Antimicrobial combination treatment including ciprofloxacin decreased the mortality rate of Pseudomonas aeruginosa bacteraemia: a retrospective cohort study.

Ineffective antimicrobial therapy of Pseudomonas aeruginosa bacteraemia increases mortality. Recent studies have proposed the use of antimicrobial combination therapy composed of a beta-lactam with either ciprofloxacin or tobramycin. To determine if combination therapy correlates to lower mortality and is superior compared to monotherapy, we investigated the effect of antimicrobial treatment regimens on 30-day mortality in a cohort with Pseudomonas aeruginosa bacteraemia. All cases of P. aeruginosa bacteraemia (n = 292) in southwest Skåne County, Sweden (years 2005-2010, adult population 361,112) and the whole county (2011-2012, 966,130) were identified. Available medical and microbiological records for persons aged 18 years or more were reviewed (n = 235). Antimicrobial therapy was defined as empiric at admission or definitive after culture results and was correlated to 30-day mortality in a multivariate regression model. The incidence and mortality rates were 8.0 per 100,000 adults and 22.9% (67/292), respectively. As expected, multiple comorbidities and high age were associated with mortality. Adequate empiric or definitive antipseudomonal treatment was associated with lower mortality than other antimicrobial alternatives (empiric p = 0.02, adj. p = 0.03; definitive p < 0.001, adj. p = 0.007). No difference in mortality was seen between empiric antipseudomonal monotherapy or empiric combination therapy. However, definitive combination therapy including ciprofloxacin correlated to lower mortality than monotherapy (p = 0.006, adj. p = 0.003), whereas combinations including tobramycin did not. Our results underline the importance of adequate antipseudomonal treatment. These data also suggest that P. aeruginosa bacteraemia should be treated with an antimicrobial combination including ciprofloxacin when susceptible.

Decreased prevalence of Moraxella catarrhalis in addition to Streptococcus pneumoniae in children with upper respiratory tract infection after introduction of conjugated pneumococcal vaccine: a retrospective cohort study.

OBJECTIVES: To study effects of the introduction of pneumococcal conjugate vaccines (PCV) on the interspecies dynamics of Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis in preschool children with respiratory tract infection. METHODS: Nasopharyngeal samples from children aged ≤6 years with upper respiratory tract infection (n = 14 473) in South Sweden were analysed during 14 consecutive years, 5 years before and 9 years after PCV introduction. The yearly prevalence was calculated, and multivariate count regressions between prevalence and estimated yearly proportions of vaccinated children were performed. Associations between pneumococcal serotypes and the other pathogens were assessed. RESULTS: When comparing the prevaccine period with the years after introduction, the prevalence of S. pneumoniae decreased by 65.2% (16.4 to 5.7 per 1000 individuals; p < 0.001), whereas M. catarrhalis and H. influenzae decreased by 52.1% (21.5 to 10.3 per 1000 individuals; p < 0.001) and 46.6% (13.6 to 7.3 per 1000 individuals; p < 0.001), respectively. In multivariate negative binomial regressions adjusted for yearly numbers of samples taken, S. pneumoniae and M. catarrhalis were significantly negatively associated with increasing vaccine coverage proportions (adjusted prevalence ratio (aPR) = 0.17; p < 0.001 and aPR = 0.48; p < 0.001, respectively), whereas H. influenzae (aPR = 0.75; p = 0.17) was not. In addition, the proportion of cultures positive for S. pneumoniae as well as M. catarrhalis was significantly lower in the postvaccine period compared to the prevaccine period, while this was not the case for H. influenzae. A significant positive association between certain PCV serotypes and simultaneous growth with M. catarrhalis was observed. CONCLUSIONS: After introduction of PCV, the prevalence of M. catarrhalis in addition to S. pneumoniae in children with respiratory tract infection decreased; this was also the case after adjusting for reduced numbers of samples taken. This may partly be attributed to a positive association between PCV serotypes and M. catarrhalis.

Evidence that ecdysteroids and methyl farnesoate control allometric growth and differentiation in a crustacean.

Allometric, or disproportionate, growth of body parts is a basic problem in morphogenesis. Male spider crabs, Libinia emarginata, have several forms or morphotypes. During the terminal molt, the propodus enlarges disproportionately, exceeding the carapace length by as much as 35%. Even though shorter clawed males are reproductive, the large-clawed males become primary reproductives. We stimulated penultimate stage males to molt by eyestalk ablation, which removes molt inhibiting hormone (MIH) and mandibular organ inhibiting hormone (MIOH), and measured ecdysones by radioimmunoassay and methyl farnesoate (MF) in hemolymph by high-performance liquid chromatography (HPLC) using an internal standard. Eyestalk ablation accelerated molting and increased ecdysteroids to peak at 150 ng/ml before the molt. In control animals the ecdysteroids peaked at 90 ng/ml 3 days before the molt, with MF remaining less than 0.5 ng/ml. These became large males with large allometric claws. In contrast, the ablated ones, with increased MF (1 to 1.5 ng/ml), increased carapace size, but retained shorter non-allometric claws, with length shorter than the carapace. The results are consistent with experiments that we have performed with MF administration (Abdu et al., Biol. Bull., Woods Hole, MA 195 (1998) 112; Laufer et al., Gen. Comp. Endocrinol. 111 (1998) 113; Laufer et al., in: IV Symp. Aquaculture in Central America: Focusing on Shrimp and Tilapia, (1997a), p. 161; Laufer et al., Invert. Reprod. Dev. 31 (1997b) 63) which led to the interpretation that ecdysteroids and low MF concentrations promote allometric growth, while ecdysones with relatively higher concentrations of MF inhibited allometric growth. These results indicate and support the conclusion that MF and ecdysteroids determine the control of morphogenesis in allometric growth of Crustacea.

Intraoperative determination of the extent of corpus callosotomy for epilepsy: two simple techniques.

There is increasing interest in staged corpus callosotomy for intractable generalized epilepsy. At the first procedure, a portion (usually the anterior two-thirds) of the corpus callosum is sectioned. If seizures persist, completion of callosotomy or alternative treatment approaches can be considered. It is obviously important to ascertain that the desired extent of callosotomy was in fact accomplished at the time of initial operation. Our experience and the published literature indicate that the surgeon's impression at operation can be erroneous. We describe a technique of determining extent of corpus callosotomy during the procedure. The magnetic resonance imaging (MRI) scan in the midsagittal plane is used to select the desired extent of callosotomy. That point on the corpus callosum is characterized using simple planar geometry in relation to three anatomic landmarks in that same plane: the glabella, the inion, and the bregma (midline intersection of the coronal suture). The same point along the corpus callosum can then be located on a lateral skull x-ray using these same three anatomic landmarks. At surgery, an intraoperative lateral skull x-ray is obtained with a marking clip, thereby verifying the actual extent of callosotomy. We have verified the reliability of this scheme in 5 callosotomy procedures and have used this technique for intraoperative localization of midline and parasagittal targets in another 7 cases (3 tumors, 2 aneurysms, and 2 placements of interhemispheric subdural grids). In addition, we reviewed corpus callosum topography on 25 randomly selected MRI scans.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course.

The natural history of cranial dural arteriovenous malformations (AVM's) is highly variable. The authors present their clinical experience with 17 dural AVM's in adults, including 10 cases with an aggressive neurological course (strictly defined as hemorrhage or progressive focal neurological deficit other than ophthalmoplegia). Two of these 10 patients died prior to surgical intervention and a third was severely disabled by intracerebral hemorrhage. Six patients underwent surgical resection of their dural AVM, with preparatory embolization in two cases. One patient received embolization and radiation therapy without surgery. Six of the seven cases without an aggressive neurological course were treated conservatively, and the seventh patient underwent embolization of a cavernous sinus dural AVM because of worsening ophthalmoplegia. In order to clarify features associated with aggressive behavior, a comprehensive meta-analysis was performed on 360 additional dural AVM's reported in the literature with sufficiently detailed clinical and angiographic information. The location and angiographic features of 100 aggressive cases were compared to those of 277 benign cases. No location of dural AVM's was immune from aggressive neurological behavior; however, an aggressive neurological course was least often associated with cases involving the transverse-sigmoid sinuses and cavernous sinus and most often associated with cases at the tentorial incisura. Contralateral contribution to arterial supply and rate of shunting (high vs. low flow) did not correlate with aggressive neurological behavior as defined. Leptomeningeal venous drainage, variceal or aneurysmal venous dilations, and galenic drainage correlated significantly (p less than 0.05) with aggressive neurological presentation. The latter three angiographic features often coexisted in the same dural AVM. It is concluded that these features significantly increase the natural risk of dural AVM's, and warrant a more vigilant therapeutic strategy.

Cost of mastitis and its prevention in four dairy cattle herds on St Croix, US Virgin Islands.

Nonclinical mastitis in the dairy herds on St Croix, US Virgin Islands, represents a prevalent (97%) and severe problem (44% of quarters had California Mastitis Test results of 2 or 3). Streptococcus agalactiae (26%) and Staphylococcus aureus (22%) were the most prevalent pathogens. More than half (54%) of all organisms isolated and tested for resistance were resistant to ampicillin and benzyl penicillin; 29% were resistant to trimethoprim/sulfadiazine. Estimates of the loss of milk production suggested that there was a loss of 4.40 to 13.33 lb/cow/day. The yearly economic cost of prevention was estimated for each cow ($22.07); yearly income loss attributable to mastitis was estimated to be from $339 to $1,022/cow/yr. Suggestions for the prevention and control of mastitis are included.

Invasive disease caused by Haemophilus influenzae in Sweden 1997-2009; evidence of increasing incidence and clinical burden of non-type b strains.

Introduction of a conjugated vaccine against encapsulated Haemophilus influenzae type b (Hib) has led to a dramatic reduction of invasive Hib disease. However, an increasing incidence of invasive disease by H. influenzae non-type b has recently been reported. Non-type b strains have been suggested to be opportunists in an invasive context, but information on clinical consequences and related medical conditions is scarce. In this retrospective study, all H. influenzae isolates (n = 410) from blood and cerebrospinal fluid in three metropolitan Swedish regions between 1997 and 2009 from a population of approximately 3 million individuals were identified. All available isolates were serotyped by PCR (n = 250). We observed a statistically significant increase in the incidence of invasive H. influenzae disease, ascribed to non-typeable H. influenzae (NTHi) and encapsulated strains type f (Hif) in mainly individuals >60 years of age. The medical reports from a subset of 136 cases of invasive Haemophilus disease revealed that 48% of invasive NTHi cases and 59% of invasive Hif cases, respectively, met the criteria of severe sepsis or septic shock according to the ACCP/SCCM classification of sepsis grading. One-fifth of invasive NTHi cases and more than one-third of invasive Hif cases were admitted to intensive care units. Only 37% of patients with invasive non-type b disease had evidence of immunocompromise, of which conditions related to impaired humoral immunity was the most common. The clinical burden of invasive non-type b H. influenzae disease, measured as days of hospitalization/100 000 individuals at risk and year, increased significantly throughout the study period.

High speed tuning mechanism for CO2 lidar systems.

A method for rapidly tuning lasers is presented. The system utilizes a rotating eight-sided mirror and a fixed grating. It is demonstrated that the entire CO2 lasing spectrum can be tuned at effective rates of up to 400 Hz. It is shown that, although the pulse energy is diminished as the tuning rate is increased, the loss comes from the tail of the pulse, and the peak power is almost unchanged. In addition, the tuning method preserves the spatial beam profile while contributing a minimum of beam steering.

The effect of juvenile hormone III, methyl farnesoate, and methoprene on Na/K-ATPase activity in larvae of the brine shrimp, Artemia.

1. Ion transport enzyme (Na/K-ATPase) activity in stage III larvae of the brine shrimp, Artemia, remains elevated throughout the stadium when populations are exposed to methoprene in artificial seawater. 2. Infusion of methoprene, juvenile hormone, or methyl farnesoate causes increased Na/K-ATPase activity in homogenates of mid-stadium larvae that would otherwise exhibit low activity. 3. The sensitivity of the enzyme system to extremely low concentrations of the juvenoids suggests that this may be a common mode of action of these compounds. Additionally it suggests that the enzyme may be under the influence of a similar compound present in the larvae.

Methyl farnesoate levels in male spider crabs exhibiting active reproductive behavior.

The concentration of methyl farnesoate (MF) in the hemolymph and its synthesis by the mandibular organs (MOs) were investigated to determine whether this compound is related to the differences in the size of the reproductive system and the mating behavior among male morphotypes of the spider crab, Libinia emarginata. Large-claw abraded males displayed mating behavior under competitive conditions. They have the largest reproductive systems, their MOs synthesize large amounts of MF in vitro, and the concentration of MF in their hemolymph is high. Small-claw abraded males displayed mating behavior with receptive females only when isolated. These smaller crabs have intermediate-sized reproductive systems, their MOs synthesize the most MF, and they have the highest circulating level of MF relative to their body size. The unabraded males did not display mating behavior; their reproductive systems are smaller; their MO activity is low, as is their circulating level of MF. The strong relationship between MF levels and the intensity of reproductive behavior suggests that MF may be one of the driving forces behind mating behavior in Crustacea.

Stimulation of ovarian maturation in the crayfish Procambarus clarkii by methyl farnesoate.

Stimulation of ovarian maturation in the red swamp crayfish Procambarus clarkii was accomplished in three different trials by administration of methylfarnesoate (MF). After 30 days of treatment, the ovaries of prereproductive females were 2- to 10-fold larger and in later stages of vitellogenesis than those of the controls. Similar and statistically significant results were observed in a second 30-day trial, which was begun during the middle of the vitellogenic cycle. In this experiment the ovaries of the controls and the treated groups were in late vitellogenesis, and the oocyte diameters of both groups were similar, suggesting that MF stimulated more oocytes to mature. In a third experiment of 60 days duration, the ovary was again enlarged in the treated animals. In addition, MF levels in the hemolymph of treated females undergoing vitellogenesis were found to be twice as great as those of the controls. We conclude that exogenous MF can stimulate and enhance ovarian maturation. These experiments strongly support the concept that MF acts as a gondatropin in crustaceans.

Intractable epilepsy and structural lesions of the brain: mapping, resection strategies, and seizure outcome.

Forty-seven patients with structural brain lesions on neuroimaging studies and partial epilepsy intractable to medical therapy were studied. Prolonged noninvasive interictal and ictal EEG recording was performed, followed by more focused mapping using chronically implanted subdural electrode plates. Surgical procedures included lesion biopsy, maximal lesion excision, and/or resection of zones of epileptogenesis depending on accessibility and involvement of speech or other functional areas. The epileptogenic zone involved exclusively the region adjacent to the structural lesion in 11 patients. It extended beyond the lesion in 18 patients. Eighteen other patients had remote noncontiguous zones of epileptogenesis. Postoperative control of epilepsy was accomplished in 17 of 18 patients (94%) with complete lesion excision regardless of extent of seizure focus excision. Postoperative control of epilepsy was accomplished in 5 of 6 patients (83%) with incomplete lesion excision but complete seizure focus excision and in 12 of 23 patients (52%) with incomplete lesion excision and incomplete focus excision. The extent of lesion resection was strongly associated with surgical outcome either in itself (p less than 0.003), or in combination with focus excision. Focus resection was marginally associated with surgical outcome as a dichotomous variable (p = 0.048) and showed a trend toward significance (p = 0.07) only as a three-level outcome variable. We conclude that structural lesions are associated with zones of epileptogenesis in neighboring and remote areas of the brain. Maximum resection of the lesion offers the best chance at controlling intractable epilepsy; however, seizure control is achieved in many patients by carefully planned subtotal resection of lesions or foci.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracarotid amobarbital procedure: I. Prediction of decreased modality-specific memory scores after temporal lobectomy.

To assess predictive value of the intracarotid amobarbital procedure (IAP) for decreased postoperative modality-specific memory, we studied 37 temporal lobectomy patients with intractable partial epilepsy who were selected for operation independent of preoperative IAP findings. When ipsilateral IAP failure was defined by an absolute method as a retention score less than 67%, the results were not associated with decreased modality-specific memory after operation. When ipsilateral IAP failure was defined by a comparative method as a retention score at least 20% lower after ipsilateral than contralateral injection, the results showed greater differences between groups, but differences still did not achieve statistical significance. Four left-resection patients who failed the ipsilateral IAP had a median postoperative change in the Wechsler Memory Scale-Revised (WMS-R) Verbal Memory Index score of -14%, whereas 16 left-resection patients who passed the ipsilateral IAP had a mean postoperative change in the WMS-R Verbal Memory Index score of -7.5% (p = 0.12). These results suggested that the IAP interpreted comparatively may be a helpful adjunctive test in assessment of relative risk for modality-specific memory dysfunction after temporal lobectomy, but larger series of operated patients are needed to confirm this possibility. In this series, complete amnesia was not noted after ipsilateral injection, even in patients with postoperative modality-specific memory decline.

Extent of resection in temporal lobectomy for epilepsy. I. Interobserver analysis and correlation with seizure outcome.

The extent of resection was assessed in 45 temporal lobectomies for medically intractable epilepsy with mapped temporal lobe foci. Postoperative magnetic resonance imaging (MRI) in the coronal plane was used to quantify the extent of resection of superior lateral, inferior lateral, basal, and medial structures, including the amygdalohippocampal complex. A new 20-compartment model of the temporal lobe was used for this assessment. Blinded interobserver variability was minimal. Intraoperative measurements and maps routinely overestimated the actual extent of resection, especially of medial structures. One year after surgery, 70% of patients remained seizure-free (except for auras). Seizure-free outcome was accomplished despite varying degrees of resection, but was more likely achieved with more extensive resections in all compartments. Among patients with mesiobasal foci, seizure-free outcome correlated significantly with extent of resection of amygdalohippocampal complex. We conclude that assessment of extent of resection by postoperative MRI provides an objective basis of evaluating outcome after temporal lobectomy. It allows a rational approach to understanding of operative failures and is potentially useful in comparing efficacy of various surgical approaches.