[Extensor tendon injuries of the thumb]. / Strecksehnenverletzungen des Daumens.

Extensor tendon injuries of the thumb include lesions of the tendons of the extensor pollicis longus, extensor pollicis brevis and abductor pollicis longus muscles. The latter is practically only affected in open injuries. Open injuries require a tendon reconstruction by suture followed by immobilization in the distal and an adequate aftercare depending on the zone of injury. In distal injuries static splinting is applied, whereas proximal injuries from T4 on require a dynamic after-treatment. Different courses of the tendon of the extensor pollicis brevis muscle exist distal to the metacarpophalangeal joint and must be considered. The rare ruptures of the extensor hood at the metacarpophalangeal joint provoke an ulnar displacement of the extensor pollicis longus or both extensor tendons with concomitant lack of active extension in the metacarpophalangeal and interphalangeal joints. This injury is often misdiagnosed as a rupture of the ulnar collateral ligament of the metacarpophalangeal joint. It should be treated by refixation of the ruptured structures. Closed chronic ruptures of the extensor pollicis longus tendon go along with a defect that requires a tendon transfer or a tendon autograft.

[A 44 year old patient presenting with Ewing's sarcoma of the big toe]. / 44-jährige Patientin mit Ewing­Sarkom der Großzehengrundphalanx.

We present the case of a patient with osseous Ewing's sarcoma of the big toe occurring during the healing process after a fracture of the little toe, which significantly delayed diagnosis, despite striking findings on imaging. We subsequently performed further diagnostics, neoadjuvant chemotherapy, tumor resection in the form of a resection of the first ray, and adjuvant chemotherapy. This case shows that the occurrence of a secondary disease should always be considered in untypical courses of healing.

Ice sheet-free West Antarctica during peak early Oligocene glaciation.

One of Earth's most fundamental climate shifts, the greenhouse-icehouse transition 34 million years ago, initiated Antarctic ice sheet buildup, influencing global climate until today. However, the extent of the ice sheet during the Early Oligocene Glacial Maximum (~33.7 to 33.2 million years ago) that immediately followed this transition-a critical knowledge gap for assessing feedbacks between permanently glaciated areas and early Cenozoic global climate reorganization-is uncertain. In this work, we present shallow-marine drilling data constraining earliest Oligocene environmental conditions on West Antarctica's Pacific margin-a key region for understanding Antarctic ice sheet evolution. These data indicate a cool-temperate environment with mild ocean and air temperatures that prevented West Antarctic Ice Sheet formation. Climate-ice sheet modeling corroborates a highly asymmetric Antarctic ice sheet, thereby revealing its differential regional response to past and future climatic change.

Feasibility of Patient-Centric Remote Dried Blood Sampling: The Prediction, Risk, and Evaluation of Major Adverse Cardiac Events (PRE-MACE) Study.

Background: Remote patient monitoring can shift important data collection opportunities to low-cost settings. Here, we evaluate whether the quality of blood-samples taken by patients at home differs from samples taken from the same patients by clinical staff. We examine the effects of socio-demographic and patient reported outcomes (PRO) survey data on remote blood sampling compliance and quality. Methods: Samples were collected both in-clinic by study-staff and remotely by subjects at home. During cataloging the samples were graded for quality. We used chi-squared tests and logistic regressions to examine differences in quality and compliance between samples taken in-clinic versus samples taken by subjects at-home. Results: 64.6% of in-clinic samples and 69.7% of samples collected remotely at home received a Good (compared to Not Good) quality grade (chi2 = 4.91; p =.03). Regression analysis found remote samples had roughly 1.5 times higher odds of being Good quality compared to samples taken in-clinic (p <.001; 95% CI 1.18-2.03). Increased anxiety reduced odds of contributing a Good sample (p =.04; 95% CI.95-1.0). Response rates were significantly higher for in-clinic sampling (95.8% vs 89.8%; p <.001). Conclusion: Blood-samples taken by patients at home using a microsampling device yielded higher quality samples than those taken in-clinic.

Monitoring galenical process development by near infrared chemical imaging: one case study.

The objective of this study is to evaluate by NIR imaging the homogeneity of process intermediates obtained with different process parameters during the development of a new pharmaceutical solid form. The process under investigation is a solid dosage form based on extrusion. The parameters are two kinds of crystallizations, two sizes of particle of API, two screw speeds during the extrusion and two milling screens used to reduce the extrudates into a granulate form. Two kinds of intermediates are evaluated: the extrudates and the cores. Two approaches are used to analyze the data: the univariate NIR analysis which consists in wavelength selection and multivariate analysis, i.e., Classical Least Squares (CLS), which takes into account the whole spectra. The univariate method reveals good chemical homogeneity of the extrudates but differences in their physical aspect. CLS shows well-distributed excipients for all the cores; differences in the sizes of the granules have also been revealed. The univariate method can be applied on simple chemical systems such as binary mixtures. When complex samples are analyzed, multivariate analysis is the method of choice. This study demonstrates that NIR imaging can be a useful tool for the optimization of the process and for the selection of the final parameters of the process.

(1S,3S,7R)-3-methyl-alpha-himachalene from the male sandfly Lutzomyia longipalpis (Diptera: Psychodidae) induces neurophysiological responses and attracts both males and females.

Lutzomyia longipalpis adult males form leks on or near hosts and release (1S,3S,7R)-3-methyl-alpha-himachalene from their tergal glands to lure females to the same site for mating and feeding. Here we have examined whether the male-produced attractant could also serve as a male aggregation stimulus. High resolution chiral capillary gas chromatography analysis of male tergal gland extracts, synthetic (1S,3S,7R)-3-methyl-alpha-himachalene, and a synthetic mixture of all isomers of 3-methyl-alpha-himachalene, was coupled to electrophysiological recordings from ascoid sensillum receptor cells in antennae of male and female sandflies. Receptor cells of both sexes responded only to the main component of the male tergal gland extract that eluted at the same retention time as (1S,3S,7R)-3-methyl-alpha-himachalene. Furthermore, of the eight 3-methyl-alpha-himachalene isomers in the synthetic mixture only the fraction containing (1S,3S,7R)-3-methyl-alpha-himachalene, co-eluting with an isomer of (1S*,3S*,7S*)-3-methyl-alpha-himachalene, elicited an electrophysiological response from male and female ascoid sensillum receptor cells. Both males and females flew upwind in a wind tunnel towards a filter paper disk treated with either 4-6 male equivalents of the tergal gland extract, pure (1S,3S,7R)-3-methyl-alpha-himachalene or the synthetic mixture of eight isomers. This indicates that (1S,3S,7R)-3-methyl-alpha-himachalene derived from L. longipalpis males may have a dual function in causing male aggregation as well as serving as a sex pheromone for females.

Endocarditis due to streptomycin-susceptible Enterococcus faecalis with high-level gentamicin resistance.

A case of community-acquired endocarditis caused by Enterococcus (Streptococcus) faecalis with high-level resistance to gentamicin sulfate but not to streptomycin sulfate is described. Killing curves performed using achievable serum levels showed synergistic killing when streptomycin but not gentamicin, tobramycin, or amikacin was combined with penicillin G sodium or vancomycin hydrochloride. Combination therapy with vancomycin and streptomycin resulted in cure. Serum bactericidal levels indicated activity of the synergistic, as well as a nonsynergistic (vancomycin plus gentamicin), combination. Routine screening of blood isolates for high-level resistance to streptomycin and gentamicin can provide guidance for selection of therapeutic combinations in serious enterococcal infections, including endocarditis.

Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations.

Numerous previous studies of nonspecific vaginitis have yielded contradictory results regarding its cause and clinical manifestations, due to a lack of uniform case definition and laboratory methods. We studied 397 consecutive unselected female university students and applied sets of well defined criteria to distinguish nonspecific vaginitis from other forms of vaginitis and from normal findings. Using such criteria, we diagnosed nonspecific vaginitis in up to 25 percent of our study population; asymptomatic disease was recognized in more than 50 percent of those with nonspecific vaginitis. A clinical diagnosis of nonspecific vaginitis, based on simple office procedures, was correlated with both the presence and the concentration of Gardnerella vaginalis (Hemophilus vaginalis) in vaginal discharge, and with characteristic biochemical findings in vaginal discharge. Nonspecific vaginitis was also correlated with a history of sexual activity, a history of previous trichomoniasis, current use of nonbarrier contraceptive methods, and, particularly, use of an intrauterine device. G. vaginalis was isolated from 51.3 percent of the total population using a highly selective medium that detected the organism in lower concentration in vaginal discharge than did previously used media. Practical diagnostic criteria for standard clinical use are proposed. Application of such criteria should assist in clinical management of nonspecific vaginitis and in further study of the microbiologic and biochemical correlates and the pathogenesis of this mild but quite prevalent disease.

Identification of methicillin-resistant staphylococci by multiplex polymerase chain reaction assay.

A multiplex polymerase chain reaction (PCR) assay using oligonucleotide primers to detect mecA and 16S ribosomal RNA gene was developed to aid in identification of methicillin-resistant staphylococci. Validation included 99 isolates of staphylococcus grouped into one of five categories: methicillin-susceptible coagulase-negative staphylococcus (MSCNS), methicillin-resistant coagulase-negative staphylococcus (MRCNS), methicillin-susceptible Staphylococcus aureus (MSSA), high beta-lactamase producing S aureus (HiBSA), and methicillin-resistant S aureus (MRSA). mecA was detected in MRSA (21/21), and in MRCNS (20/20), but not in MSSA (0/20). mecA was occasionally detected in HiBSA (1/19) and MSCNS (3/19). This multiplex PCR assay was also used to test 30 clinical isolates of coagulase-negative staphylococci with discrepancies between results of in vitro tests for susceptibility to oxacillin and was found to be valuable when a more definitive determination of intrinsic methicillin-resistance was desired.

Treatment of intra-abdominal infections is appropriate with single-agent or combination antibiotic therapy.

In a prospective, randomized, single-blind trial, we studied 112 adults with intra-abdominal infections and compared antibiotic therapy with cefoxitin plus placebo to therapy with tobramycin plus clindamycin. Seventy-five percent of patients receiving tobramycin-clindamycin and 71% of those receiving cefoxitin-placebo had either shock, bacteremia, malnutrition, alcoholism, rapidly or ultimately fatal underlying disease, infection originating from the distal small bowel or colon, or had had failed therapy before treatment ("high-risk" group). One third of the patients in both groups grew bacteria in the initial culture resistant to the antibiotic regimen used. Ten patients receiving cefoxitin-placebo (17%) and 11 receiving tobramycin-clindamycin (21%) had recurrence of infection or died of infection (clinical failures). Nineteen failures occurred in high-risk patients (p less than 0.05) and 17 were in patients that had antibiotic-resistant bacteria in the initial culture (p less than 0.01). Adverse effects were rare and remitted after antibiotics were stopped. Our results suggest that both cefoxitin and tobramycin-clindamycin are appropriate antibiotic regimens to treat intra-abdominal infections. Clinical failure is more common in high-risk patients and when antibiotic-resistant organisms are isolated from initial cultures.

Gas-liquid chromatography for rapid diagnosis of intra-abdominal infection.

We assessed the usefulness of gas-liquid chromatography in detecting fecal anaerobes in patients with suspected intra-abdominal infection related to the lower gastrointestinal tract. Twenty-five (89%) of 28 cultures with and five (26%) of 19 cultures without anaerobic isolates were positive for succinate. Data analysis showed that Bacteroides but not Enterobacteriaceae organisms were responsible for succinate production. Volatile acids other than acetate (VAs) were present in 16 (57%) of 28 culture-positive and one (7%) of 14 culture-negative specimens. Sixteen (94%) of 17 VA-positive and seven (28%) of 25 VA-negative specimens had anaerobic isolates shown by culture. The presence of certain VAs was associated with the recovery of specific groups of anaerobic bacteria. The presence of succinate or VA in intra-abdominal fluid provides a specific, useful method for the rapid detection of fecal anaerobes in patients with intra-abdominal infections.

Vaginitis/vaginosis.

Vaginitis/vaginosis is an extremely common medical problem. Most cases are caused by yeast (predominantly Candida albicans), the protozoan Trichomonas vaginalis, or a specific mixture of bacteria (bacterial vaginosis). The prevalence of each of these varies with the patient population. The clinical signs used in differentiating among these and the associated bacterial flora are shown in Table 3. Because vaginitis/vaginosis cannot be adequately diagnosed solely on the basis of symptoms or physical examination, some laboratory methods are required. Yeast vaginitis is diagnosed by microscopic detection of budding yeast or pseudohyphae in vaginal secretions. The most sensitive method for detection of Trichomonas vaginalis is culture, but microscopic methods are more commonly used. Wet-mount examination for motile trichomonads is the least sensitive microscopic method. The sensitivity is increased when fluorescent monoclonal antibodies are used. Bacterial vaginosis may be diagnosed in the clinic by detecting three or more of the following on examination: (1) homogeneous adherent discharge, (2) vaginal fluid pH greater than 4.5, (3) amine odor, and (4) clue cells. A diagnosis may also be made by detecting the replacement of lactobacilli by a mixed presumably anaerobic flora. This is accomplished by examining a Gram stain of vaginal fluid. It is not uncommon for a woman to have more than one microbial source for her vaginal signs and symptoms. A vaginal examination should include appropriate tests for detection of all three of these agents.

Sensilla on the terminalia of Lutzomyia spp. (Diptera: Psychodidae) sand flies.

Sensilla on the male terminalia of four different species of sand flies (Diptera: Psychodidae) are described. Two species belonged to the same species complex: Lutzomyia longipalpis (Lutz & Neiva) and L. cruzi (Mangabeira). Other Brazilian species complex was represented by L. lenti (Mangabeira) and L. carmelinoi (Ryan, Fraiha, Lainson & Shaw). Approximately 5-15 sensilla were found on the initial part of the styles of all species. Structurally, the sensory organs were similar to small coeloconica sensilla. Their number varied both individually and interspecifically. These sensilla may play an important role in the copulation behavior of these species of sand flies.

The ELISA system for measuring antibody reactive to Fusobacterium nucleatum in the sera of patients with chronic periodontitis.

Humoral IgG, IgA and IgM responses to three typed oral strains of F. nucleatum were examined in patients with chronic periodontitis and in individuals with clinically healthy gingiva. Attempts were made to isolate F. nucleatum from either the pathologic gingival crevices or healthy sulci in this study. Higher levels of IgG and IgA reactive to all three strains were observed in the chronic periodontitis patients; however, there were no differences between the IgM levels in the diseased and healthy individuals. Immunodiffusion studies with rabbit antiserum and adsorption studies of the human sera demonstrated a sharing of antigenic determinants by the F. nucleatum strains. F. nucleatum strains were isolated from 14 of the 15 individuals in the study.

New developments in the etiology and pathogenesis of bacterial vaginosis.

Bacterial vaginosis is unlike the "classic" sexually transmitted diseases. Unlike cervical infection with Chlamydia or salpingitis caused by N. gonorrhoeae, no single etiologic agent has been identified, and the organisms which are associated with infection have all been found as members of endogenous vaginal flora, with the possible exception of Mobiluncus species. If, as we suspect, BV is due to interactions among various organisms found in the vagina during vaginal health, we must determine what changes in the microbial or chemical ecology determine the development of BV. If, for instance, BV is simply due to an inversion in the concentrations of various organisms such that the anaerobes which are usually present in low numbers become predominant and the lactobacilli which usually predominate become few in number, we must determine which causes what. That is, does some organism or environmental change allow the anaerobes to overgrow and thereby inhibit the lactobacilli, or does some change inhibit the lactobacilli, thereby, allowing the other flora to overgrow? Answers to questions such as these await further research.

Biological effects of lithium chloride on Herpetomonas muscarum muscarum and Blastocrithidia culicis (kinetoplastida: trypanosomatidae).

Lithium is widely used in medicine as an antidepressive drug and for myelosuppression attenuation during chemotherapy. In spite of abundant literature, questions on the biological action of lithium ions are far from being answered. We have here examined the effects of lithium (10-200 mM) on culture forms of the trypanosomatid protozoa Herpetornonas muscarum muscarum and Blastocrithidia culicis. Incubation of these parasites with LiCl inhibited cell growth in a concentration-dependent manner, but growth could be restored when the drug was removed from the medium. Furthermore, Li+ induced cell differentiation in H. m. muscarum. Light microscopy examination of cell viability, using erythrosin B staining, showed that all treated parasites remained viable with all drug concentrations used. Ultrastructural analysis by transmission electron microscopy showed that the cells presented no signs of degeneration. However, in H. m. muscarum the nuclei lost their peripheral heterochromatin and appeared filled with a homogeneous matrix, whereas in B. culicis an increased amount of lipid droplets was present in the cytoplasm. Our data show that LiCl treatment arrested the cell division process, stimulated cell differentiation, and affected the metabolism of these parasites.

Laboratory detection of high-level aminoglycoside-aminocyclitol resistance in Enterococcus spp.

Methods for detection of high-level resistance to aminoglycoside-aminocyclitol antibiotics were evaluated using 104 blood isolates of enterococci (97 Enterococcus faecalis and 7 Enterococcus faecium). Kanamycin was used to predict resistance to amikacin. Discrepancies between methods were resolved by time-kill studies. Four methods (MicroScan, macrotube, microtiter, and disk diffusion) for detecting resistance to gentamicin and streptomycin were compared, using 51 consecutive strains. There were 13 gentamicin-resistant strains, all of which were detected by macrotube, microtiter, and disk diffusion. MicroScan detected 2 (15%) of the 13. Of the 18 streptomycin-resistant strains, 17 (93%) were detected by disk diffusion, 16 (89%) by microtiter, 9 (50%) by macrotube, and 6 (33%) by MicroScan. An additional 53 consecutive strains were examined only by disk diffusion and microtiter for resistance to gentamicin, streptomycin, and kanamycin. The entire population of 104 strains contained 35 gentamicin-, 22 streptomycin-, and 54 kanamycin-resistant enterococcal isolates. All 35 gentamicin-resistant strains were detected by both methods. Of the 22 streptomycin-resistant strains, 1 was detected only by microtiter, 2 only by disk diffusion, and 19 by both methods. Of the 54 kanamycin-resistant strains, 1 was detected only by microtiter, 2 only by disk diffusion, and 51 by both methods. One additional strain which was resistant only by disk diffusion was susceptible to amikacin plus penicillin by time-kill studies. Disk diffusion is a suitable method for detection of high-level aminoglycoside-aminocyclitol resistance in E. faecalis and is well suited for sporadic testing. Additional data are necessary to determine the suitability of these tests for E. faecium.

Susceptibility of Mobiluncus species to 23 antimicrobial agents and 15 other compounds.

The susceptibility of 12 strains of Mobiluncus curtisii and 10 strains of M. mulieris to 23 antimicrobial agents and 15 other compounds was determined. All strains were susceptible to chloramphenicol, clindamycin, rifampin, tobramycin, vancomycin, virginiamycin, and all beta-lactam antibiotics tested, including imipenem. One strain of M. mulieris was resistant to erythromycin and josamycin. All were resistant to colistin, cycloserine, nalidixic acid, and neomycin. Tetracycline had variable activity. All M. curtisii strains were resistant to metronidazole and its hydroxy metabolite. Of 10 M. mulieris strains, 5 were resistant to metronidazole and 2 were resistant to its hydroxy metabolite. All 12 M. curtisii and 1 of 10 M. mulieris strains were resistant to tinidazole. M. curtisii and M. mulieris produced two mutually exclusive clusters of MICs when tested against ampicillin, cefoxitin, cephalothin, moxalactam, alizarin red, Evans blue, and sodium fluoride. Gardnerella vaginalis was more susceptible to Nile blue A than was either M. curtisii or M. mulieris. Clindamycin and imipenem may be useful agents in the therapy of metronidazole-resistant bacterial vaginosis. Metronidazole, tinidazole, and Nile blue A may be of value in the development of a selective agar for Mobiluncus species.