Lycopene and Caffeic Acid Phenethyl Ester Affect Caspase-3 Activity, but Do Not Alter the NO Pathway in Lung Tissue Damage Induced by Cisplatin.

INTRODUCTION: Antioxidants such as lycopene (LCP) and caffeic acid phenethyl ester (CAPE) represent ideal molecules for the treatment of different reactive oxygen species (ROS) associated disorders. Cisplatin is a chemotherapeutic agent, causing an increase in ROS and DNA damage, with numerous side effects, which include lung toxicity. In the presents study, we evaluated and mutually compared the potential of LCP and CAPE in preventing cisplatin-induced rat lung damage. METHODS: The study was done using pathohistological analysis and a panel of biochemical parameters that reflect lung oxidative tissue damage, inflammation, and apoptosis. RESULTS: The obtained results suggest that cisplatin (10 mg/kg) causes significant disturbances in the lung tissue morphology, followed by an increase in lipid peroxidization and protein modification. Also, a pronounced inflammatory response and cell apoptosis cascade activation was noted. Both LCP and CAPE were able to mitigate the changes, to a different extent, in oxidative damage and apoptosis progression induced by cisplatin. However, they both had limited effect on inflammation since they only prevented an increase in myeloperoxidase activity but had not been able to prevent the NO generation. CONCLUSION: It is hard to be exact in saying whether LCP or CAPE is better in preventing cis-platin-induced lung damage since they obviously possess different mechanisms of action.

Comparison of recurrence patterns of colorectal cancer in laparoscopic and open surgery groups of patients: A meta-analysis.

PURPOSE: The purpose of this meta-analysis was to evaluate differences between laparoscopic and open surgery and also the development of local and distant colorectal cancer (CRC) recurrences in treated patients. METHODS: 2,058 cases treated with laparoscopic surgery and 2,365 cases with open surgery from 20 included studies were analyzed, using the random-effects model. The mean difference and odds ratio (OR) with 95% confidence interval (95%CI) were calculated. An overall and a subgroup analysis was performed according to the type of cancer - colon or rectal, and we registered the operating time, number of dissected lymph nodes and need for intraoperative blood transfusion in the laparoscopic and open surgery group of patients. RESULTS: The operating time in the laparoscopic surgery group was significantly longer than in the open surgery group (mean difference 38.23 min). There was no significant differences in the number of dissected lymph nodes between the two groups when we pooled data for treatment of CRC (p=0.16). The OR of overall and local recurrences was significantly decreased in patients in the laparoscopic surgery group compared to those in the open surgery group (OR 0.83; 95%CI 0.70-0.98; p=0.03) and (OR 0.70; 95%CI 0.50-0.97; p=0.03), respectively. No significant differences were found between patients who underwent laparoscopic surgery and those that had open surgery for distant recurrences after CRC treatment. CONCLUSIONS: There was statistically significant difference between laparoscopic or open surgery and development of local and overall CRC recurrences.

Clinical characteristics of imported malaria: An 11-year experience in a Serbian referral center.

INTRODUCTION: Due to intercontinental traffic, population migration trends, natural disasters, and climate change, imported malaria remains important to consider in a febrile returning traveler. This study aims to raise awareness about malaria and help European clinicians maintain a working knowledge of this disease by reviewing the most important clinical characteristics in a non-endemic setting. METHODOLOGY: Using medical records, a retrospective study was performed on clinical and laboratory data in order to analyze 103 malaria cases managed at the Clinic for Infectious and Tropical Diseases in Belgrade, from 2000 to 2010. Descriptive statistics, Chi-squared test, Spearman's rank correlation, and analysis of variance were used. RESULTS: Patients were predominantly male (89.3%) with a mean age of 46.66 ± 12.45 years, and most (98.06%) returned from Africa without having taken chemoprophylaxis (72.88%). Fever, arthralgia, myalgia, headache, vomiting, dark urine, and cough were common at presentation. Hepatosplenomegaly, jaundice, neurological and pulmonary findings, and thrombocytopenia were dominant findings on physical and laboratory examinations. Most (73.48%) were infected with P. falciparum. Few patients (17.55%) who were hyperparasitemic had significantly higher values of bilirubin and more frequent neurological complications. All patients were treated with artemisinin-based drug combinations regardless of Plasmodium species. Three (2.9%) patients succumbed to P. falciparum malaria. CONCLUSION: We suggest a high index of suspicion of malaria be maintained when evaluating febrile patients returning from endemic regions, especially if thrombocytopenia and hemolysis are present. Hyperparasitemia, high bilirubin levels, and neurological symptoms are associated with severe malaria. The importance of adequate malaria chemoprophylaxis cannot be overstated.

AN INCIDENTAL FINDING OF THYMIC CARCINOMA DURING ELECTIVE CORONARY ARTERY BYPASS GRAFTING.

INTRODUCTION: Thymoma is a rare malignant tumor of the anterior mediastinum. Thymic squamous cell carcinoma has been recognized as an aggressive form of thymoma with different behavior. It is associated with paraneoplastic syndromes, variety of clinical presentations, different way of treatment and complex prognosis. Improved imaging techniques show that an early diagnosis of thymoma is possible, which makes thymoma a potentially dangerous but preventable disease. CASE REPORT: In this report. we describe the clinical and histological findings of a patient with incidental finding of squamouscell thymic carcinoma presented during elcc tive coronary artery bypass grafting surgery.

Retrospective PCR-based species identification of Leishmania in two patients with visceral leishmaniasis in Serbia.

INTRODUCTION: Retrospective molecular identification of Leishmania parasites in two patients with visceral leishmaniasis (VL) previously treated in Serbia was carried out. DNA was isolated from unstained bone marrow smears (BMSs) kept for 11 and 8 years. Genus-specific real-time PCR was combined with conventional PCR and sequencing for detection and species identification. CASE PRESENTATION: In 2003, a 40-year-old Serbian male was admitted to the Clinical Centre of Serbia (CCS) with fever, sweating, fatigue and splenomegaly, which developed over a period of 7 weeks. He had frequently travelled around Europe. VL was confirmed by microscopy of Giemsa-stained BMS. Treatment by pentavalent antimonials was successfully completed. Two years later, the patient developed post-kala-azar dermal leishmaniasis. Treatment resulted in symptom resolution. Later on, Leishmania infantum was identified as the causative agent of the VL by sequencing of the ITS (internal transcribed spacer) region; mixed Leishmania spp. infection could not be excluded. In 2006, a 33-year-old female from Vojvodina, Serbia, with pre-existing diabetes mellitus and chronic meningoencephalitis and a history of frequent visits to the Montenegrin seacoast, was admitted to the CCS with fever, pancytopenia and moderate hepatosplenomegaly. A stained BMS revealed abundant Leishmania amastigotes. Indirect haemagglutination analysis was positive with a titre of 1 : 2048, and a rapid dipstick rK39 test was also positive. Treatment by liposomal amphotericin B was successful; however, shortly after, the patient developed neural infection and pneumonia and died. The causative agent was identified as L. infantum. CONCLUSION: Molecular diagnosis of VL and species delineation using DNA from unstained BMSs stored for several years is possible.

Clinical significance of molecular methods in the diagnosis of imported malaria in returning travelers in Serbia.

OBJECTIVES: The goal of this study was to assess the clinical significance of conventional and PCR-based molecular diagnosis in patients with imported malaria in Serbia. METHODS: Giemsa microscopy, the rapid diagnostic test, and quantitative real-time PCR (qPCR) were used to detect Plasmodium species in 109 whole-blood samples from patients after their return from malaria endemic areas, including those clinically suspected for malaria (n=97) and healthy travelers (n=12) examined as part of epidemiological surveillance. RESULTS: A total of 45 patients were diagnosed with malaria: 42 (93.3%) by microscopy and three (6.7%) additional ones by qPCR. The agreement between the results of species-specific qPCR and microscopy was 73.3%; it was as high as 90.6% for Plasmodium falciparum infections. Follow-up analysis demonstrated persistence of Plasmodium sp DNA for a mean 6 days after the disappearance of parasitemia on microscopy. CONCLUSIONS: Due to its sensitivity and specificity, qPCR is a helpful method complementary to microscopy, particularly in cases of low parasitemia. In addition, it is superior to microscopy for species identification.

Mitral valve endocarditis caused by Pseudomonas aeruginosa: a case report.

Previously, endocarditis caused by Pseudomonas aeruginosa mostly involved right-sided valvular infection and generally carried a good prognosis. Recently, changes have been observed in the occurrence and clinical presentation of pseudomonal endocarditis, with increasing incidence of nosocomial infections and involvement of the aortic and mitral valves. Still, pseudomonal left-sided endocarditis is rare, but is frequently associated with complications and high mortality rates. A case of a high-risk patient with coronary artery disease and left-ventricular dysfunction, successfully treated for pseudomonal mitral valve endocarditis complicated by splenic abscess formation, is presented here.

Nosocomial infections in the Intesive Care Unit, Univerisity Hospital for Infectious and Tropical Diseases, Belgrade, Serbia.

BACKGROUND/AIM: Nosocomial infections (NIs) are an important cause of morbidity, mortality and prolonged hospitalizations. Fifty percent of NIs have been reported in Intensive Care Units. The aim of this study was to determine the frequency and type of NIs among critically ill patients treated in the University Hospital for Infectious and Tropical Diseases, Clinical Centre of Serbia, as well as risk factors for acquiring them. METHODS: This prospective cohort study included 52 patients treated in the Intensive Care Unit from January to June 2004. The diagnosis of NI was established according to the Centers for Disease Control and Prevention (CDC) definition, based on clinical presentation, radiological and microbiological findings, etc. Statistical data processing was done by using the electronic data base organized in SPSS for Windows version 10.0. The level of statistical significance was defined as p < 0.05. RESULTS: NIs were found in 33 (63.4%) of 52 inpatients. Urinary tract infections (UTIs), pneumonia, and soft tissue infections, the most common nosocomial infections in our setting, were recorded in 41.0%, 25.6%, and 23.1%, of patients, respectively. Several factors contributed to a high incidence of these infections: chronic comorbidities (p < 0.01), the presence of indwelling devices such as urinary tract catheters (p < 0.01), endotracheal tubes (p < 0.05) along with mechanical ventilation (p < 0.05). CONCLUSION: The majority of patients with NIs had chronic underlying comorbidities. All the patients with UTIs had urinary catheters. The most important risk factors for the development of nosocomial pneumonias were endotracheal intubation and mechanical ventilation. The patients with pneumonia had the highest mortality.

Human case of fasciolosis in Serbia treated with triclabendazole.

INTRODUCTION: The number of humans infected by Fasciola hepatica is increasing worldwide. Humans can become accidental hosts by ingesting drinking water or plants contaminated with metacercariae. CASE REPORT: We reported a case of a 68-year-old Serbian woman, in which the diagnosis of acute fasciolosis had been established after serious diagnostic concerns. Based on clinical picture (episodic right upper quadrant abdominal pain, febrility and generalized body pain) and biochemical analyses (high eosinophilia and high activity of alkaline phosphatase), she was appointed as suspected to the acute fasciolosis. Stool and duodenal aspirate exams were negative for Fasciola ova. In the absence of adequate serologic diagnostic for fasciolosis in Serbia, the diagnosis was confirmed using enzyme immunoassays and immunoblot at the Institute for Tropical Diseases in Hamburg, Germany. Soon after triclabendazole was administered, the symptoms disappeared and biochemical values returned to normal. CONCLUSION: The diagnosis of human fasciolosis may be problematic and delayed, especially in non endemic areas, because physicians rarely encounter this disease and a long list of other diseases must be considered in the differential diagnosis. The syndrome of eosinophilia, fever, and right upper quadrant abdominal pain suggest acute fasciolosis. Unclear source does not rule out fasciolosis.

Mitral valve endocarditis during brucellosis relapse.

INTRODUCTION: Endocarditis is the most common cardiovascular manifestation of brucellosis with high mortality rate. Brucella is less accesable to antibiotic (but not for all) and relapse can occur after a various period of clinical latency. CASE REPORT: A 55-year-old farmer was diagnozed with acute systemic Brucella infection in May 2008 and treated with antibiotic therapy in regional hospital for two months and for three months after discharge. He began to feel myalgia, arthralgia, malaise, shortness of breath, abdominal pain, vomiting, diarrhoea and lost weight eight months after initial symptoms occured. Because symptoms progressed he was admitted to our hospital in February 2009. Based on a combination of epidemiological, clinical data (on admission he was catchetic, adynamic, dyspneic, hypotensive 80/50 mmHg, fever up to 39.5 degrees C), positive serological Wright test for brucellosis (1 : 5,120), and echocardiographic examination findings, the diagnosis of very severe relapse of brucellosis with mitral valve endocarditis, complicated with perforation of anterior mitral leaflet, severe mitral regurgitation and pulmonary hypertension was established. He was treated with a combined triple antibiotic therapy (vancomycin, ciprofloxacin and gentamicin, and swiched to regimen with doxycycline, gentamicin and imipenem, replacing gentamicin by rifampicin) for 4 weeks and for the next 2 weeks was receiving trimetoprime/sulfamethoxazole and rifampicin. The patients' condition was improved and he was operated. The diagnosis of infective endocarditis was confirmed intraoperatively. Mitral valve replacement was performed, and combined triple antibiotic treatment (amikacin + ciprofloxacin + cefazolin, for 2 weeks and cephazolin + doxycycline + rifampicin, for 2 weeks) was continued, following with two antibiotics (doxycycline + rifampicin) for 5 months. The patient completely recovered without any signs of infection 30 months postoperatively. CONCLUSION: A combined antibiotic therapy and surgery reduce complications and mortality associated with Brucella endocarditis and improve quality of patients' life.

Ossifying chondrolipoma of the tongue.

INTRODUCTION: Chondrolipomas and osteolipomas are uncommon variants of lipomatous tumors. CASE REPORT: We presented a 60-year-old woman with ossifying chondrolipoma of the tongue. Clinical examination revealed a firm nodular mass, located in the midline of the posterior region on the dorsal surface of the tongue. Histologically, the lesion was well-delimited showing areas of mature adipocytes arranged in lobules and separated by fibrous connective tissue septa, islands of mature cartilaginous tissue and osseous metaplasia. Trabeculae of lamellar bone within a fibro-fatty background were visible throughout the tumor. The cartilaginous areas merging centrally with bone formation and fatty marrow tissue were present, as well as the hematopoietic elements in the fatty marrow. The bone forming was found to be through both membranous and enchondral mechanisms. CONCLUSION: Ossifying chrondrolipoma with hematopoietic elements is extremely unusual lesion. This interesting entity should be kept in mind in the differential diagnosis of lingual lesions.

[Therapeutic approach to actinomycosis--experience gained at the department of infectious and tropical diseases].

INTRODUCTION: Actinomycosis is a chronic infectious disease caused by anaerobic, gram-positive microorganisms from the order of Actinomyce or Propionobacterium. The disease manifests iself mostly in cervicofacial form and less frequently in thoracic and abdominal form. The study was aimed at reviewing clinical manifestations and therapeutic approaches in treatment of patients with Actinomycosis. MATERIAL AND METHODS: The study sample consisted of four patients with different clinical manifestations of Actinomycosis, who had been treated at the Institute for Infectious and Tropical Diseases in Belgrade in 2002, 2003, 2006 and 2008. RESULTS: Four patients with Actinomycosis were treated during the above mentioned periods of time. One patient had kidney Actinomycosis, which developed into generalized Actinomycosis. Two patients had the most common cervical form, while the forth one had abdominal form; all patients received Penicillin G followed by Ampicillin, during the period of four weeks to up to a year. CONCLUSION: Actinomycosis is a rare disease, which imposes great diagnostic dilemmas. The treatment of this disease requires long term use of antibiotics.

Imported malaria in Belgrade, Serbia, between 2001 and 2009.

Since 2000, travel of Serbian citizens to tropical areas has been slowly but steadily increasing. To determine the epidemiological and clinical characteristics of imported malaria in Serbia, we analyzed clinical history data of all travelers who presented at the Clinic for Infectious and Tropical Diseases in Belgrade after their return from tropical and subtropical areas between 2001 and 2009. The study series involved a total of 2981 travelers, and included both those with (847) and without (2134) health problems. Malaria was diagnosed in 102 cases (3.4% of all travelers; 12.0% of travelers with febrile episodes). Occurring at a rate of 6 to 16 cases per year, it was predominantly imported from Africa (92.2%), particularly from Equatorial Guinea (38.2%) and Nigeria (15.7%). The most frequent reason for travel was work/business. Patients were predominantly (87.3%) male, and the majority (66.7%) was between 40 and 59 years of age. A total of 15 (14.7%) patients took some form of anti-malarial chemoprophylaxis. The dominant causative species was Plasmodium falciparum (78), alone (70) or in mixed infection with P. vivax (5) and P. malariae (3). P. vivax, P. ovale and P. malariae as single agents were each identified in 11, 1 and 1 cases, respectively. Of the 11 cases in which the parasite was not detected, six appeared to be true submicroscopic cases. The clinical course of the disease was severe in 13 patients, all with falciparum malaria, of which three (2.9%) died. Rather than for all travelers, in Serbia screening for malaria should be mandatory in all travelers to endemic regions who present with fever irrespective of chemoprophylaxis history. Inadequate sensitivity of conventional diagnostic methods, illustrated by the cases of submicroscopic malaria, requires introduction of molecular diagnosis in routine practice.

Acinetobacter spp. colonization and infection risk factors in surgical patients.

INTRODUCTION: The results of numerous studies carried out over the last two decades have increasingly important cause of intrahospital infections (IHI). The aim of the study was to determine potential differences in distribution of individual risk factors between the group of patients in whom multiresistant Acinetobacter spp. was isolated and the group of patients in whom it was not. MATERIAL AND METHODS: A prospective cohort study of 64 patients hospitalized with recorded IHI at the University Hospital for Digestive Surgery, Clinical Center of Serbia in the period between January and July 2011. The subjects were divided into two groups: patients with IHI in whom multiresistant Acinetobacter spp. was isolated from the biological material samples, and those with IHI without the presence of Acinetobacter spp. RESULTS: Univariate data analysis indicated presence of statistically significant difference in distribution of certain types of surgeries (esophageal, pancreatic and hepatobiliary) among the two groups of subjects, distribution of CVC placement, application of mechanical ventilation and nasogastric tube placement, length of stay in ICU, lethal outcomes and administration of third generation cephalosporins. The results of multivariate analysis indicated that length of hospitalization in ICU (> 7 days), CVC, mechanical ventilation, esophageal, pancreatic and hepatobiliary surgeries as well as administration of third generation cephalosporins are independent risk factors for colonization and infection of patients with Acinetobacter spp. CONCLUSION: Colonized or infected patients with Acinetobacter spp. play a major role in contamination of hands of the medical staff in the course of care and treatment, while inadequate hand hygiene of the staff leads to cross transmission of the causative organism to infection-free patients. Selective antibiotic pressure, particularly administration of quinolones and broad-spectrum cephalosporins, favor onset of multiresistant species of Acinetobacter spp., and therefore appropriate prophylaxis and treatment represent basic preventive measures against the onset and spreading of the causative organisms.

Prolonged infections associated with antineutrophil cytoplasmic antibodies specific to proteinase 3 and myeloperoxidase: diagnostic and therapeutic challenge.

Chronic infections may mimic antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). We investigated which markers may help in the diagnosis and the prognosis of infections associated with proteinase 3 (PR3) and myeloperoxidase (MPO)-ANCA. In this study (1993-2008)--with an average follow-up of 5.1 years--we compared 66 AAV patients with 17 PR3 and/or MPO-ANCA-positive patients with protracted bacterial (11/17) or viral (6/17) infections. Seven of 17 patients had subacute bacterial endocarditis (SBE), while six of 17 patients had various autoimmune manifestations of chronic hepatitis C virus (HCV) infection. We determined ANCA, antinuclear antibodies, anti-PR3, anti-MPO, anticardiolipin (aCL), antibeta 2 glycoprotein I (beta2-GP I), cryoglobulins, C3, and C4. Patients with infections were younger than AAV patients (p < 0.01). There was no difference in frequency of renal and skin lesions. AAV patients more frequently had pulmonary and nervous system manifestations (p < 0.01). Patients with infections more frequently had dual ANCA (high PR3, low MPO), aCL, anti-beta2-GP I, cryoglobulins, and hypocomplementemia (p < 0.001). Immunosuppressive therapy (IST) was used in five 17 patients who had persistently high ANCA, cryoglobulinemia, and hypocomplementemia. There was no difference in frequency of lethality and renal failure in the two study groups. In patients who are PR3- and/or MPO-ANCA positive, SBE and HCV infection should be excluded. Although similar in renal and skin manifestations in comparison to AAV, only patients with infections developed multiple serological abnormalities. In patients with infections, concomitant presence of ANCA, cryoglobulins, and hypocomplementemia was associated with severe glomerulonephritis. The serological profile should be repeated after specific antimicrobial or surgical therapy, since some cases might require IST.

[Are new recommendations on the prevention of infective endocarditis applicable in our environment?].

INTRODUCTION: Over half a century ago the process of prevention of infective endocarditis in patients with predisposed cardiac diseases was started. The application of prevention has been based on the fact that infective endocarditis is preceded by bacteraemia, which can be caused by some invasive diagnostic and therapeutic procedures, and whose development can be prevented by applying antibiotics before an intervention. According to the latest guidelines of the European Society of Cardiology published this year, prevention is recommended only in high risk patients with previous infective endocarditis, prosthetic valves, cyanotic congenital heart diseases without surgical repair or with residual defects, palliative shunts or conduits, congenital heart diseases with complete repair with prosthetic material up to six months after the procedure (surgery or percutaneous intervention), and when the residual defect persists at the site of implantation of a prosthetic material. In addition, antibiotic prophylaxis is limited to dental procedures with the manipulation of gingival or periapical region of the teeth or perforation of the oral mucosa. OBJECTIVE: The aim of this testing was to confirm whether these novelties in recommendations were applicable in our environment. METHODS: Fifty-seven patients (44 men and 13 women) with infective endocarditis were included in the testing. Infective endocarditis was diagnosed in 68% of patients based on two major criteria and in 32% based on one major and three minor criteria. RESULTS: In 54.4% of patients the entry site of infection could be determined. Twenty-one percent of patients developed infection after a dental intervention, 17.5% of patients the infection occurred after a skin/soft tissue lesion, whereas urinary infection preceded infective endocarditis in 14% of patients and bowel diverticulosis was a possible cause in of 1.75% of patients. In all cases with infective endocarditis preceded by the dental intervention, antibiotic prophylaxis was not applied due to absent data of heart disease or negligence. CONCLUSION: In our country a high incidence of infective endocarditis following dental procedures has been observed. One of possible reasons is poor oral hygiene. Its improvement and a regular dental control, as well as the individual risk assessment of intervention and conditions under which the intervention is performed could determine risk reduction for the development of infective endocarditis.

[Antimicrobial treatment of polymicrobial infections].

INTRODUCTION: Polymicrobial infections are concomitant or successive infections caused by two or more microorganisms at the same site. The most common types of these infections include orofacial, gastro-intestinal, pelvic (PID) infections, solid organ abscesses (brain, liver, lungs), chronic infections (sinusitis, mastoiditis), skin and soft tissue infections ("diabetic foot", cellulitis, necrotic fasciitis), sepsis. CHOICE OF THERAPY: The most important clues in the therapeutic choice include isolation of the causative agents and empirical data concerning the most common microorganisms of'the affected region. The sensitivity of the most common anaerobic pathogen in polymicrobial infections--B.fragillis, is closely monitored, and according to the latest data it is maintained as such to metronidazole, carbapenems. aminopenicillins with beta-lactamase inhibitors and tigecycline, fluoroquinolones. CONCLUSION: However it must be emphasized that antimicrobial therapy represents only one aspect of the treatment in this type of infections, and can not replace a more adequate multi-disciplinary approach, which often includes surgical treatment.

Systemic manifestations in the course of meningococcal disease.

BACKGROUND/AIM: Meningococcal disease most often manifests itself as meningitis or sepsis. During the course of these diseases, other clinical events sometimes develop such as pneumonia, pericarditis, arthritis, and they are referred to as extrameningeal or systemic manifestations of the meningococcal disease. The aim of this study was to investigate the type and the incidence of particular extrameningeal/systemic manifestations among patients with meningococcal meningitis and sepsis, including time of their onset and the influence on the disease outcome. METHODS: The retrospective study of the medical records of 246 patients treated for meningococcal disease over the 25-year period in the Institute for Infectious and Tropical Diseases, Belgrade was conducted. The patients, aged 3 months to 82 years both sexes, were divided into two groups. RESULTS: Out of 246 patients extrameningeal/systemic manifestations were found in 42 (17.1%) patients: 35 (14.2%) occurred during meningitis, and seven (2.8%) during sepsis. Pulmonary manifestations (mostly pneumonia) were the most prevalent, found in 12 (4.9%) patients, followed by heart involvement in nine (3.6%) patients (mostly pericarditis, in seven or 2.8% patients). Various ophthalmic manifestations occurred in seven (2.8%), arthritis in 4 (1.6%) and sinusitis in six (2.4%) patients. Otitis, multiple renal embolisms with hematuria, osteomyelitis and thrombophlebitis were evidenced in one patient, each. Most of the systemic manifestations (30 patients or 71.4%), developed within the initial three days of the disease (p < 0.01), suggesting direct pathogenic mechanism induced by meningococci per se, while only three (7.1%) developed after seven days, when immune-mediated disease was more likely. Even though these manifestations complicate and prolong treatment of the meningococcal disease, they had no major influence on the disease outcome. Lethal outcome occurred in 2 (4.76%) patients, both with the meningococcal type of the disease. CONCLUSION: Extrameningeal or systemic manifestations are uncommon complications during the course of both meningococcal meningitis and sepsis. The onset of pneumonia, pericarditis, eye involvement, and arthritis, within the initial seven days of the disease, were most prevalent in the course of meningitis. They had no major influence on the disease outcome.

Size of the protein-coding genome and rate of molecular evolution.

In diploid populations of size N, there will be 2 Nmu mutations per nucleotide (nt) site (or per locus) per generation (mu stands for mutation rate). If either the population or the coding genome double in size, one expects 4 Nmu mutations. What is important is not the population size per se but the number of genes (coding sites), the two being often interconverted. Here we compared the total physical length of protein-coding genomes (n) with the corresponding absolute rates of synonymous substitution (K(S)), an empirical neutral reference. In the classical occupancy problem and in the coupons collector (CC) problem, n was expressed as the mean rate of change (K(CC)). Despite inherently very low power of the approaches involving averaging of rates, the mode of molecular evolution of the total size phenotype of the coding genome could be evidenced through differences between the genomic estimates of K(CC) [K(CC)=1/(ln n + 0.57721) n] and rate of molecular evolution, K(S). We found that (1) the estimates of n and K(S) are reciprocally correlated across taxa (r=0.812; p<< 0.001); (2) the gamete-cell division hypothesis (Chang et al. Proc Natl Acad Sci USA 91:827-831, 1994) can be confirmed independently in terms of K(CC)/K(S) ratios; (3) the time scale of molecular evolution changes with change in mutation rate, as previously shown by Takahata (Proc Natl Acad Sci USA 87:2419-2423, 1990), Takahata et al. (Genetics 130:925-938, 1992), and Vekemans and Slatkin (Genetics 137:1157-1165, 1994); (4) the generation time and population size (Lynch and Conery, Science 302:1401-1404, 2003) effects left their "signatures" at the level of the size phenotype of the protein-coding genome.