Acute Sternoclavicular Joint Sepsis With Medial Clavicle Osteomyelitis (Staphylococcus aureus) and Cervical-Thoracic Epidural Phlegmon in an Adult Female With No Apparent Risk Factors.

This is a case of a 71-year-old female with a history of only one known medical problem (hypertension) who presented with a right sternoclavicular joint (SCJ) infection in addition to (1) a contiguous lower cervical and upper thoracic epidural phlegmon and (2) cellulitis and a phlegmon in her posterior neck, which was subcutaneous and near the lower cervical and upper thoracic spinous processes. These loci of infection developed several days after she had pricked her fingers when cutting rose bushes and were initially considered to be epidural abscesses. However, after the patient was transferred to our tertiary medical center, a neurosurgeon and radiologist determined that the cervicothoracic infections were phlegmons rather than fully developed abscesses. The phlegmons were treated with only IV antibiotics. The SCJ infection was surgically debrided, and the medial clavicle was excised. Bone and fluid cultures grew methicillin-sensitive Staphylococcus aureus (S. aureus). The patient recovered uneventfully (the final follow-up was four years later). This case is uncommon because of the concurrent SCJ infection with medial clavicle osteomyelitis, cervical-thoracic epidural, and paraspinous phlegmons.

Octogenarian With Acromion Stress Fracture Nonunion With Reverse Total Shoulder Prosthesis Reconstructed With Plates and Screws: A Case Report.

An 85-year-old male underwent open reduction and internal fixation (ORIF) for a displaced acromion stress fracture that occurred two years prior. The complete fracture occurred two months after an ipsilateral reverse total shoulder arthroplasty (RTSA). Four weeks after his RTSA, the pain was felt at the posterior-superior shoulder with activities of his daily living as a rancher, reflecting non-compliant use. A stress fracture was suspected but not detected radiographically. Four weeks later, higher pain occurred after he lifted a hay bale, and a displaced basilar acromion fracture was detected. Non-operative management spanned 20 months, which he ultimately deemed unacceptable because of pain with minor activities. ORIF was then done. Approximately 10 months after the ORIF surgery, both plates sustained fatigue breakage; however, the fracture consolidated, and his pain remained low. He is the oldest patient described to ultimately have a successful acromion fracture ORIF and only the third reported acromion fracture ORIF in octogenarians following RTSA. We report the ORIF technique, its good outcome, and a literature review of elderly patients who had ORIF for this problem.

Longitudinal alterations in gamma-aminobutyric acid (GABAA) receptor availability over ∼ 1 year following traumatic brain injury.

Longitudinal alterations of gamma-aminobutyric acid (GABAA) receptor availability following traumatic brain injury have remained uncharacterized and may reflect changes in neuronal structure and function linked to cognitive recovery. We measured GABAA receptor availability using the tracer [11C]flumazenil in nine adults with traumatic brain injury (3-6 months after injury, subacute scan) and in 20 non-brain-injured individuals. A subset of subjects with traumatic brain injury (n = 7) were scanned at a second chronic time-point, 7-13 months after their first scan; controls (n = 9) were scanned for a second time, 5-11 months after the first scan. After accounting for atrophy in subjects with traumatic brain injury, we find broad decreases in GABAA receptor availability predominantly within the frontal lobes, striatum, and posterior-medial thalami; focal reductions were most pronounced in the right insula and anterior cingulate cortex (p < 0.05). Greater relative increase, compared to controls, in global GABAA receptor availability appeared between subacute and chronic scans. At chronic scan (>1 year post-injury), we find increased pallidal receptor availability compared to controls. Conversely, receptor availability remained depressed across the frontal cortices. Longitudinal improvement in executive attention correlated with increases in receptor availability across bilateral fronto-parietal cortical regions and the anterior-lateral aspects of the thalami. The specific observations of persistent bi-frontal lobe reductions and bilateral pallidal elevation are consistent with the anterior forebrain mesocircuit hypothesis for recovery of consciousness following a wide range of brain injuries; our results provide novel correlative data in support of specific cellular mechanisms underlying persistent cognitive deficits. Collectively, these measurements support the use of [11C]flumazenil to track recovery of large-scale network function following brain injuries and measure response to therapeutics.

Phages Bind to Vegetative and Spore Forms of Paenibacillus larvae and to Vegetative Brevibacillus laterosporus.

Paenibacillus larvae is the causative agent of American Foulbrood (AFB), the most destructive bacterial infection in honeybees. Even antibiotic-sensitive strains of P. larvae can produce recurrent AFB months to weeks post-antibiotic treatment due to the survival of bacterial spores. Recently, phages that infect P. larvae have been shown to effectively combat AFB in the field. Here, we present evidence that phages not only bind to vegetative P. larvae but also bind to P. larvae spores. Spore binding was observed in the results of three specific experiments: (1) bacteria counted by flow cytometry generated quantitative data of FITC-labeled phages that were bound to vegetative bacteria as well as those bound to spores, (2) electron microscopy captured images of phages bound to the surface of spores in both horizontal and vertical positions, and (3) phages incubated with P. larvae spores bound to the spores and created plaques in vegetative bacteria under conditions not conducive to spore activation, indicating that binding to spores is reversible and that the phages are still active. Identification of phages with reversible spore-binding capability for use in phage therapy may improve treatment of sporulating bacterial infections.

Genome Sequences of 12 Phages That Infect Klebsiella pneumoniae.

Klebsiella pneumoniae is a pathogen responsible for significant proportions of nosocomial and health care-associated infections and is known to acquire multiple antibiotic resistance genes. Here, we announce the full genome sequences of 12 K. pneumoniae bacteriophages from samples collected in wastewater treatment facilities across the western United States.

Genomic Analysis of 48 Paenibacillus larvae Bacteriophages.

The antibiotic-resistant bacterium Paenibacillus larvae is the causative agent of American foulbrood (AFB), currently the most destructive bacterial disease in honeybees. Phages that infect P. larvae were isolated as early as the 1950s, but it is only in recent years that P. larvae phage genomes have been sequenced and annotated. In this study we analyze the genomes of all 48 currently sequenced P. larvae phage genomes and classify them into four clusters and a singleton. The majority of P. larvae phage genomes are in the 38⁻45 kbp range and use the cohesive ends (cos) DNA-packaging strategy, while a minority have genomes in the 50⁻55 kbp range that use the direct terminal repeat (DTR) DNA-packaging strategy. The DTR phages form a distinct cluster, while the cos phages form three clusters and a singleton. Putative functions were identified for about half of all phage proteins. Structural and assembly proteins are located at the front of the genome and tend to be conserved within clusters, whereas regulatory and replication proteins are located in the middle and rear of the genome and are not conserved, even within clusters. All P. larvae phage genomes contain a conserved N-acetylmuramoyl-l-alanine amidase that serves as an endolysin.

Complete Genome Sequences of Paenibacillus larvae Phages BN12, Dragolir, Kiel007, Leyra, Likha, Pagassa, PBL1c, and Tadhana.

We present here the complete genomes of eight phages that infect Paenibacillus larvae, the causative agent of American foulbrood in honeybees. Phage PBL1c was originally isolated in 1984 from a P. larvae lysogen, while the remaining phages were isolated in 2014 from bee debris, honeycomb, and lysogens from three states in the USA.

Complete Genome Sequences of 18 Paenibacillus larvae Phages from the Western United States.

We present here the complete genomes of 18 phages that infect Paenibacillus larvae, the causative agent of American foulbrood in honeybees. The phages were isolated between 2014 and 2016 as part of an undergraduate phage discovery course at Brigham Young University. The phages were isolated primarily from bee debris and lysogens.

MRI correlates of suicide attempt history in unipolar depression.

BACKGROUND: Suicide represents a major health problem in the United States, and prediction of suicide attempts is difficult. No structural neuroimaging studies have been done to specifically examine findings in patients who have attempted suicide. The objective of this study was to compare MRI findings in unipolar patients with and without a history of a suicide attempt. METHODS: In this post hoc analysis, 20 unipolar subjects with a history of a suicide attempt were matched by age and gender to unipolar subjects without a history of an attempt. Subjects were also matched on parameters such as cardiovascular history, electroconvulsive treatment history, and history of psychosis. Subjects with a history of any neurologic condition were excluded. There were no significant differences in age of onset of depression, number of episodes of depression, and Hamilton Depression scores between the two groups. T2-weighted magnetic resonance imaging (MRI) scans were rated using the Coffey and Boyko rating scales. RESULTS: Unipolar patients with a history of a suicide attempt demonstrated significantly more subcortical gray matter hyperintensities compared with patients without such a history. CONCLUSIONS: Patients with abnormal MRI findings may be at higher risk for mood disorders and suicide attempts because of disruption of critical neuroanatomic pathways. Gray matter hyperintensities in the basal ganglia may be especially associated with risk for suicide attempts.

A comparison of outcome in adolescent- and later-onset bipolar manic-depressive illness.

The authors hypothesized that childhood-and adolescent-onset bipolar manic-depressive patients might have a more severe or a different type of affective disorder; early-onset patients were therefore compared with patients whose illness onset was after the age of 45. The results indicate that early age of onset is not a factor in the variable course and prognosis of manic-depressive illness.

Life events and the course of bipolar disorder.

The authors examined the impact of life stress on the course of bipolar disorder over a 2-year period in a group of 61 outpatients. The patients were followed prospectively with ongoing assessments of stressful life events, symptoms, levels of maintenance medication, and compliance with treatment regimens. As predicted, survival analyses indicated a significant association between life events and relapse or recurrence of the disorder. These effects could not be explained by differences in levels of medication or compliance. Further research is recommended to examine which specific subgroups of bipolar patients are most susceptible to stress.

Psychosocial aspects of mastectomy: I. the women's perspective.

The authors administered a questionnaire to 41 women who had had mastectomies to investigate aspects of the procedure itself, pre- and postmastectomy adjustment, effects on sexual relationships, and the influence of age. Although most women reported good overall adjustment, there were strong indications of psychological suffering (suicidal ideation, increased use of alcohol and tranquilizers, etc.). Psychological intervention may be called for in many cases, and age, support systems, and premorbid functioning may be indicators of the amount and type of intervention needed. Counseling is particularly important before surgery, since this was viewed as the period of maximum stress by most women. Further research with larger, more random samples and postsurgical control groups is indicated to determine more precisely the factors related to adjustment to mastectomy.

Psychosocial aspects of mastectomy: II. the man's perspective.

In order to assess factors related to men's adjustment to mastectomy and its aftermath the authors administered a questionnaire to 31 men whose wives or partners had had mastectomies. Most men reported a good overall adjustment, but a subgroup remained distressed and reported adverse effects on their relationships with wives or lovers. The data indicate that the nodal points in the process are the involvement of partners in the decision-making process, the frequency of hospital visits, resumption of the sexual relationship, and the man looking at his partner's body after surgery. These findings have implications for counseling couples who face this emotionally stressful procedure.

Clouds and silver linings: positive experiences associated with primary affective disorders.

Clinical psychiatry has focused almost entirely on the psychopathology of the affective disorders. The authors studied responses of 61 patients (35 bipolar. 26 unipolar) to questions about perceived short- and long-term benefits (increased sensitivity, sexuality, productivity, creativity, and social outgoingness) they attributed to their affective illness. Bipolar patients strongly indicated positive experiences associated with manic-depressive illness; few unipolar patients perceived their disorder in such a way. Significant sex differences emerged in the attributions made by bipolar patients.

Pilot study on patients' and spouses' attitudes toward potential genetic testing for bipolar disorder.

OBJECTIVE: The purpose of this pilot study was to gain information about attitudes of individuals with bipolar disorder and their spouses toward some of the ethical and social issues arising from rapidly advancing genetic research on bipolar disorder. METHOD: Patients with bipolar disorder and their unaffected spouses were asked to answer questionnaires assessing their knowledge and attitudes about treatment response rates for bipolar disorder, probability of inheritance, genetic testing, disclosure of genetic information, abortion, marriage, and child-bearing. RESULTS: The overwhelming majority of the patients and spouses said that they would take advantage of genetic tests for bipolar disorder if such tests were to become available. Most patients and spouses agreed that the benefits of knowing whether one carries a gene for bipolar disorder would outweigh the risks. The decisive majority of respondents also felt that they would not abort a fetus that carried a gene for bipolar disorder. Furthermore, most patients and spouses agreed that the knowledge that one of them carried a gene for bipolar disorder would not have deterred them from marriage or childbearing. CONCLUSIONS: The results of this study suggest that most individuals believe that they would benefit from the use of genetic testing for bipolar disorder if it were to become available. Follow-up studies using a broader patient sample and nonclinical control groups would be useful in further evaluating the issues addressed in this pilot study.

Comparison of chloroform-induced toxicity in the kidneys, liver, and nasal passages of male Osborne-Mendel and F-344 rats.

Chloroform given by gavage in corn oil at 180 mg/kg per day induced kidney tumors in male Osborne-Mendel rats. Chloroform-induced cytotoxicity and regenerative cell proliferation have been observed in the kidneys of male F-344 rats. In order to compare the acute sensitivity of male Osborne-Mendel with F-344 rats, animals from both strains were administered a single gavage dose of 0, 10, 34, 90, 180, or 477 mg/kg chloroform and necropsied 48 h later. Known target tissues were examined for histological changes. Regenerative cell proliferation was assessed as a labeling index (LI, percent of cells in S-phase) as determined by nuclear incorporation of bromodeoxyuridine. The epithelial cells of the proximal tubules of the kidney cortex were the primary target cells for cytotoxicity and regenerative cell proliferation. A dose-dependent increase in the LI was present in the kidney of Osborne-Mendel rats given doses of 10 mg/kg chloroform and above and in F-344 rats given 90 mg/kg and above. The maximal increase in the LI was 4.5- or 3.7-fold over control in Osborne-Mendel or F-344 given 477 mg/kg, respectively. The only increase in the hepatocyte LI was in the F-344 rats given 477 mg/kg. Edema and periosteal hypercellularity were observed in the nasal passages of both strains at doses of 90 mg/kg and above. These data indicate that Osborne-Mendel and F-344 rats are about equally susceptible to chloroform-induced nephrotoxicity. These results provide a basis for linking the extensive data base on mechanisms of action of chloroform toxicity in F-344 rats to the Osborne-Mendel rat and support the hypothesis that events secondary to chloroform-induced cytolethality and regenerative cell proliferation played a role in the induction of renal tumors in the Osborne-Mendel rat.

Chloroform-induced cytotoxicity and regenerative cell proliferation in the kidneys and liver of BDF1 mice.

In a 2-year chloroform inhalation bioassay, an increased incidence of tumors was observed in the kidneys of male BDF1 mice and the liver of female BDF1 mice exposed to the highest exposure concentration of 90 ppm. To investigate the role of cytotoxicity and regenerative cell proliferation in tumor formation, male and female BDF1 mice were exposed to chloroform vapor concentrations of 0, 0.3, 5, 30, or 90 ppm 6 h/day for 4 days. Bromodeoxyuridine (BrdU) was administered via osmotic pumps implanted 3.5 days prior to necropsy, and the labeling index (LI), or percentage of cells in S-phase, was quantified using BrdU immunohistochemistry. To assess longer-term responses, additional male mice were exposed 5 days/week for 2 weeks to 0, 30, or 90 ppm. Degenerative lesions and an increase in the LI of seven- to ten-fold over controls were observed in the kidneys of male but not female mice exposed to 30 or 90 ppm. Liver lesions and increased hepatocyte LI were observed in male mice exposed to 30 or 90 ppm and in female mice exposed to 90 ppm. In the 2-week exposure groups 40% of the 30 ppm group and 80% of the 90 ppm group died with severe kidney damage, indicating that both 30 and 90 ppm exceed a maximum tolerated dose. Thus, in the 2-year bioassay chloroform concentrations had to be stepped-up over a period of weeks in order for the male mice exposed to 30 or 90 ppm to survive. The extrapolation of tumor data from such an unusual procedure is questionable. These observations are consistent with a substantial database that indicates that tumor induction by chloroform occurs via a non-genotoxic-cytotoxic mode of action and is secondary to organ-specific toxicity. These data further support the premise that doses that do not induce regenerative cell proliferation do not present an increased risk of cancer.

Suicide and bipolar disorder.

Suicide, which is both a stereotypic yet highly individualized act, is a common endpoint for many patients with severe psychiatric illness. The mood disorders (depression and bipolar manic-depression) are by far the most common psychiatric conditions associated with suicide. At least 25% to 50% of patients with bipolar disorder also attempt suicide at least once. With the exception of lithium--which is the most demonstrably effective treatment against suicide-remarkably little is known about specific contributions of mood-altering treatments to minimizing mortality rates in persons with major mood disorders in general and bipolar depression in particular. Suicide is usually a manifestation of severe psychiatric distress that is often associated with a diagnosable and treatable form of depression or other mental illness. In a clinical setting, an assessment of suicidal risk must precede any attempt to treat psychiatric illness.

Suicide prevention in depressed women.

This paper focuses on risk factors and clinical states associated with suicide in depressed women and the necessity for thorough clinical evaluation of family and personal histories of suicidal, impulsive, and violent behaviors. Treatment issues addressed include the importance and content of detailed communication to patients and their families, medication noncompliance, the risks associated with the recovery and other high-risk periods, and problems associated with the adjunctive use of alcohol and other drugs.