex food webs to realistic extinction sequences.

Although an ecosystem's response to biodiversity loss depends on the order in which species are lost, the extinction sequences generally used to explore such responses in food webs have been ecologically unrealistic. We investigate how several extinction orders affect the minimum number of secondary extinctions expected within pelagic food webs from 34 temperate freshwater lakes. An ecologically plausible extinction order is derived from the geographically nested pattern of species composition among the lakes and is corroborated by species' pH tolerances. Simulations suggest that lake communities are remarkably robust to this realistic extinction order and highly sensitive to the reverse sequence of species loss. This sensitivity is not well explained by the known sensitivity of networks to the loss of highly connected species but appears to be better explained by our observation that trophic specialists preferentially consume widely distributed species at low risk of extinction. Our results highlight an important aspect of community organization that may help to maintain biodiversity amidst changing environments.

Probe hybridization array typing: a binary typing method for Escherichia coli.

The ability to distinguish between Escherichia coli strains is critical for outbreak investigations. Binary typing, based on the presence or absence of genetic material, provides a high-throughput alternative to gel- and PCR-based typing techniques that generate complex banding patterns and lack uniform interpretation criteria. We developed, validated, and determined the discriminatory power of an E. coli binary typing method, probe hybridization array typing (PHAT). In PHAT, the absence or presence of genetic material is identified by using DNA hybridization to produce a reproducible and portable fingerprint for each genome. PHAT probes were generated from genome subtractive hybridization experiments. We PHAT typed the ECOR collection of strains from a variety of geographical locations, and 33 rectal E. coli strains selected from college-aged women with urinary tract infection. In the set of 33 human rectal strains, the discriminatory power of PHAT (98%) equaled that of multilocus sequence typing (MLST) and pulsed-field gel electrophoresis. However, for ECOR strains, which include nonhuman strains, the current set of PHAT probes was less discriminating than MLST, ribotyping, and enterobacterial repetitive intergenic consensus sequence PCR (80% versus 97, 92, and 97%, respectively). When we limited the analysis to ECOR strains of B2 and D lineage, which are associated with human infection, current PHAT probes were highly discriminatory (94%). PHAT can be applied in a high-throughput format (i.e., "library on a slide"), the discriminatory ability can be varied based on the probe set, and PHAT is readily adapted to other bacterial species with high variation in genetic content.

A mathematical model for predicting the outcome in moderate head injury.

BACKGROUND: Virtually all the literature on head injury has focused on the outcome prediction of severe and mild head injuries and very few studies have been dedicated to patients sustaining moderate head injuries. AIM: To identify the patient following moderate head injury who may die, develop severe disability or significant cognitive and behavioral problems on the first day of injury itself. SETTING: Tertiary teaching hospital. DESIGN: Prospective study divided into two groups. MATERIALS AND METHODS: The study included 85 patients whose Glasgow coma scale score were 9-12 and who had isolated moderate head injury. Among the above patients a preliminary prospective study was conducted in first group of 64 patients using 7 clinical factors, 18 neuro-behavioral sequel and CT brain data in prediction of outcome with moderate head injury. From the results obtained in the above study three statistically significant factors were identified and a mathematical model was developed and used prospectively in the next 21 patients and its accuracy was evaluated. STATISTICAL METHODS USED: Multiple regression analysis and Kendall's tau non- parametric test using statistical package for social sciences (SPSS 11-5-version) were used to find out the predictive factors. RESULTS: Results of these patients showed combination of CT scan brain data, verbal response and neurological signs could provide a reliable prediction in moderate head injury. CONCLUSION: Based upon the above results a mathematical model was developed giving a value for the above-mentioned factors. The mathematical model was "CT brain data x (Verbal response + Neurological Signs)". Its overall accuracy when used on the day of admission was around 80%.

Immunohistochemical analysis of coeliac mucosa following ingestion of oats.

There is now considerable clinical evidence that oats do not activate coeliac disease. Nonetheless, a reluctance to include oats in the gluten-free diet remains. Because gluten-induced damage is accompanied by activation of the gastrointestinal immune system, the purpose of this study was to investigate if similar changes were induced by oats ingestion. Small intestinal histological sections from 10 patients who ingested 50 g of oats daily for 3 months were investigated for possible evidence of immune activation. Tissue obtained before and after oats challenge was stained with a series of antibodies directed against the following molecules: human leucocyte antigen D-related (HLA-DR), Ki-67, CD25, CD54 [intercellular adhesion molecule 1 (ICAM-1)] and mast cell tryptase. None of the patients developed clinical or laboratory evidence of adverse effects. The distribution of intestinal HLA-DR expression was not affected by oats ingestion and the crypt epithelium remained unstained. In the pre-oats biopsies, the percentage of Ki-67 positive enterocytes, 29.5 +/- 6.9 [95% confidence interval (CI) 13.9-45.0] did not differ significantly from that found in post-oats biopsies, 41.2 +/- 3.7 (95% CI, 32.8-49.6), P = 0.19, not significant. Furthermore, oats ingestion did not alter the number of CD25 positive and tryptase positive cells. Finally, the distribution and intensity of ICAM-1 staining was unchanged by dietary oats. In summary, detailed immunohistological studies of biopsies from patients ingesting oats for 3 months did not reveal evidence of immune activation. Together with other reported findings, this study strengthens the view that oats can be included safely in the diet of gluten sensitive patients.

Crystine: fibrous biomolecular material from protein crystals cross-linked in a specific geometry.

Cysteine substitutions were engineered on the surface of maltose binding protein to produce crystine fibers, linear polymers of folded protein formed within a crystal. Disulfide bond formation between adjacent protein molecules within the lattice was monitored by X-ray crystallography. The cross-linked crystals were resistant to dissolution in water or neutral buffer solutions, even though the cross-linking was one-dimensional. However, crystine fibers were observed by transmission electron microscopy to dissociate from the crystals in acidic solutions. Some fibers remained associated as two-dimensional bundles or sheets, with a repeat unit along the fibers consistent with the packing of the individual protein molecules in the crystal. Neutralization of the acidic solutions caused the fibers to re-associate as a solid. Crystine threads were drawn out of this solution. In scanning electron microscopy images, many individual fibers could be seen unwinding from the ends of some threads. Crystine fibers are a new type of biomolecular material with potential applications wherever the use of proteins in a fibrous form is desirable, for example, the incorporation of enzymes into cloth or filtration material.