Clin Infect Dis, 2004 Jan 15, 38(2), 284 - 8 Epub 2003 Dec 22. Adequacy of early empiric antibiotic treatment and survival in severe sepsis: experience from the MONARCS trial; MacArthur RD et al.; As part of the Monoclonal Anti-TNF: A Randomized Controlled Sepsis (MONARCS) trial, which enrolled patients with suspected sepsis, we sought to determine whether adequate antibiotic therapy was associated with a decreased mortality rate . The study enrolled 2634 patients, 91% of whom received adequate antibiotic therapy . The mortality rate among patients given adequate antibiotic treatment was 33%, versus 43% among patients given inadequate treatment (P<.001) . We conclude that adequate antibiotic therapy results in a significant decrease in the crude mortality rate among patients suspected of sepsis. Kulak Burun Bogaz Ihtis Derg, 2003 Aug, 11(2), 56 - 9 {The adverse effect of gas formation on prognosis in a patient with deep neck infection}; Yasan H et al.; A seventy-one-year-old woman was hospitalized with a suspicion of deep neck infection and poor general health . She had been receiving treatment for hepatitis, diabetes mellitus, and cardiac failure and had a history of tooth ache and severe neck pain lasting for the past 10 days . She had been admitted to another center where she had received antibiotic treatment for five days for widespread swelling in the neck and lower extremities, fatigue, and difficulty in breathing and swallowing . Upon admission, computed tomography showed gas formation in the neck and facial regions . Prompt abscess drainage was performed and intense treatment with antibiotics was continued . Despite all efforts, the patient died on the second day of hospitalization from cardiopulmonary arrest . This case emphasizes how urgent drainage is when gas formation is detected in deep neck infections, with inevitable poor prognosis with antibiotic treatment alone. Curr Hematol Rep, 2004 Jan, 3(1), 11 - 6 Are antibiotics the treatment of choice for gastric lymphoma? Zucca E, Cavalli F. There is compelling evidence supporting the link between Helicobacter pylori infection and gastric mucosa-associated lymphoid tissue (MALT) lymphoma, and it seems undeniable that eradication of H . pylori with antibiotics can be effectively used as the sole initial treatment of localized (ie, confined to the gastric wall) gastric MALT lymphoma . This treatment is the best studied therapeutic approach, with more than 20 reported studies confirming that histologic regression of the lymphoma can be achieved in most cases . However, antibiotic treatments seem to suppress but not eradicate the neoplastic clone, and MALT lymphoma relapses have been seen years after treatment . Molecular follow-up studies revealed the persistence of the malignant clone in more than 50% of the cases in histologic remission after antibiotic therapy . The clinical significance of this finding is still unclear . Transient and self-limiting histologic and molecular relapses can also occur . Therefore, a careful long-term follow-up is mandatory for all of the patients who received antibiotic treatment. Srp Arh Celok Lek, 2003 May-Jun, 131(5-6), 249 - 53 {Agranulocytosis and acute coronary syndrome in apathetic hypothyroidism}; Ivovic M et al.; INTRODUCTION: Tissue expose to excessive levels of circulating thyroid hormones results in thyrotoxicosis . In most cases, thyrotoxicosis is due to hyperactivity of the thyroid gland . Cardiovascular and myopathic manifestations are predominant clinical features in most hyperthyroid patients, aged 60 years and older . Some of patients have apathetic hyperthyroidism which presents with weight loss, small goiter, severe depression and without clinical features of increased sympathetic activity {3, 6} . About 50% of patients with cardiovascular manifestations have no evidence of underlying heart disease . Cardiac problems resolve when euthyroid state is established {3} . Three treatment modalities are available in hyperthyroidism, namely medicament therapy, surgery and radioactive iodine . Antithyroid drug therapy complications, can be mild such as rash, which is managed without cessation of therapy by antihistamines administration . On the other hand, very serious complications such as agranulocytosis, necessitate immediate discontinuation of the medication and appropriate treatment . Although extremely rear, it is life-threatening with highly variable recovery time . CASE REPORT: A 62-year-old woman with recurrent hyperthyroidism was admitted after treatment of agranulocytosis due to antithyroid drugs in another institution with G-CSF . The patient presented with clinical features of apathetic hyperthyroidism with extremely elevated thyroid hormone levels (total and free T4) and suppressed TSH . Radioactive iodine (5 mCi) was administered after increased thyroid uptake was confirmed . Echocardiography on admission was normal . ECG revealed moderately inverted T waves in standard and V1, V2 precordial leads . Laboratory analysis revealed mild normocytic anemia with normal white blood cell count, hypokaliemia and normal concentration of creatine phosphokinase, lactic dehydrogenase and mildly elevated aspartate transminase in sera . Chest X-ray was consistent with pulmonary emphysema . Because the worsening of ECG changes she was transferred to Coronary unit . The diagnosis of non-Q myocardial infarction was confirmed and treatment with nitrates and beta-adrenergic antagonists was instituted . Four weeks later she became euthyroid and coronarography was performed . Subepicardial coronary arteries were normal (Figure 1) . She was dismissed, and still euthyroid three months later . DISCUSSION: Agranulocytosis is very rare but very serious complication of antithyroid drug therapy . It can be detected in about 0.1-1% patients during the first three months of treatment . Sudden appearance, heralded by sore throat and fever, prompt physicians to seek white blood cell and differential count {1-3} . Confirmation of diagnosis urges cessation of drug therapy and appropriate antibiotic treatment . Recently, it was reported that recombinant human granulocyte colony-stimulating factor (rhG-CSF) is to be effective in shortening the recovery time in the neutropenic patients undergoing chemotherapy and also in patients with other types of neutropenia {5} . Tamai at al . {7} confirmed positive outcome in 34 patients treated with rhG-CSF compared to corticosteroid treatment . Hematologic laboratory abnormalities disappear 7-10 days after session of therapy . Patients completely recover two to three weeks later . Fatal outcome was also described {1-5} . Thyroid hormones have profound effects on cardiovascular physiology, especially on heart rate, cardiac output and systemic vascular resistance . In patients with hyperthyroidism, cardiac output is much higher than in normal persons . This is the result of direct effect of thyroid hormones on cardiac muscle contractility, heart rate and decrease in systemic vascular resistance . Excessive thyroid hormone secretion increases cardiac Na-K-activated plasma membrane ATP-ase and sarcoplasmic reticulum Ca-activated ATP-ase with resultant in increase myocardial contractility {6, 9} . Sinus tachycardia is the most common rhythm disorder in hyperthyroidism, but paroxysmal tachycardia and atrial fibrillation are not rare . This can be explained by increased heart rate, cardiac output, blood volume, coronary artery flow and peripheral oxygen consumption in thyrotoxicosis {9} . Patients with coronary arteriosclerosis can develop angina pectoris during thyrotoxic stage, which can be explained by imbalance between cardiac demand and supply . Myocardial damage is often in thyrotoxic patients with chronic hart failure, together with myocardial infarction in patients without coronary disease {2,6} . Congestive heart failure and atrial fibrillation are relatively resistant to digitalis treatment because of high metabolic turn over of medication and excessive myocardial irritability in hyperthyroidism {6} . Cardiovascular and myopathic manifestations predominate in older hyperthyroid patients (over 60 years) and some of them can have only few symptoms of hyperthyroidism {1-3} . Thyrotoxic state characterized by fatigue, apathy, extreme weakness, low-grade fever and sometimes congestive heart failure are designated as apathetic hyperthyroidism . Such patients have small goiters, mild tachycardia and often cool and dry skin with few eye signs {6} . Patients with subclinical hyperthyroidism are at increased risk for atrial fibrillation {9} . Unstable angina and non-Q myocardial infarction (non ST elevation) are acute manifestation of coronary artery disease . The acute coronary syndrome of unstable angina, non-Q myocardial infarction and Q-wave myocardial infarction have atherosclerotic lesions of the coronary arteries as a common pathogenic substrate . Erosions or ruptures of unstable atherosclerotic plaque triggered pathophysiologic processes, resulted in thrombus formation at the site of arterial injury . This leads to abrupt reduction or cessation through the affected vessel . Clinical manifestations of unstable angina and non-Q myocardial infarction are similar and diagnosis of non-Q myocardial infarction is made on the basis of elevated serum markers indicative of cardiac necrosis, detected in peripheral circulation . Acute coronary syndrome ranging from unstable angina to myocardial infarction an non-Q myocardial infarction represents increasingly severe manifestations of the same pathophysiologic processes {10,11} . In conclusion, these 62-year-old woman presented with apathetic form of recurrent hyperthyroidism associated with two serious complications, life-threatening agranulocytosis and acute coronary syndrome. J Pediatr (Rio J), 1996 Jul-Aug, 72(4), 258 - 62 {Septic sacroiliitis: case report}; Marques Filho J; Bacterial pyogenic sacroiliitis is a relatively rare infection that may be difficult to diagnose . A delay in the diagnosis may be associated with marked toxemia and demanded surgical drainage of the septic joint . We report clinical and laboratorial findings in a 12-year-old white girl with onset low back and leg pain two weeks before admission to the hospital . Bone scintigraphy showed increased uptake in the right sacroiliac joint and radiologic changes were typical of sacroiliitis . Oxacilin-sensitive S . aureus was cultured from fluid of surgical biopsy . Antibiotic treatment leads to complete recovery after long time with low back pain . The diagnosis and treatment of this rare disease are discussed based upon our finding and the literature data. Curr Med Res Opin, 2003, 19(8), 699 - 701 Medical treatment of miscarriage in a district general hospital is safe and effective up to 12 weeks' gestation; Greenland H et al.; The findings are reported of a retrospective study of 207 women undergoing medical evacuation of the uterus for first trimester miscarriage, using mifepristone followed by a single dose of oral misoprostol . All women had the diagnosis confirmed by ultrasonography . Complete medical evacuation was achieved in 88% of cases . The success rate and incidence of complications was observed to be the same regardless of whether gestation was below or above 9 weeks . The number of cases in which antibiotic treatment for presumed pelvic infection was prescribed was 3% . The incidence of anaemia requiring blood transfusion was 3%. Clin Infect Dis, 2004 Jan 1, 38(1), 38 - 44 Epub 2003 Dec 08. The clinical management and outcome of nail salon-acquired Mycobacterium fortuitum skin infection; Winthrop KL et al.; Nontuberculous mycobacterial infections are becoming more common . Recently, Mycobacterium fortuitum and other rapidly growing mycobacteria have been found to cause severe skin and soft-tissue infections in association with nail salon whirlpool footbaths . We recently investigated a large outbreak of M . fortuitum furunculosis among women who received pedicures at a single nail salon . To better define the clinical course of such infections, we collected clinical details from physicians who were treating outbreak patients . We constructed multivariable linear models to evaluate the effect of antibiotic treatment on disease duration . Sixty-one patients were included in the investigation . The mean disease duration was 170 days (range, 41-336 days) . Forty-eight persons received antibiotic therapy for a median period of 4 months (range, 1-6 months), and 13 persons were untreated . Isolates were most susceptible to ciprofloxacin and minocycline . Early administration of therapy was associated with shorter duration of disease only in persons with multiple boils (P<.01) . One untreated, healthy patient had lymphatic disease dissemination. Rev Stomatol Chir Maxillofac, 2003 Oct, 104(5), 285 - 9 {Brain abscess and diffuse cervico-facial cellulitis: complication after mandibular third molar extraction}; Revol P et al.; The authors report a case of cervico-facial cellulitis with brain abscess after mandibular third molar removal . This is the observation of a 26 years old boy surgically treated for a cervico-facial cellulitis ten days after a third molar's removal . He was given anti-inflammatory drugs after removal for analgesia . After a phase of clinical improving, the patient developed pulmonary and brain abscess with neurological signs . He needed neurosurgery in emergency . After eight weeks of antibiotic treatment, the patient was cured with aftereffects (jaw constriction and sensory disorders of the right thigh) . Cerebro-meningeal complications of diffuse cervico-facial cellulitis are exceptional but are responsible for heavy aftereffects . This observation confirms that using anti-inflammatory drugs for analgesia is associated with a higher rate of complications after dental removal. Ann Agric Environ Med, 2003, 10(2), 137 - 41 Canine ehrlichiosis; Skotarczak B; Ehrlichia spp . are obligate intracellular bacteria with tropism for hematopoietic cells . Monocytic ehrlichioses in dogs and humans are transmitted by ticks and primarily caused by E . canis and E . chaffeensis, respectively . E . canis causes canine monocytic ehrlichioses (CME), a potentially fatal disease in dogs that requires rapid and accurate diagnosis in order to initiate appropriate therapy leading to a favorable prognosis . CME is characterized by three stages; 1) acute, 2) subclinical and 3) chronic . Dogs infected with E . canis remain infected for their entire lives, even after receiving antibiotic treatment with doxycycline . The prevalence of E . canis is dependent on the distribution of the vector, Rhipicephalus sanguineus tick, which occurs mainly in tropical and subtropical regions . The agent causing canine granulocytic ehrlichiosis (CGE) in Europe has been determined by nucleotide sequencing of the 16S rRNA gene to be similar to both Ehrlichia equi and E . phagocytophila (Anaplasma phagocytophila), and is identical to the agent of human granulocytic ehrlichiosis (HGE) . The vector of this pathogen in Europe is the common European tick, Ixodes ricinus and its reservoir - wild and domestic animals . Two distinct clinical disease syndromes, including chronic, moderate to sever anemia and polyarthritis, are associated with CGE . In areas infested with vectors of tick-borne agents known to be endemic for Lyme disease, veterinarians may suspect ehrlichiosis in dogs. Clin Rheumatol, 2003 Dec, 22(6), 443 - 6 Epub 2003 Oct 02. Spondylodiscitis as the first manifestation of Whipple's disease -a removal worker with chronic low back pain; Weber U et al.; Whipple's disease is a rare systemic infectious disease caused by the actinobacterium Tropheryma whipplei . Spondylodiscitis is an extremely rare manifestation of the infection and has previously been described in only three case reports . We present a 55-year-old man with persistent lumbago and signs of systemic illness, but without any gastrointestinal symptoms or arthralgia . The signal response in the lumbar spine in magnetic resonance tomography, both native and after intravenous gadolinium administration, was compatible with spondylodiscitis at the L4/L5 level . Culture of a specimen obtained by radiographically guided disc puncture and repeated blood cultures remained sterile . Tropheryma whipplei was detected by PCR amplification in material obtained from the disc specimen, from a biopsy of the terminal ileum and from the stool . The histology of duodenum, terminal ileum, colon and disc material was normal and, in particular, showed no PAS-positive inclusions in macrophages . Long-term antibiotic treatment with sulphamethoxazole and trimethoprim was successful, with marked improvement of the low back pain and normalisation of the systemic inflammatory signs . The possibility of Whipple's disease must be suspected in the case of a 'culture-negative' spondylodiscitis even if there are no gastrointestinal symptoms and no arthralgia present. J Pediatr Gastroenterol Nutr, 2004 Jan, 38(1), 70 - 4 Gastroesophageal reflux disease and Helicobacter pylori infection in neurologically impaired children: inter-relations and therapeutic implications; Pollet S et al.; BACKGROUND: The aim of this retrospective study was to assess the relationship between Helicobacter pylori infection and gastroesophageal reflux disease in a high-risk population of children . METHODS: Forty-three neurologically impaired pediatric patients with H . pylori had upper gastrointestinal endoscopy between 1990 and 2000 . Infection was confirmed by positive H . pylori culture or by identification of organisms in gastric biopsy specimens (fundus, n = 2; antrum, n = 3) . Reflux esophagitis was diagnosed by ulceration of the esophageal mucosa at endoscopy . Four to 6 weeks after the completion of antibiotic treatment of H . pylori, a second endoscopy was performed and the gross appearance of the esophagus was recorded . RESULTS: At the first endoscopy, esophagitis was noted in 14 of 43 patients . After treatment, H . pylori infection was eradicated in all 14 patients with esophagitis but in only 19 of 29 (66%) of those with normal esophagus (P = 0.01) . Esophagitis was still present in 4 of 14 (29%) patients who had esophagitis at the first endoscopy . Persistent esophagitis was only related to the presence of esophagitis before treatment (P = 0.02) . In 29 patients with a normal esophagus at the first endoscopy, only one case of esophagitis was observed after H . pylori eradication . CONCLUSION: The data suggest that treatment of H . pylori infection should be considered in children with concomitant GERD, and such treatment is unlikely to either induce or exacerbate peptic esophagitis. Am J Surg, 2003 Dec, 186(6), 685 - 8; discussion 688-9 Is delayed operative treatment worth the trouble with perforated appendicitis is children? Weber TR, Keller MA, Bower RJ, Spinner G, Vierling K. BACKGROUND: Approximately 30% to 50% of appendicitis in children is already perforated at presentation . The optimal management of these children remains controversial . METHODS: Ninety-six children (aged 2 to 16 years) were treated for perforated appendicitis . Seventy-one underwent immediate appendectomy and drainage of abscess, if present (group I) . In the other 25 an attempt was made to treat with intravenous antibiotics, combined with transrectal (4) or percutaneous (2) drainage of abscess . This treatment was successful in 16 patients (group II), who underwent appendectomy 6 to 8 weeks later, and unsuccessful in 9 patients (group III), who underwent appendectomy 3 to 12 days later . RESULTS: The mean length of stay was as follows: group I, 6.7 days; group II, 8.9 days; and group III, 10.9 days (not significant) . The white blood cell count (WBC) at presentation was group I, 18.6 K; group II, 17.9 K; group III, 18.8 K . The percent fall of WBC on day 4 was group I, 55%; group II, 25.5%; group III, 17% (P >0.05 versus groups I and II) . Twenty of 71 patients in group I (28%) developed wound infection (5), pelvic abscess (14), and pancreatitis (1), while 2 of 16 (12.5%) of group II and 1 of 9 (11%) of group III patients required readmission (both P <0.05 versus group I) . CONCLUSIONS: These data show that initial antibiotic treatment of perforated appendicitis in children, followed by interval appendectomy, is useful for a select group who present with little or no peritonitis, slightly elevated temperature, and WBC that falls at least 25% within 3 to 4 days. Eur J Clin Microbiol Infect Dis, 2004 Jan, 23(1), 7 - 14 Epub 2003 Dec 11. Efficacy and safety of cefotaxime in combination with metronidazole for empirical treatment of brain abscess in clinical practice: a retrospective study of 66 consecutive cases; Jansson AK et al.; Sixty-six consecutive patients with brain abscesses referred to a department of neurosurgery during a 10-year period and treated with cefotaxime were studied retrospectively by means of a prospectively designed protocol whose main areas of emphasis were duration of antibiotic treatment, sterilization rate, clinical outcome in relation to prognostic factors, and side effects . Sixty-two of these patients were treated additionally with metronidazole, and surgery was performed in 53 patients . Mental status was altered in 33 patients, 11 of whom were comatose . Rupture of the abscess into the ventricles occurred in eight patients . Death was attributable to brain abscess formation in three patients (4.5%) . Forty-six percent of the surviving patients recovered without any neurological deficits . Reversible adverse reactions, which occurred in 38 patients, were the most common reason for withdrawal of cefotaxime . In 76% of these cases, there was a significant improvement before the onset of the adverse reaction . The median duration of parenteral antibiotic treatment was 36, 41, 22, and 46 days in patients treated with excision, aspiration, evacuation of subdural empyema, and antibiotics alone, respectively . Taking prognostic factors into consideration, mortality attributable to brain abscess was lower than previously reported . This finding, along with the abscess sterilization results, indicates that cefotaxime in combination with metronidazole is a highly effective treatment but is associated with a high frequency of reversible side effects . The results indicate that a shorter duration of treatment should be investigated. Genome, 2003 Dec, 46(6), 974 - 82 Two kinds of sex ratio distorters in a moth, Ostrinia scapulalis; Kageyama D et al.; We surveyed female-biased sex ratio traits (SR traits) in a moth, Ostrinia scapulalis (Lepidoptera: Crambidae) from six geographic locations in Japan . A small proportion (8.3%) of females showed the SR trait . About half of them were associated with a Wolbachia infection (SRw+), whereas the remaining ones were not (SRw-) . No significant differences in frequencies were detected among locations and years for either SRw+ or SRw- females . In SRw+ matrilines, the SR trait was inherited . Curing the Wolbachia infection by tetracycline at the larval stages resulted in all-male broods in the next generation . These characteristics were identical to the Wolbachia-induced SR trait observed previously in the related species Ostrinia furnacalis . The Wolbachia strain in O . scapulalis was indistinguishable from that in O . furnacalis in terms of the wsp and ftsZ gene sequences, suggesting either that infection originated from a common ancestor of the two hosts or that Wolbachia was transmitted horizontally between the host species . In SRw- matrilines, on the other hand, the SR trait was not due to bacterial infection but some other maternally inherited element, since antibiotic treatment had no effect and bacterial PCR did not give the characteristic product . In these matrilines, the SR trait occasionally failed to show, suggesting the presence of nuclear factor(s) suppressing the SR trait. Theriogenology, 2004 Jan 15, 61(2-3), 337 - 49 Involvement of the plasminogen activation system in cow endometritis; Moraitis S et al.; The objectives of this study were to investigate the: (a) presence and activity of components of the "plasminogen activators/plasmin" system in dairy cows with or without endometritis; (b) variations in enzyme activity according to the degree of endometritis; and (c) associations between these enzymes and changes in endometrial histology after intrauterine antibiotic treatment . Endometrial biopsies were collected from anestrus (no palpable ovarian structures and milk progesterone <1 ng/ml) Holstein cows, 30-40 days postpartum . On the basis of a vaginoscopic examination, rectal palpation of the cervix and uterus, and endometrial histology, there were 92 cows with endometritis and 20 cows without endometritis . After biopsy collection, each cow was given an intrauterine infusion of 1.5x10(6) IU of procaine penicillin G . In cows with endometritis, genital tract examinations and biopsies were repeated 2 weeks later . Both plasminogen activators (PAs), tissue type (t-PA) and urokinase (u-PA), were immunologically identified in all uterine biopsies . Plasminogen activator activity (PAA) increased, whereas plasminogen activator inhibition (PAI) and plasmin inhibition (PI) decreased in proportion to the degree of inflammation . Two weeks after intrauterine treatment, PAA had decreased significantly in all cows that had reduced severity of endometrial inflammation and had increased significantly in all cows with increased severity of inflammation . The change in the degree of inflammation depended upon plasminogen activator activity; cows with higher PAA were more likely to improve . In conclusion, there was evidence for a role of the plasminogen activation proteolytic system in bovine endometritis. Ultraschall Med, 2003 Dec, 24(6), 393 - 8 {Sonographically guided percutaneous needle aspiration of breast abscesses - a minimal-invasive alternative to surgical incision}; Strauss A et al.; AIM: The current standard treatment of breast abscesses is surgical incision and drainage . This method, however, frequently yields poor cosmetic results . Sonographically guided percutaneous aspiration of breast abscesses and local antibiotic treatment need to be considered as an interesting alternative . The present study aimed to compare these treatment alternatives . METHOD: The patient population analysed comprised 24 patients with 28 breast abscesses who presented to the Department of Obstetrics and Gynaecology of Munich University Hospital Grosshadern between 12/1997 and 9/2002 . 25 % of these patients (6/24) suffered from a puerperal and 75 % (18/24) from a non-puerperal breast abscess . The study group of surgically treated patients comprised 15 women (16 abscesses) . Ten patients (10 abscesses) were treated with the novel, minimally invasive method . The treatment success was statistically analysed using chi (2)- and t-Tests (p < 0,05) . RESULTS: The minimally invasive approach did not extend the length of intravenous antibiotic treatment or hospital stay and did not lead to an increase in the need for analgesic drugs . We encountered recurrent abscesses in 31 % (5/16) of the surgical treatment group, yet none in the group undergoing minimally invasive treatment . The aesthetic-cosmetic as well as the functional result in lactating patients was satisfactory in all cases . CONCLUSION: Sonographically guided percutaneous aspiration of breast abscesses represents a less invasive and very promising alternative to surgical incision, showing the following advantages: no general anaesthesia required, a superior cosmetic result and shorter hospitalisation . The method was highly accepted by all patients treated. Aliment Pharmacol Ther, 2003 Dec, 18(11-12), 1113 - 20 Antibiotics and azathioprine for the treatment of perianal fistulas in Crohn's disease; Dejaco C et al.; BACKGROUND: Antibiotics and thiopurines have been employed in the management of fistulizing Crohn's disease, although evidence of their efficacy is rare . AIM: To evaluate, in a prospective, open-label study, the influence of antibiotics and azathioprine on the clinical outcome of perianal fistulas in patients with Crohn's disease . METHODS: Fifty-two patients entered the study, starting with an 8-week regimen of ciprofloxacin (500-1000 mg/day) and/or metronidazole (1000-1500 mg/day) . Seventeen patients had already received daily azathioprine (2-2.5 mg/kg) at enrollment, whereas in 14 patients azathioprine was initiated after 8 weeks of antibiotic treatment . Outcome was evaluated by Fistula Drainage Assessment and the Perianal Disease Activity Index at weeks 8 and 20 . RESULTS: Overall, 26 patients (50%) responded to antibiotic treatment, with complete healing in 25% of patients at week 8 . The Perianal Disease Activity Index decreased significantly from 8.4 +/- 2.9 to 6.0 +/- 4.0 (P < 0.0001) . At week 20, the outcome was assessed in 49 patients (94%), 29 of whom (59%) had received azathioprine . Response was noted in 17 of the 49 patients (35%), with complete healing in nine patients (18%) . Patients who received azathioprine were more likely to achieve a response (48%) than those without immunosuppression (15%) (P = 0.03) . The Perianal Disease Activity Index was closely associated with treatment response and perianal disease activity . CONCLUSION: Antibiotics are useful to induce a short-term response in perianal Crohn's disease, and may provide a bridging strategy to azathioprine, which seems to be essential for the maintenance of fistula improvement. Aliment Pharmacol Ther, 2003 Dec, 18(11-12), 1107 - 12 Antibiotic treatment of small bowel bacterial overgrowth in patients with Crohn's disease; Castiglione F et al.; BACKGROUND: Small bowel bacterial overgrowth is common in Crohn's disease but its treatment is not clearly defined . Metronidazole and ciprofloxacin are effective antibiotics in active Crohn's disease . AIM: To investigate the efficacy of metronidazole and ciprofloxacin in the treatment of bacterial overgrowth in patients with Crohn's disease . PATIENTS AND METHODS: We performed the lactulose breath test in 145 consecutive patients affected by Crohn's disease . Patients positive to the lactulose breath test underwent a glucose breath test to confirm the overgrowth . These patients were randomized in two treatment groups: metronidazole 250 mg t.d.s . (Group A) and ciprofloxacin 500 mg b.d . (Group B), both orally for 10 days . The glucose breath test was repeated at the end of treatment . The clinical outcome after therapy was also recorded . RESULTS: Bacterial overgrowth was present in 29 patients (20%) . Breath test normalization occurred in 13 out of 15 patients treated by metronidazole and in all 14 patients treated by ciprofloxacin (P = ns) . In both groups antibiotic treatment induced an improvement of intestinal symptoms: bloating (Group A 85% and Group B 83%), stool softness (44% and 50%), and abdominal pain (50% and 43%) . CONCLUSIONS: Small bowel bacterial overgrowth is a frequent condition in Crohn's disease which can be effectively treated by metronidazole or ciprofloxacin. Acta Orthop Belg, 2003 Oct, 69(5), 400 - 4 Risks and complications of prolonged parenteral antibiotic treatment in children with acute osteoarticular infections; Ceroni D et al.; This study aimed at assessing the prevalence of complications encountered during prolonged intravenous antibiotic (AB) therapy when treating acute osteoarticular (OA) infections in children . We reviewed retrospectively 60 paediatric patients treated in our department between 1988 and 1998 for acute osteoarticular infections (27 with acute haematogenous osteomyelitis, 25 with septic arthritis and 8 with septic osteoarthritis) . C-reactive protein, erythrocyte sedimentation rate (ESR), and full blood count were monitored during the entire treatment . Body temperature was recorded three times per day until the fever subsided, and then daily during the remaining hospitalisation . Finally, we listed complications related to the antibiotic therapy and those linked to the presence of a venous catheter . Seventeen allergic reactions to drugs were recorded during the intravenous AB therapy . This complications occurred on average after 24.4 +/- 4.4 days of treatment . The clinical manifestations most often encountered were a delayed rise in temperature and cutaneous symptoms . Blood tests showed an isolated increase in the ESR and eosinophilia (> 1000 eosinophils/ml) . Four venous catheters had to be removed, in two cases owing to their obstruction and in two cases owing to an infection . Prolonged intravenous AB therapy is not without complications due to its duration and its mode of administration . Drug allergies to AB constitute a major complication of the treatment . They may render the treatment of subsequent infections problematic and expose these patients to major allergic reactions if they accidentally encounter the molecule incriminated . Moreover, the anaesthetics required to insert a central venous catheter and the need to leave it in place for a prolonged duration constitute another source of potential complications . The duration of i.v . AB therapy could therefore be shortened if the clinical and biological evolution is favourable and the pathogen is identified. Int J Pediatr Otorhinolaryngol, 2003 Dec, 67(12), 1375 - 8 Thyroid abscess at an adolescent age; Astl J et al.; We report a case of thyroid abscess in a 17-year-old girl . She was presented with swelling and pain in the region of the left thyroid lobe . The diagnosis was confirmed by ultrasonography and fine needle aspiration . After incision, evacuation of the pus and antibiotic treatment manifestations of disease disappeared . Barium swallow did not prove any hypopharyngeal fistula . The girl is now without any problems for 3 years . The patient had infectious mononucleosis 2 months prior development of the thyroid abscess . We contemplate that it may had changed the immunological state that facilitated this rare inflammation. Antivir Ther, 2003 Oct, 8(5), 479 - 83 Drug-resistant HIV-1 in the semen of men receiving antiretroviral therapy with acute sexually transmitted infections; Taylor S et al.; Sexually transmitted infections may enhance the sexual transmission of HIV-1 . It is possible that loss of virological control in patients with such infections receiving antiretroviral therapy (ART) may even facilitate the transmission of drug-resistant HIV . We have recently demonstrated that in those on maximally suppressive ART this effect is reduced . We have examined the virus obtained from the blood plasma and seminal plasma of six HIV-1-infected men receiving poorly suppressive ART with acute urethritis for the presence of drug resistance-associated mutations . In four men with gonorrhoea the blood and seminal plasma HIV-1 had mutations conferring reduced susceptibility to one or more available drugs . In one of these men the viral load of drug-resistant virus in seminal plasma was 20-fold higher during gonorrhoea than following antibiotic treatment, with no change in blood plasma viral load . We conclude that in the presence of suboptimal ART, sexually transmitted infections may enhance the spread of drug-resistant HIV-1. Laryngorhinootologie, 2003 Nov, 82(11), 794 - 8 {Grisel's syndrome following ENT-surgery: report of two cases}; Hirth K et al.; BACKGROUND: Non-traumatic atlanto-axial subluxation is a rare complication of upper neck inflammatory processes and head and neck surgery . It is called Grisel's syndrome named after P . Grisel, who first described this condition in 1930 . Persistent torticollis following head and neck surgery or upper respiratory tract infections should alert the surgeon to a beginning atlanto-axial subluxation . Due to lax ligaments it especially occurs in children and patients with Down's syndrome . PATIENTS: We present two cases of Grisel's syndrome in children following head and neck surgery with prolonged history, discussing pathogenesis, diagnostic measures and therapy . RESULTS AND CONCLUSIONS: Although there are several theories concerning the actual pathogenesis, it is generally agreed that an inflammatory process is the primary cause of Grisel's syndrome . Therefore, early antibiotic treatment is recommended . Further treatment depends on clinical findings and Fielding classification of the degree of the subluxation and includes muscle relaxations, soft collar or stiff neck, cervical traction or even arthrodesis of C1 and C2 . If recognised early and appropriate treatment is applied, the prognosis is excellent . Severe cases can present with degenerative disorders of the cervical spine or even with neurological malfunction. Br J Haematol, 2003 Dec, 123(5), 810 - 8 Increased remissions from one course for intermediate-dose cytosine arabinoside and idarubicin in elderly acute myeloid leukaemia when combined with cladribine . A randomized population-based phase II study; Juliusson G et al.; Cladribine has single-drug activity in acute myeloid leukaemia (AML), and may enhance the formation of the active metabolite (ara-CTP) of cytosine arabinoside (ara-C) . To evaluate the feasibility of adding intermittent cladribine to intermediate-dose ara-C (1 g/m2/2 h) b.i.d . for 4 d with idarubicin (CCI), we performed a 2:1 randomized phase II trial in AML patients aged over 60 years . Primary endpoints were time to recovery from cytopenia and need for supportive care following the first course . Sixty-three patients (median 71 years, range 60-84 years) were included, constituting 72% of all eligible patients . Toxicity was limited, with no differences between the treatment arms . The early toxic death rate was 11% . The median time to recovery from neutropenia and thrombocytopenia was 22 and 17 d from the start of course no . 1, respectively, and the requirement for platelet and red cell transfusions was four and eight units respectively . Patients had a median of 8 d with fever over 38 degrees C, and 17 d with intravenous antibiotic treatment . The overall complete remission (CR) rate was 62%, with 51% CR from one course of CCI in comparison with 35% for the two-drug therapy (P = 0.014) . The median survival with a 2-year follow-up was 14 months, and the 2-year survival was over 30%, with no differences between the treatment arms . Considering the median age and our population-based approach, the overall results are encouraging. Surg Endosc, 2004 Jan, 18(1), 80 - 2 Epub 2003 Nov 21. Pediatric laparoscopic splenectomy: benefits of the anterior approach; de Lagausie P et al.; INTRODUCTION: Splenectomy is frequently performed in children for various hematologic and autoimmune disorders . We reviewed our indication for splenectomy, our technique of laparoscopic, splenectomy, and our results . The aim of this study was to show if an anterior approach with elective vessel endoligature in a patient in decubitus position was a better and safer approach than the other techniques previously published . PATIENTS AND METHODS: Between January 1996 and December 2002, 54 children underwent laparoscopic splenectomy . We use the anterior pedicle approach and elective vessel endoligature in order to prevent persistence of any exogenous material . Sixteen children also had a concomitant cholecystectomy . Their age ranged between 1 and 18 years (mean 7.5 years) . Twenty children had hereditary spherocytosis, 15 were affected by sickle cell disease, six had an idiopathic thrombocytopenia, four had beta-thalassemia, and nine another hemolytic disease . RESULTS: Mean operative time was 150 min (range, 115-230 min) . Hospital stays ranged from 3 to 15 days (mean: 5.4) . Seven patients had complications (four pneumonia and three deep abscess with successful antibiotic treatment) . Median follow-up was 42 months (2 months-6 years) without problems regarding procedure . DISCUSSION: With this technique consisting in first elective arterial and secondary venal ligature, we preserved blood splenic sequestration and pancreatic tail lesion . The procedure is safer . For us, considering the low complication rate for this type of patient, and the advantages of a small abdominal trauma in the postoperative period, laparoscopy with anterior approach for elective splenectomy and eventual cholecystectomy in hematologic disorders is the best technique. Curr Opin Lipidol, 2003 Dec, 14(6), 605 - 14 Antibiotic treatment of atherosclerosis; Muhlestein JB; PURPOSE OF REVIEW: Several lines of evidence have demonstrated an association between a variety of chronic bacterial infections and atherosclerotic cardiovascular disease . This has led to the proposal that antibiotic therapy might be helpful in the secondary prevention of atherosclerosis . A variety of smaller pilot studies have been reported testing this hypothesis and several large multicenter trials are also underway . The purpose of this review is to summarize the results of these studies and comment on their implications for the treatment of atherosclerosis . RECENT FINDINGS: Most of the antibiotic studies to date have been secondary prevention studies that have targeted patients exposed to Chlamydia pneumoniae . Most have used either azithromycin or roxithromycin with treatment courses ranging from a few days to 3 months . Several small studies of coronary artery disease patients have shown significant promise for reducing cardiovascular events such as death, myocardial infarction, or admission for unstable angina . However, other studies have not been so positive . Weekly Intervention with Zithromax for Atherosclerosis and its Related Disorders, WIZARD, the largest study to date, in which stable post-myocardial infarction patients were randomized to receive a 3-month course of azithromycin or placebo, demonstrated a significant reduction in death and myocardial infarction by 6 months, but this benefit was not sustained throughout the remaining course of follow-up . The Azithromycin and Coronary Events (ACES) and Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE-IT) trials are ongoing and are testing the effect of more prolonged treatment duration . SUMMARY: A variety of antibiotic trials for the secondary prevention of atherosclerosis have been performed . Several pilot studies have shown significant positive clinical effects, but, thus far, no large randomized trial has confirmed those findings . Some concerns over the antibiotics chosen and the duration of treatment have been raised . Other trials are underway to address some of those concerns . In the meantime, no recommendation for the use of antibiotic therapy for the secondary prevention of atherosclerosis can yet be made. Arch Pediatr, 2003 Nov, 10(11), 979 - 82 {Nasal angiocentric T cell-natural killer cell lymphoma with pancreatic localisation in a child}; Hamzaoui M et al.; The nasal angiocentric T-cell-natural killer cell lymphoma is an aggressive tumor, exceptional in Tunisia, which is observed especially in Asia, Mexico and South America . We report the case of an 11-year-old boy, presenting with an exuberant and ulcerative tumor of the right nasal pit . Radiological investigation evidenced a right ethmoido-frontal tumor . Evolution was characterized by the installation of abdominal pain and fever, the evidenciation of a mass within the head of the pancreas that compressed the extra hepatic biliary duct and Wirsung's canal and was associated to hyperamylasemia . Biopsy under ultrasound revealed a histiocytic nature . Nasal biopsy found histiocytic and lymphocytic cells and led to a diagnosis of rhinoscleroma . The absence of improvement under antibiotic treatment and the development of fever with leuconeutropenia oriented towards the diagnosis of a non-Hodgkinian malignant lymphoma . Medullary biopsy and immunohistochimic study confirmed a T/NK cells lymphoma, with medullary invasion . The child died from acute respiratory distress syndrome . The authors insist on the rarity of this bipolar location, in particular in children, emphasize the difficulty of the diagnosis and review the literature. Clin Orthop, 2003 Oct, (415), 279 - 85 Antibiotic microspheres: preliminary testing for potential treatment of osteomyelitis; Ambrose CG et al.; Osteomyelitis is a difficult problem for orthopaedic surgeons . The current standard of treatment requires high doses of antibiotic to be administered parenterally, which can damage vital organs . A local drug delivery system, which targets only the infected tissues, would eliminate some of the complications associated with extended courses of parenteral antibiotic treatment . In the current study, biodegradable microspheres were manufactured from a high molecular weight copolymer of 50% lactic and 50% glycolic acid and the antibiotic tobramycin . Various formulations of microspheres were tested for in vitro elution characteristics to determine the optimum formulation for linear release of antibiotic for at least 4 weeks . The optimal formulation then was implanted into a pouch created in the quadriceps muscle of mice to evaluate the in vivo elution of the antibiotic and the inflammatory response elicited by the microspheres . Results indicate that a sustained linear release of antibiotic from the microspheres is possible for a period of at least 4 weeks and that the inflammatory response was within levels required for the microspheres to be considered biocompatible. Postgrad Med J, 2003 Oct, 79(936), 597 - 9 Multiple brain abscesses in a patient with bilateral pulmonary arteriovenous malformations and immunoglobulin deficiency; Tse KC et al.; A 34 year old Chinese man presented with grand mal seizures complicating multiple brain abscesses caused by mixed oral flora . Because of persistent hypoxaemia contrast spiral thoracic computed tomography was done, which revealed bilateral pulmonary arteriovenous malformations (PAVMs) . Concomitant IgA and IgG subclass deficiency was also found . The combination of these two conditions appears to have predisposed this patient to presumably paradoxical septic embolism . The patient's cerebral condition responded to postoperative antibiotic treatment and he eventually received selective coil embolisation of right lower lobe PAVMs, which relieved his hypoxaemia and dyspnoea. Minerva Pediatr, 2003 Oct, 55(5), 407 - 14 Otitis media . A scholarly review of the evidence; Pappas DE et al.; Antibiotic therapy remains the treatment of choice for otitis media in most countries despite persuasive evidence that antibiotic therapy provides limited clinical benefit and promotes bacterial resistance . Meta-analysis of randomized, placebo-controlled trials demonstrated that antibiotics increased resolution at 1 week by only 13% . Amoxicillin remains as effective as any other antibiotic, despite increasing resistance to amoxicillin among the major bacterial pathogens . Immediate antibiotic treatment has been shown to reduce the duration of symptoms by 1 day but not until after the first 24 hours when symptoms were already improving . A delayed prescribing strategy is currently utilized in most children for management of acute otitis media in the Netherlands; this method is now being evaluated elsewhere . Antibiotic therapy is delayed for 48-72 hours after diagnosis; thereafter, antibiotics are initiated only if symptoms persist or worsen . In 2 studies utilizing this strategy (England and the United States), only 24-30% of the patients in the delayed treatment group initiated antibiotic therapy; a majority of parents of children in the delayed group were satisfied with their child's treatment . Treatment of bacterial otitis media ("pus drum") with high dose amoxicillin (80-100 mg/kg/kd) is recommmended; for acute otitis media without bulging, watchful waiting with a delayed prescribing strategy and treatment of pain is preferred . Yearly administration of the influenza vaccine and/or treatment of influenza with an antiviral (oseltamivir) can significantly decrease the incidence of acute otitis media during influenza season . Although pneumococcal vaccination effectively reduces the incidence of acute otitis media due to vaccine-related serotypes, there is a significant increase in the number of episodes of acute otitis media due to other serotypes of S . pneumoniae such that the overall incidence of acute otitis media is reduced only minimally by pneumoccocal vaccine . The careful use of strict diagnostic criteria coupled with judicious use of antibiotic therapy will direct antibiotic treatment to only those patients likely to benefit. J Clin Microbiol, 2003 Nov, 41(11), 4955 - 60 C6 test as an indicator of therapy outcome for patients with localized or disseminated lyme borreliosis; Philipp MT et al.; Management of Lyme disease would benefit from a test to assess therapy outcome . Such a test could be employed to ascertain if treatment of early Lyme disease was successful and would be helpful to clinicians assessing patients with lingering posttreatment symptoms . We reported recently that levels of the antibody to C(6), a Borrelia burgdorferi-derived peptide that is used as an antigen in the C(6)-Lyme diagnostic test, declined after successful antibiotic treatment of Lyme borreliosis patients . We assessed retrospectively the change in anti-C(6) antibody titers in 131 patients with either early localized disease (erythema migrans) or disseminated disease . All of these patients were treated with antibiotics and were free of the clinical signs shown at presentation within 12 weeks after the initiation of treatment . Decreases in reciprocal geometric mean titers (rGMT) of the anti-C(6) antibody were quantified for the subpopulation of 45 patients whose baseline rGMT were >/=80 and whose second serum specimens were obtained at least 6 months after the baseline specimen . Eighty percent of this patient group (36 of 45) experienced a >/=4-fold decrease in their rGMT (P < 0.0003) . These results suggest that a change in the anti-C(6) antibody titer may serve as an indicator of therapy outcome for patients with localized or disseminated Lyme borreliosis. MMW Fortschr Med, 2003 Sep 18, 145(38), 45 - 8 {Pain, fatigue, depression after borreliosis . Antibiotics used up--what next?}; Woessner R et al.; Antibiotic treatment--usually stage-dependent in terms of the active agent, duration and form of application--is the central pillar in the management of Lyme disease . In the late stages of borreliosis, symptoms may persist despite extensive and repeated antibiotic treatment . In this phase, borreliosis-typical neuropathy and neuralgia, chronic fatigue and neuropsychological deficits predominate . Irrespective of whether renewed antibiotic treatment is indicated or not, symptomatic treatment must be continued. J Clin Pathol, 2003 Nov, 56(11), 866 - 7 Pulmonary tumour microembolism clinically mimicking alveolitis; Lo AW et al.; A 56 year old man with previously unsuspected recurrence of squamous cell carcinoma of the oesophagus presented with dyspnoea . Bronchoscopy and computed tomography suggested bronchopneumonic changes with an infectious cause . He suffered a rapidly deteriorating course and died despite active treatment, including antibiotics and mechanical ventilation . Necropsy revealed a florid pulmonary tumour microembolism mimicking alveolitis . No bronchopneumonia was seen . The emboli arose from loosely attached tumour vegetations in the tricuspid valve . In a patient with known malignancy, tumour microembolism should be considered as an uncommon cause of rapid respiratory failure, refractory to antibiotic treatment. Pediatrics, 2003 Nov, 112(5), 1069 - 75 Clinical presentation of pertussis in unvaccinated and vaccinated children in the first six years of life; Tozzi AE et al.; OBJECTIVES: Identifying the determinants of the clinical presentation of pertussis is important for the purposes of diagnosis, therapy, and control and for predicting the disease's clinical course and choosing an appropriate case definition for surveillance . Potential determinants include vaccination status, antibiotic treatment, age at diagnosis, and sex, although the available data are inconsistent . The objective of this study was to compare the clinical course of pertussis in unvaccinated and vaccinated children in a well-defined and strictly studied population and to identify determinants of the disease's clinical presentation . METHODS: The clinical presentation of pertussis was studied in children who participated in a randomized, controlled clinical trial of efficacy of acellular pertussis vaccine . The children belonged to the same birth cohort and were followed from infancy to 6 years of age in 3 distinct periods (stages 1, 2, and 3) . Children had received 1 of 2 three-component acellular pertussis vaccines produced by 2 manufacturers (diphtheria-tetanus-acellular pertussis from, Chiron Biocine {DTaP CB}; DTaP from SmithKline Beecham {DTaP SB}) or a diphtheria-tetanus vaccine only (DT; Chiron Biocine) . Pertussis was confirmed through culture or serology . For each pertussis episode, information was collected on age at onset, sex, type of vaccine received, antibiotic treatment, culture results, duration of cough, spasmodic cough, and other symptoms . The simultaneous effect of potential determinants of clinical presentation of pertussis on the duration of cough and spasmodic cough was studied through analysis of variance models . RESULTS: The analysis was conducted on 788 laboratory-confirmed cases of pertussis . The median duration of cough in DT recipients varied from 52 to 61 days across the 3 stages, whereas the median duration of cough in DTaP recipients varied from 29 to 39 days . The median duration of spasmodic cough varied from 20 to 45 days in DT recipients and from 14 to 29 days in DTaP recipients . The results of the analysis of variance models showed that vaccination against pertussis reduced the length of cough from 3 to 10 days and the length of spasmodic cough from 4 to 8 days . Culture-positive patients had a cough 11 to 22 days longer and a spasmodic cough 12 to 22 days longer than culture-negative patients . Children who received an antibiotic had a duration of cough 6 to 11 days longer and spasmodic cough 4 to 13 days longer than untreated patients . Girls had a duration of spasmodic cough 7 days longer than boys only after 3 years of age . Age was directly related to duration of cough, whereas it was inversely related to duration of spasmodic cough after 3 years of age . CONCLUSIONS: Duration of cough can be greatly influenced by vaccination status . A positive culture for Bordetella pertussis is more frequently found in patients with long duration of cough, and antibiotic therapy may be a marker of severe disease . Gender may affect the clinical presentation of pertussis only after infancy . Pertussis in older children may be characterized by short duration of spasmodic cough . These results should be taken into account in the clinical evaluation of patients with suspected pertussis . Clinical case definitions for the purpose of surveillance based on the presence of 2 weeks of spasmodic cough may not be appropriate where pertussis vaccination uptake is high. Lancet Infect Dis, 2003 Nov, 3(11), 709 - 21 Q fever: a biological weapon in your backyard; Madariaga MG et al.; Coxiella burnetii, which causes Q fever, is a highly infectious agent that is widespread among livestock around the world . Although the culture process for coxiella is laborious, large amounts of infectious material can be produced . If used as an aerosolised biological weapon, coxiella may not cause high mortality, but could provoke acute disabling disease . In its late course, Q fever can be complicated by fatal (eg, endocarditis) or debilitating (eg, chronic fatigue syndrome) disorders . The diagnosis of Q fever might be delayed because of non-specific and protean presentations . Effective antibiotic treatment is available for the acute form of disease but not for the chronic complications . Vaccination and chemoprophylaxis in selected individuals may be used in the event of bioterrorism. Pediatr Surg Int, 2003 Nov, 19(9-10), 695 - 6 Epub 2003 Oct 29. Pyloromyotomy through circumbilical incision with fascial extension; Karri V et al.; Extending the fascial incision underlying the circumbilical approach to the shape of an 'inverted T' permits easy delivery of the pyloric tumour for Ramstedt's pyloromyotomy . This modification was used in 51 consecutive infants (42 male, 9 female) with a mean age of 4.7 weeks . Extension of the skin incision or conversion to the right hypochondrium approach was not necessary in any patient and the mean operating time was 31.4 min . Mild wound infection occurred in two infants (3.9%) that resolved with antibiotic treatment . Follow-up at 3 months did not detect any incisional hernia . This modification allows delivery of small or large pyloric tumours, is associated with a low rate of wound infection and does not alter the excellent cosmetic finish. Med Sci Monit, 2003 Nov, 9(11), CR449 - 55 Apoptosis in Lyme borreliosis--a preliminary study; Grygorczuk SS et al.; BACKGROUND: Apoptosis plays an important role in the control of the immune system, and its impairment may be associated with autoimmune responses . Different bacterial and viral pathogens interfere with the regulation of apoptosis . This may take place in Lyme borreliosis, in which pathological autoimmune reactions are likely to occur . MATERIAL/METHODS: A study group consisted of 15 patients with erythema migrans (group I), 15 with Lyme arthritis (group II) and 9 with neuroborreliosis (group III); the control group consisted of 10 healthy subjects . The concentrations of the factors involved in apoptosis regulation--transforming growth factor-beta1 (TGF-beta 1), soluble Fas (sFas), soluble Fas ligand (sFasL) and protein bcl-2--were measured in serum before (examination 1) and after (examination 2) four weeks of antibiotic treatment . RESULTS: The mean concentration of sFas was significantly higher in all study groups compared to controls in examination 1 and 2, and showed a tendency to increase during treatment . The concentration of sFasL was significantly increased in groups II and III in examination 1 . The concentration of bcl-2 was elevated significantly in all groups in examination 1 and dropped during treatment, remaining significantly increased in group I . The concentration of TGF-beta 1 was not significantly elevated except for group II in examination 2 . CONCLUSIONS: The concentrations of soluble factors involved in the regulation of apoptosis were increased in serum of patients with different forms of Lyme borreliosis . Further studies are necessary to confirm if inappropriate apoptosis of immune cells may contribute to the pathogenesis of Lyme disease. Cochrane Database Syst Rev . 2003;(4):CD001392. Prolonged antibiotics for purulent bronchiectasis; Evans DJ et al.; BACKGROUND: The vicious cycle hypothesis for bronchiectasis predicts that bacterial colonisation of the respiratory tract perpetuates inflammatory change . This damages the mucociliary escalator preventing bacterial clearance and allowing the persistence of pro-inflammatory mediators . Conventional treatment with physiotherapy and intermittent antibiotics are felt to improve the condition of bronchiectasis patients although there are no conclusive data showing that these interventions influence the natural history of the condition . Various strategies have been tried to interrupt this cycle of infection and inflammation and one of these is to prolong antibiotic treatment in the hope of allowing the airway mucosa to heal . OBJECTIVES: This systematic review brings together the evidence and where possible presents a meta-analysis of the data available to answer the question 'Does treatment with prolonged courses of antibiotics influence the outcome in purulent bronchiectasis?' SEARCH STRATEGY: The Cochrane Airways Group trials register and reference lists of identified articles were searched . SELECTION CRITERIA: Randomised trials looking at the use of prolonged antibiotic therapy in the treatment of bronchiectasis . DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data extraction was carried out by the reviewers independently . Study authors were contacted for missing information . MAIN RESULTS: 447 abstracts were found and reviewed for suitability . Six trials were included and 302 patients were randomised amongst these trials . 40% of the patients were contributed by one trial . Antibiotics were given for between 4 weeks and one year . There were 40 withdrawals due to treatment failure and intolerable side effects . Only limited meta-analysis was possible due to the diversity of the trials . Response rates showed significant effects in favour of prolonged antibiotic treatment (Peto OR (95% CI), 3.37 (1.60 to 7.09)) . Conversely for exacerbation rates there was no significant difference between prolonged antibiotics and placebo (Peto OR (95% CI), 0.96 (0.27 to 3.46)) . For withdrawals there was no significant difference between treatment and placebo management (Peto OR (95% CI), 1.06 (0.42 to 2.65)).Data for lung function showed no significant benefit in favour of antibiotic treatment (% predicted FEV1, WMD (95% CI) -1.05 (-6.93 to 4.83)) . REVIEWER'S CONCLUSIONS: The evidence available shows a small benefit for the use of prolonged antibiotics in the treatment of bronchiectasis . This review is limited by the diversity of the trials . Further randomised controlled trials with adequate power and standardised end points are required. Eur Respir J, 2003 Oct, 22(4), 643 - 8 Duration of length of stay in pneumonia: influence of clinical factors and hospital type; Menendez R et al.; Length of stay (LOS) in hospital for community-acquired pneumonia depends on the characteristics of the patient and hospital . The present study sought to identify these variables within the first 24 h of hospitalisation . Patients hospitalised for pneumonia in four hospitals (one teaching and three general hospitals) had their data analysed by univariate and multivariate statististics . The variables entered were LOS, demographical characteristics, referral source, comorbidity, initial severity of illness, laboratory analyses, initial radiograph findings and antibiotic treatment regimens . The study sample included 425 patients . The overall mortality was 8.2% and the median LOS was 9 days . Using LOS as a dependent variable, three multivariate linear regression analyses were performed with: 1) the whole cohort; 2) the low-risk classes (categories I and II of Fine); and 3) the high-risk classes (categories III, IV and V of Fine) . The mathematical model identified hypoxemia, low diastolic pressure, pleural effusion, multi-lobe involvement and hypoalbuminaemia as associated with longer stays in risk classes III-V, while in the low-risk patients (I-II) only hypoxemia and pleural effusion appeared in the equation . Following adjustment for these clinical variables, the LOS remained lower in some hospitals . Several independent clinical factors increased the pneumonia-associated length of stay with significant differences between hospitals . Hypoxemia and pleural effusions were the predictive variables of length of stay in low-risk patients and, additionally, diastolic blood pressure, multi-lobe involvement and hypoalbuminaemia were significant in the higher-risk classes III-V. Andrologia, 2003 Oct, 35(5), 279 - 82 Cellular and biochemical markers in semen indicating male accessory gland inflammation; Krause W et al.; Leucocytospermia is considered to be a sign of male accessory gland inflammation . The leucocytes in semen are mainly polymorphonuclear neutrophilic granulocytes . Leucocytospermia is not associated with the presence of bacteria and antibiotic treatment does not significantly lower the extent of leucocytospermia . A higher frequency of elevated herpes simplex antibodies titres were found in men with leucocytospermia . The concentration of inflammatory cytokines, interleukin-6 and -8, is closely correlated with the number of leucocytes . Their determination does not provide additional information . Reactive oxygen species (ROS) are generated at least in part by seminal leucocytes in response to stimulating factors . Purified leucocytes produce high levels of ROS . The determination of ROS appears to represent a parameter of functional activity of leucocytes . The role of chlamydiae in male accessory gland infection is unclear . Their determination in semen by DNA amplification and by immunological tests does not provide reliable results. Nihon Kokyuki Gakkai Zasshi, 2003 Sep, 41(9), 655 - 9 {A case of allergic granulomatosis and angiitis without symptoms of asthma}; Morimatsu Y et al.; We present a case of allergic rhinitis in a 68-year-old woman in whom eosinophilia was found when she complained of common cold-like symptoms . The patient noticed a mass lesion on her left neck, which improved with antibiotic treatment, but her coughing continued and edema of both lower extremities appeared . She was admitted to our hospital, because of abnormalities in her electrocardiogram and cardiomegaly seen in a chest radiograph . The discomfort due to the edema in the soles of both feet remained even after steroid therapy . Her chest radiograph revealed ground-glass opacity, and a transbronchial lung biopsy revealed granulation tissue with the infiltration of eosinophils into the interstitium . Allergic granulomatosis angiitis was diagnosed because of granulomatosis vasculitis resulting from sural nerve biopsy . This was a rare case of allergic granulomatosis angiitis because her lung function was normal, she had no history of bronchial asthma, and there were no clear symptoms of bronchial asthma. Crit Care Med, 2003 Oct, 31(10), 2535 - 8 Decompressive craniectomy for severe traumatic brain injury: Evaluation of the effects at one year; Albanese J et al.; OBJECTIVE: To assess the effect on outcome (1 yr) of decompressive craniectomy performed within or after the first 24 hrs post-trauma in severely head-injured trauma patients with intractable cerebral hypertension . DESIGN: Retrospective cohort study . SETTINGS: Intensive care unit of a university hospital . PATIENTS: Among 816 patients with severe head trauma (Glasgow Coma Scale < or =8), 40 underwent decompressive craniectomy . After data collection, patients were divided into two groups: early and late decompressive craniectomy . An early decompressive craniectomy was performed within the first 24 hrs in patients according to the following criteria: a Glasgow Coma Scale score <6 and the existence of clinical signs of cerebral herniation (absence of pupillary reflexes), correlated with abnormalities in computed tomography scan including hematoma, appearance of diffuse or unilateral brain swelling, and/or cerebral herniation . The intracranial pressure in these patients was not measured before the decompressive craniectomy was performed . A late decompressive craniectomy (>24 hrs) was performed according to following criteria: an intractable intracranial hypertension with intracranial pressure >35 mm Hg, a unilateral or bilateral absence of pupillary reflexes, and the same abnormalities in computed tomography scan as previously described . INTERVENTION: Twenty-seven patients with signs of cerebral herniation required the procedure at the time of initial evacuation of a mass lesion . In 13 patients, decompressive craniectomy was performed because of elevated intracranial pressure refractory to medical treatment consisting of cerebrospinal fluid derivation, deep sedation, osmotherapy, hyperventilation, and nesdonal or propofol . MEASUREMENTS AND MAIN RESULTS: Five patients (19%) in whom an early decompressive craniectomy was performed had good recoveries (social rehabilitation), eight patients (30%) remained in a persistent vegetative state or with a severe disability, and 14 died (52%) . On the other hand, the performance of late decompressive craniectomy in case of medical treatment failure was followed by social rehabilitation in five patients (38%) and death in three patients (23%) . A persistent vegetative state or a severe disability was observed in five patients (38%) . Meningitis or cerebral abscess occurred in six patients after decompressive craniectomy and were easily cured by antibiotic treatment . CONCLUSIONS: In 40 patients with intractable intracranial hypertension and at very high risk of brain death, decompressive craniectomy allowed 25% of patients to attain social rehabilitation at 1 yr. Rev Mal Respir, 2003 Sep, 20(4), 609 - 13 {"Post traumatic" leptospirosis complicated by acute respiratory insufficiency}; Clarissou J et al.; INTRODUCTION: Leptospirosis is a rare cause of alveolar haemorrhage . The diagnosis is often delayed particularly when the mode of infection is atypical . These serious complications require prompt antibiotic treatment . CASE REPORT: A 21-year-old man was involved in a road accident and found lying unconscious in a roadside ditch containing stagnant water . Ten days later he presented with bilateral interstitial pneumonia and rapidly increasing hypoxaemia associated with cholestasis and liver cell necrosis . Broncho-alveolar lavage revealed alveolar haemorrhage . There was satisfactory resolution following antibiotic therapy . CONCLUSIONS: The diagnosis of leptospirosis was considered initially despite negative serology (Martin and Petit) and confirmed by sero-conversion 20 days after the onset of symptoms. Int J Antimicrob Agents, 2003 Oct, 22 Suppl 2, 45 - 7 Asymptomatic bacteriuria . Clinical significance and management; Raz R; The clinical significance and management of asymptomatic bacteriuria (ASB) differs according to different groups of patients . ASB requires antibiotic treatment in pregnant women, children aged 5-6 years and prior to invasive genitourinary procedures . However, there is a consensus that ASB in the elderly, healthy school girls and young women, diabetic women and patients with indwelling catheters or intermittent catheterization has no clinical significance and antibiotic prescription is not indicated. Eur Heart J, 2003 Oct, 24(19), 1779 - 87 Suspected pacemaker or defibrillator transvenous lead infection . Prospective assessment of a TEE-guided therapeutic strategy; Dumont E et al.; AIMS: The aim of this prospective study was to assess the clinical value of a management strategy principally based on the results of multiplane transoesophageal echocardiography (TEE) in patients with suspected lead infection . METHODS AND RESULTS: Seventy-seven consecutive patients were included . Based on Duke's modified criteria, PTLI was considered as definite in 54 patients (70%) and possible in 23 patients (30%) . Nineteen patients with a diagnosis of possible infection, as defined by bacteraemia without abnormal TEE images and without evidence of pacemaker pocket infection, were treated by antibiotics alone . In all other cases, the pacing material was totally removed . During a mean follow-up time of 3.1+/-2.5 years, 21 patients (27%) died, mostly from cardiovascular causes . Only one patient died from infection and there was only one case of delayed infection recurrence in an other localization . No significant differences in outcome were observed between explanted and non-explanted patients . CONCLUSIONS: The results observed confirm that early and total explantation of pacing material has to be done in patients with bacteraemia and abnormal images at TEE . But conversely conservation of the pacing system can be proposed to patients with bacteraemia but without abnormal images at TEE provided prolonged antibiotic treatment is given. Refuat Hapeh Vehashinayim, 2003 Jul, 20(3), 30 - 41, 100 {Differential diagnosis and treatment strategies for peri-implant diseases}; Kozlovsky A et al.; The aim of this article is to discuss the requirements to prevent, intercept and treat the peri-implant diseases at different stages . The ethiology and pathogenesis of peri-implant disease is presented, followed by definition and characteristics of the two main entites: peri-implant mucositis and peri-implantitis . Data and concepts regarding various evaluation parameters, such as pocket probing depth, bleeding on probing, gingival and plaque scores, radiographic and mobility which should be used to assess the clinical status of the peri-implant environment are discussed . The detection and treatment of early pathogenic changes during regular recall maintenance visits can prevent peri-implant soft tissue inflammation and progressive bone loss . The biologic rationale and guidelines for therapeutic procedures aimed to prevent and arrest the Peri-implant Disease according to a maintenance system termed Comulative Interceptive Supportive Therapy (CIST) is presented . The CIST protocol includes as a first sequence mechanical antiseptic and antibiotic treatment to control ongoing infection . Following this, peri-implant bony lesion may be corrected by regenerative or resective surgical techniques . IN CONCLUSION: By continuing diagnosis during maintenance, developing peri-implant infections can be controlled successfully by providing mechanical, antiseptic, antibiotic and surgical supportive therapy, individually or combined. Scand J Infect Dis, 2003, 35(8), 506 - 8 High rate of Simkania negevensis among Canadian inuit infants hospitalized with lower respiratory tract infections; Greenberg D et al.; To determine the prevalence of Simkania negevensis in causing pulmonary infections in children, nasopharyngeal washes were obtained from 22 infants hospitalized with acute bronchiolitis in the Baffin Island, Canada . 14 (63.6%) were positive for S . negevensis . Mixed infections with other respiratory viruses were common . All patients recovered without specific antibiotic treatment . Even though a high prevalence of S . negevensis was found, this organism may potentially well be an opportunistic agent rather than a true pathogen. Ann Trop Med Parasitol, 2003 Sep, 97(6), 639 - 44 Wolbachia infection and the expression of cytoplasmic incompatibility in sandflies (Diptera: Psychodidae) from Egypt; Kassem HA et al.; A PCR-based method was used to screen four laboratory colonies of sandflies for Wolbachia infection . The colonies - one of Phlebotomus langeroni, one of P . bergeroti and two of P . papatasi - were all derived from sandflies collected in Egypt . Only one of the colonies, derived from P . papatasi collected in Sinai, was found infected . The sequence of the PCR product for this colony was identical to that previously reported for the Wolbachia in P . papatasi from Israel . The induction with tetracycline of cytoplasmic incompatibility (CI) in flies from the P . papatasi (Sinai) colony was then investigated, through reciprocal crosses between treated and untreated P . papatasi siblings . Partial CI expression was attained in the crosses involving antibiotic-treated (i.e . uninfected) females, whether the males used were infected with Wolbachia or had also been cleared of Wolbachia by antibiotic treatment . Most (75%) of the eggs oviposited by uninfected females that had been crossed with infected males, and most (58%) of those laid by uninfected females that had been crossed with uninfected males, failed to hatch . These results provide the first published evidence showing that Wolbachia infection in sandflies is advantageous to the insects . The failure to detect Wolbachia in one of the colonies derived from Egyptian P . papatasi or in the colonies derived from Egyptian P . bergeroti and P . langeroni may indicate that the inter- and intra-specific spread of Wolbachia is discontinuous, even within one country. J Small Anim Pract, 2003 Sep, 44(9), 399 - 403 Proximal interphalangeal joint instability in the dog; Guilliard MJ; A prospective study into the use of transarticular external skeletal fixation in the treatment of proximal interphalangeal instability was undertaken . Only dogs with soft tissue injuries were included . All the dogs except one were greyhounds or related breeds . A hypothesis was proposed that if the articular surfaces were held in normal congruency for a period of time then the development of periarticular fibrosis would alone give sufficient joint support . Joint congruency was maintained by the application of a unilateral external skeletal fixator for approximately three weeks . Complications were common and were due to frame impingement on the neighbouring digit, pin tract infection and pin loosening, and all resolved following frame removal and antibiotic therapy . Careful pin placement and prophylactic antibiotic treatment prevented complications in subsequent cases . All dogs returned to normal function with no lameness, with the exception of one racing greyhound which had a recurrence of the instability. Invest Ophthalmol Vis Sci, 2003 Oct, 44(10), 4215 - 22 Which members of a community need antibiotics to control trachoma? Conjunctival Chlamydia trachomatis infection load in Gambian villages; Burton MJ et al.; PURPOSE . Trachoma is the leading cause of infectious blindness worldwide . Control strategies target antibiotic therapy to individuals likely to be infected with Chlamydia trachomatis on the basis of clinical signs . However, many studies have found chlamydial infection in the absence of clinical disease . It has been unclear whether such individuals represent a significant reservoir of infection . In the current study, a quantitative polymerase chain reaction (PCR) assay was used to investigate the distribution and determinants of chlamydial infection load in an endemic community, and the findings were used to evaluate the potential effectiveness of different control strategies . METHODS . Members of a trachoma-endemic community (n = 1319) in a rural area of The Gambia were examined for signs of disease, and tarsal conjunctival swab samples were collected . C . trachomatis was initially detected by qualitative PCR . The load of infection was then estimated by real-time quantitative PCR . RESULTS . Chlamydial infection was detected in 7.2% of the population . The distribution of infection load was skewed, with a few individuals having high loads . Only 24% of infected individuals had signs of active trachoma . Infection loads were higher in those with clinically active disease and were highest among those with severe inflammatory trachoma . High infection loads were associated with having no accessible latrine and living with a person with active disease . CONCLUSIONS . In this low-prevalence setting, infected individuals without signs of active trachoma constitute a significant reservoir of infection . Treatment of a defined unit of people who live with someone with clinically active trachoma would effectively target antibiotic treatment to infected people without signs of disease. Surg Today, 2003, 33(7), 504 - 8 The effect of granulocyte colony-stimulating factor in the treatment of Escherichia coli peritonitis with or without ceftriaxone in a nonneutropenic rat model; Saba R et al.; PURPOSE: To investigate the effect of granulocyte colony-stimulating factor (G-CSF) in the treatment of Escherichia coli peritonitis with and without ceftriaxone in a nonneutropenic rat model . METHODS: The rats were divided into five groups: control group (C) receiving physiological saline; peritonitis group (P) infected intraperitoneally with a live bacterial suspension of E . coli; peritonitis and antibiotic group (PA) receiving ceftriaxone 3 h after being infected; peritonitis, antibiotic, and G-CSF group (PAG) receiving G-CSF and antibiotic 3 h after infection; and peritonitis and G-CSF group (PG) . RESULTS: All rats in group C survived . Any animals which did not survive died within 24h after inoculation . A significantly higher rate of survival, 95%, was observed with antibiotic treatment alone (PA), in comparison to the G-CSF-treated groups, PAG and PG, 52% and 57%, respectively . CONCLUSION: No beneficial effect of G-CSF treatment was seen in the E . coli peritonitis and antibiotic therapy remains the basic treatment for this disease. Arch Dis Child, 2003 Oct, 88(10), 940 - 2 "Unresolving pneumonia" as the main manifestation of atypical Kawasaki disease; Uziel Y et al.; Two cases of atypical Kawasaki disease (KD) manifested as persistent lobar lung consolidation, prolonged fever, and active inflammatory laboratory markers unresponsive to antibiotic treatment are reported . One of the children developed a giant coronary aneurysm . Atypical KD should be considered in the differential diagnosis of young children with prolonged fever and lobar consolidation unresponsive to antibiotics. Eur J Clin Pharmacol, 2003 Nov, 59(8-9), 651 - 7 Epub 2003 Sep 12. Exploring patient- and doctor-related variables associated with antibiotic prescribing for respiratory infections in primary care; Mazzaglia G et al.; OBJECTIVE: To assess patient- and doctor-related variables leading physicians to prescribe antibiotics or parenteral antibiotics for acute respiratory infections (ARIs) and to describe the variability as well as the appropriateness of antibiotic use and its predictive factors in general practice . METHODS: We conducted a cross-sectional study among patients aged 15-85 years with a diagnosis of ARIs, using information from 469 GPs from the Health Search Database . Diagnoses were linked with antibiotic prescriptions and other patients and doctor-related variables . Available scientific evidence was used to establish the appropriateness of first-choice antibiotic treatment . Frequency analyses and logistic regressions were used to identify variables associated with antibiotic use and appropriateness . RESULTS: On 67,761 cases of ARIs, antibiotics were prescribed in 63.2%, varying from 80.9% for acute bronchitis to 43.9% for croup, influenza and common cold . Significant associations with antibiotic use were found for geographic location and number of patients under care . The use of diagnostic tests significantly lowered the risk . Geographic location and living in an urban area were associated with parenteral antibiotic use . Amoxicillin (16.7%) and amoxicillin-clavulanate (17.9%) were the most common antibiotics prescribed . Appropriateness was reported in 39.0% of cases, with geographic location, physician's gender and diagnostic tests being the factors more predictive of appropriate antibiotic use . CONCLUSIONS: There is still excessive antibiotic use for ARIs . Its overuse is influenced by the physicians' characteristics and by the environment in which they practice, whilst diagnostic tests might reduce inappropriateness . Therefore, effective strategies for changing diagnostic and therapeutic behaviour are needed. J Perinatol, 2003 Sep, 23(6), 457 - 61 Maternal epidural analgesia and rates of maternal antibiotic treatment in a low-risk nulliparous population; Goetzl L et al.; BACKGROUND: Epidural analgesia is associated with an increased rate of fever in prospective randomized trials . While the evidence suggests that epidural fever is not infectious, epidural analgesia has been associated with increased rates of antibiotic use, the indications that prompt treatment have not been examined . METHODS: We analyzed 1235 nulliparous women with singleton term pregnancies presenting in labor with a temperature of < 99.5 degrees F . Antibiotic use during labor was categorized by indication . RESULTS: A total of 59.6% of women received epidural analgesia . The rate of antibiotic use was significantly higher in women receiving epidural analgesia (28 vs 10.8%) . After adjusting for confounders using logistic regression, epidural analgesia was associated with a relative risk of 2.6 (95% CI 2.0, 3.4) for antibiotic treatment . The majority of the increased risk was due to significantly higher rates of antibiotic treatment for presumed chorioamnionitis (9.0 vs 0.4%) in the epidural analgesia group . CONCLUSION: Epidural-related fever results in excess maternal antibiotic treatment for presumed chorioamnionitis. Masui, 2003 Aug, 52(8), 866 - 9 {Anesthesia for a patient with Kartagener's syndrome undergoing ambulatory bilateral breast cancer surgery}; Shirakami G et al.; Kartagener's syndrome is an inherited disease characterized by a triad of symptoms, bronchiectasis, situs inversus and sinusitus . We report a case of a 53-year-old woman with the syndrome who received bilateral simple mastectomies and axillary lymph node dissections on ambulatory basis . She received antibiotic treatment until the day of surgery . She was admitted to our day surgery unit with productive cough and rales on both lungs on the day of surgery . General anesthesia was induced and maintained with propofol, fentanyl and vecuronium . Laryngeal mask airway (LMA) was placed . She received rectal diclofenac and bupivacaine infiltration into surgical field for pain relief . During pressure controlled ventilation, EtCO2, blood pressure and heart rate increased and SpO2 decreased gradually . These symptoms were resolved after resumption of spontaneous ventilation . She coughed out phlegm in LMA during surgery . The sputa were sucked out using bronchofiberscope . She made an uneventful recovery although she had productive cough preoperatively . She was discharged from the hospital without respiratory complication after overnight observation. Public Health, 2003 Jul, 117(4), 264 - 73 Lyme disease--what is the cost for Scotland? Joss AW, Davidson MM, Ho-Yen DO, Ludbrook A. This paper analyses likely Lyme disease costs incurred by patients tested in the authors' laboratory over an 18 month period, based on patient histories and test results relating to 2110 samples submitted from laboratories serving 59% of the Scottish population . Cost analysis takes account of the direct costs of consultation, laboratory tests, antibiotic treatment and management of any sequelae, as well as indirect costs of the loss of healthy time through illness . Standard costs for each element are derived from published information, and the proportions applied to each patient category are estimated from studies described elsewhere in the literature . Of the sample, 295 patients had evidence of early Lyme disease and 31 had late Lyme disease symptoms . Based on these figures, the total annual cost for Lyme disease, when projected to the whole of Scotland, is estimated to be significant at 331,000 Pounds (range 47,000-615,000 Pounds) . The range is inevitably wide because it was not possible to document complete clinical and management histories on individual patients . In addition, some late Lyme disease sequelae will require management for more than 1 year, and costs are also identified that could justifiably be included for all the other patients who tested negative for Lyme disease . These data raise the question of whether there is sufficient focus on prevention and the best management of this disease. J Matern Fetal Neonatal Med, 2003 Jun, 13(6), 362 - 80 Preventing low birth weight: is prenatal care the answer? Lu MC, Tache V, Alexander GR, Kotelchuck M, Halfon N. OBJECTIVES: To review the evidence of effectiveness of prenatal care for preventing low birth weight (LBW) . METHODS: We reviewed original research, systematic reviews, meta-analyses and commentaries for evidence of effectiveness of the three core components of prenatal care--risk assessment, health promotion and medical and psychosocial interventions--for preventing the two constituents of LBW: preterm birth and intrauterine growth restriction (IUGR) . RESULTS: Clinical risk assessment will fail to identify the majority of pregnancies at risk for preterm delivery or IUGR . While biophysical and biochemical modalities appear promising, their cost-effectiveness has not been demonstrated, nor can their routine use be recommended in the absence of effective interventions . Smoking cessation programs appear to be modestly effective . There is insufficient evidence to conclude a benefit for nutrition interventions, work counseling or preterm birth education . Only antenatal corticosteroid therapy has demonstrated a clear benefit in the tertiary prevention of preterm delivery . Interventions for which there is insufficient evidence to conclude a benefit include bed rest, hydration, sedation, cerclage, progesterone supplementation, antibiotic treatment, tocolysis without concomitant use of corticosteroids, thyrotropin-releasing hormone, psychosocial support and home visitation . Additionally, there is a paucity of evidence supporting the effectiveness of prenatal interventions, such as low-dose aspirin, bed rest, maternal hyperoxygenation, plasma volume expansion and antenatal fetal assessment, in preventing IUGR or its associated morbidity and mortality . CONCLUSIONS: Neither preterm birth nor IUGR can be effectively prevented by prenatal care in its present form . Preventing LBW will require reconceptualization of prenatal care as part of a longitudinally and contextually integrated strategy to promote optimal development of women's reproductive health not only during pregnancy, but over the life course. J Am Coll Cardiol, 2003 Sep 3, 42(5), 775 - 80 A randomized trial of aspirin on the risk of embolic events in patients with infective endocarditis; Chan KL et al.; OBJECTIVES: This study examined the effect of aspirin on the risk of embolic events in infective endocarditis (IE) . BACKGROUND: Embolism is a major complication of IE, and studies in animal models have shown that platelet inhibition with aspirin can lead to more rapid vegetation resolution and a lower rate of embolic events . METHODS: We conducted a randomized, double-blinded, placebo-controlled trial of aspirin treatment (325 mg/day) for four weeks in patients with IE to test the hypothesis that the addition of aspirin would reduce the incidence of clinical systemic embolic events . Patients with perivalvular abscess were excluded . Serial cerebral computed tomograms and transesophageal echocardiograms were obtained in a subset of patients . RESULTS: During the four-year study period, 115 patients were enrolled: 60 assigned to aspirin and 55 assigned to placebo . Embolic events occurred in 17 patients (28.3%) on aspirin and 11 patients (20.0%) on placebo, with an odds ratio (OR) of 1.62 (95% confidence interval {CI} 0.68 to 3.86, p = 0.29) . There was a trend toward a higher incidence of bleeding in the patients taking aspirin versus placebo (OR 1.92, 95% CI 0.76 to 4.86, p = 0.075) . Development of new intracranial lesions was similar in both groups . Aspirin had no effect on vegetation resolution and valvular dysfunction . CONCLUSIONS: In endocarditis patients already receiving antibiotic treatment, the addition of aspirin does not appear to reduce the risk of embolic events and is likely associated with an increased risk of bleeding . Aspirin is not indicated in the early management of patients with IE. Anaesthesist, 2003 Aug, 52(8), 707 - 10 {Seizure as a possible symptom of septic encephalopathy following transrectal prostate needle biopsy}; Sakka SG et al.; A 47-year-old male patient developed a seizure and was admitted to our institution by the emergency physician after tracheal intubation due to suspected primary intracerebral lesion . A primary neurological disorder could be excluded . Urosepsis with positive blood cultures for E . coli was diagnosed and the patient received appropriate antibiotic treatment . On the following day relatives mentioned an ambulatory prostate needle puncture on the day prior to admission . After stabilisation of organ function, the patient could be weaned from the ventilator and transferred to the urological ward a few days later . In conclusion, a seizure may be a possible symptom of septic encephalopathy which by definition is a diagnosis by exclusion . In general, transrectal prostate needle biopsy may be considered as a rare cause of sepsis and septic shock. J Knee Surg, 2003 Jul, 16(3), 165 - 7 Use of an intramedullary rod in knee arthrodesis following failed total knee arthroplasty; Gore DR et al.; A retrospective review was conducted of 20 consecutive patients (10 men and 10 women) with failed total knee arthroplasty (TKA) who underwent arthrodesis using an intramedullary rod . Average patient age was 70.5 years . One patient was lost to follow-up, and the remaining 19 patients were evaluated an average of 4.5 years postoperatively (range: 1-24 years) . Three patients without infections achieved a solid arthrodesis without complications . In 16 patients, the indication for fusion was an infection, and 12 of these patients had an uncomplicated postoperative course and achieved a solid arthrodesis . Of the remaining 4 patients, 1 required revision for a nonunion, 1 a skin graft, and 2 had recurrence of their infections in the postoperative period . Both patients had positive cultures at attempted arthrodesis . One patient underwent debridement at 3 months, and a solid fusion was obtained . The other patient required rod removal and currently has a nonunion, uses a brace, and is on suppressive antibiotic treatment . An intramedullary rod is the ideal fixation choice for knee arthrodesis in patients with a failed, noninfected TKA; however, in patients with an infection, the infection must be eradicated prior to rod use. Pol Merkuriusz Lek, 2003 May, 14(83), 450 - 2 {Atypical osteitis in hemodialysed child with uncontrolled secondary hyperparathyroidism: a case report}; Jobs K et al.; Ostitis in the course of secondary hyperparathyroidism can lead to heavy atypical skeletal changes . In 4-year old girl on hemodialysis, with hyperparathyroidism (iPTH level > 1500 pg/ml), despite specific pharmacological treatment, very pronounced skull and maxillary bone malformations developed within two months, which were the cause of problems with breathing . We observed also growing bones malformations concerning arms, legs, vertebral column and pelvis . Severe infectious ostitis with severe uremic osteodystrophy was diagnosed . After 3 months of antibiotic treatment (clindamycin) subtotal parathyreidectomy was performed . Control iPTH level was 111 pg/ml . In next weeks skull skeletal changes partially resolved, which was confirmed on computer tomography, and patients general condition improved . She has no longer difficulties with breathing. Eur J Pediatr Surg, 2003 Jun, 13(3), 181 - 6 Transanal coloanal pull-through with a short muscular cuff for classic Hirschsprung's disease; Rintala RJ; INTRODUCTION: A totally transanal operation for classic Hirschsprung's disease has become increasingly popular during the last few years . The procedure leaves no scars, is associated with less postoperative pain and discomfort and shortens hospital stay . The most commonly used technique for transanal pull-through is long endorectal dissection leaving a long muscular cuff, which is usually split posteriorly . We present our preliminary results following transanal endorectal operations with a short unsplit muscular cuff . MATERIALS AND METHODS: Twenty-six patients underwent short-cuff transanal endorectal operation for Hirschsprung's disease between years 2000 and 2002 . Patients' hospital records were analysed retrospectively . The collected data included age at operation, associated conditions, hospital stay and time to full enteral feeding, occurrence of pre- and postoperative enterocolitis and preoperative stoma, operative complications, need for postoperative anal dilatations, postoperative perianal skin problems and preliminary data on bowel function . RESULTS: The median age at operation was 1 month (range 0 - 60 months), 13 patients were operated on in the neonatal period . Four patients had Down's syndrome, 1 had cartilage-hair hypoplasia and one Ondine's syndrome . Five patients had preoperative enterocolitis . Four patients had undergone levelling stoma formation for unremitting constipation or enterocolitis . The proximal ganglionic stoma was concomitantly pulled-through and anastomosed to the anus in all 4 patients with a stoma . One patient with aganglionosis extending to the proximal sigmoid required additional laparoscopic colonic mobilisation . Complications related to surgery did not occur in the present series . Median postoperative hospital stay was 3 days (range 2 - 21 days) and median time to full enteral feeding was 3 days (range 1 - 14) . Six patients required anal dilatations, two of those for a period of 3 weeks . The median follow-up time was 6 months (range 1 - 22 months) . Fourteen patients had perianal skin rash, which usually resolved within 6 weeks . Postoperative enterocolitis requiring hospitalisation occurred in 1 patient, another patient had mild symptoms suggesting enterocolitis; these responded to oral antibiotic treatment . Early postoperative bowel function was characterised by frequent bowel movements in most patients . This usually resolved within a few months; of the 15 patients with a follow-up of longer than 6 months only 2 have more than 3 bowel movements per day . At the last follow-up frank soiling occurred in 1 patient with Down's syndrome, one patient requires oral laxatives for constipation . CONCLUSIONS: Transanal endorectal pull-through with a short cuff is a safe operation with a low incidence of operative and postoperative complications . Hospital stay and time to full enteral feeds is significantly shorter than after conventional procedures; this is associated with lower hospital costs . Long-term functional outcome is unclear but short-term function is very similar to that after procedures where transanal mucosectomy is combined with open rectosigmoid dissection. Rev Laryngol Otol Rhinol (Bord), 2003, 124(1), 31 - 7 {Perilymphatic effusion as a complication of otosclerosis}; Couvreur P et al.; INTRODUCTION: Stapes gusher means the leakage of perilymphatic liquid when opening the perilymphatic cistern . The perilymphatic liquid with a high pressure gushes with a great flow out of the cistern when the stapedotomy is executed . Otosclerosis surgery sometime brings to light abnormal contact between the inner ear and the sub-arachnoidian spaces in patients who didn't presented ear malformations . It's a very rare event (1/1000) which is different from a much more common and more moderate form of perilymphatic liquids high pressure (1/200) . About 4 clinical observations, we compared our experience with other authors in specialist reviews . PURPOSE OF THE STUDY: About four observations, we confronted our experience with that of the literature . MATERIAL AND METHODS: Retrospective study between 1971 and 1998 . It was about 3 males and 1 female, without antecedent except one of them who had been operated 5 years before for the opposite ear without gusher but without good audiometric result . They presented a conductive deafness with no answer of the stapedial reflex . We had 4 geysers during the platinotomia which were sealed with some connective tissue . RESULTS: Two patients had a post operative complete sensory hearing loss, one, a sensitive decline of the conduction thresholds (average 50 dB), the last one kept his bone conduction level with a mild sensory hearing loss . The most recent case had a scanner preoperatively which had not shown abnormality except for the focus of otosclerosis . DISCUSSION: Perilymphatic gusher is an unpredictable event that can not be diagnosed before the surgery, nether with clinical facts nor radiological elements . This involves serious consequences concerning not only the continuation of the surgical operation and the prognostic of the hearing but also concerning the danger of secondary meningeal infections . The best way to proceed in case of favourable cases consists in fitting the ossicular prothesis into the stapedotomy, when it's not to wide . Pieces of muscle can be used in some cases, taped on with biologic glu . Various techniques are used to lower the pression of the cerebrospinal liquid: hypertonic solutes, diuretic drugs, lumbar diversion . In all cases, it is necessary to start a wide spectrum antibiotic treatment and a vaccination against pneumococcis . CONCLUSION: The surgeon has to know all the option of the treatment when confronted with this situation in order to try to avoid tricky defect of the inner ear. Vnitr Lek, 2003 Jul, 49(7), 541 - 7 {Comparison of procalcitonin, interleukin-6 and C-reactive protein in the differential diagnosis of patients with sepsis syndrome in intensive care units}; Prucha M et al.; One of the most difficult tasks in differential diagnosis of patients with septic syndrome at the Intensive Care Units is to differentiate between infection and non-infection etiology of this syndrome . In the last years, new parameters have played an important role in this area--C-reactive protein, Interleukin-6 and procalcitonin . THE AIM: Of the investigation was to compare these three parameters in differential diagnosis of the septic syndrome . THE COHORT AND METHODS: The authors examined 56 patients (17 women and 39 men, mean age being 43 and 51 years, respectively) hospitalized at the Intensive Care Units who corresponded to the criteria of the syndrome of inflammatory response, sepsis or septic shock . A total of 99 examinations were done . The samples were taken up to 24 hours after the beginning of clinical symptomatology and submitted to the laboratory within four hours . Immediately afterwards the determination of concentrations of all three parameters--C-reactive protein, interlaukin-6 and procalcitonin, were done . The results of the examinations were compared to each other as well as to the diagnosis of sepsis--the confirmed infection etiology . RESULTS: In all the evaluated parameters the authors detected significant differences between the values of entry examination and all measurements between the patients with the syndrome of systemic inflammatory response and septic shock as well as among patients with sepsis and the septic shock . Likewise, the authors confirmed significant differences between concentrations of all three parameters in comparing the patients with sepsis and those with the septic shock . Only in the case of procalcitonin there was a significant difference in concentration between patients with the syndrome of systemic inflammatory response of non-infectious etiology and those with sepsis . The concentration of procalcitonin was the only predictive marker of diagnosis with the correlation coefficient r = 0.7263, r2 = 0.5275, P < 0.00005 . CONCLUSION: Calcitonin proved to be the most specific parameter in demonstrating infection etiology in patients with the septic syndrome, its predictive value being higher than that of C-reactive protein and Interleukin-6 . Monitoring of calcitonin dynamism provides important information on efficiency of the applied antibiotic treatment . In patients with diagnostic uncertainties as far as the etiology of the septic syndrome is concerned; procalcitonin is the parameter of choice, while it may be supplemented with the examination of C-reactive protein. Intervirology, 2003, 46(4), 232 - 8 Laboratory diagnosis of norovirus: which method is the best? Rabenau HF, Sturmer M, Buxbaum S, Walczok A, Preiser W, Doerr HW. Noroviruses (NV) are transmitted by fecally contaminated food, vomit, and person-to-person contact . They are one of the main causes of non-bacterial acute gastroenteritis in nursing, old people and children's homes . NV outbreaks are characterized by a short incubation period (12-48 h), nausea, vomiting and diarrhea, and high secondary attack rates . The illness is generally mild and self-limiting . The aim of diagnostic procedures in viral gastroenteritis is to avoid nosocomial infections on the one hand and unnecessary antibiotic treatment on the other . Diagnostic procedures for NV are based on the detection of virus in stool samples by (immune) transmission electron microscopy (TEM), antigen ELISA, or polymerase chain reaction (PCR) . In our study, a total of 244 stool samples obtained from 227 patients between March and May 2002 were tested by TEM, antigen ELISA and in-house PCR . Our data showed that PCR has the highest sensitivity (94.1%), followed by TEM (58.3%), and ELISA (31.3%), while specificity was highest for TEM (98.0%), followed by ELISA (94.9%), and PCR (92.4%) . All three methods tested (TEM, ELISA and PCR) are useful for epidemiological investigations in gastroenteritis outbreaks; however, to maximize diagnostic validity for individual cases, at least two of the methods should be combined . Eur J Gastroenterol Hepatol, 2003 Sep, 15(9), 1005 - 10 Patterns of pain in diverticular disease and the influence of acute diverticulitis; Simpson J et al.; BACKGROUND: While the association of recurrent bouts of abdominal pain with colonic diverticulosis is well recognized, the cause of this pain is obscure since in most cases it occurs without obvious diverticulitis or other potential causes . AIMS: To define the patterns of pain in diverticular disease and the influence of acute diverticulitis . METHODS: Two studies were undertaken to establish the relationship between bouts of prolonged abdominal pain (> 24 h) presumed to be due to inflammatory diverticulitis and recurrent short-lived pain . In Study 1, 261 patients with a barium enema showing diverticulosis completed a postal questionnaire concerning episodes of both prolonged and short-lived pain . In Study 2, 26 patients previously admitted to hospital with a firm diagnosis of diverticulitis were interviewed for details of their bowel habits since discharge . RESULTS: Study 1: 94/261 patients experienced recurrent, short-lived pain on a median of five days a month, with a median duration of 3 h . In addition, 51/261 patients described episodes of prolonged pain with a median duration of three days . Of these, 31/51 (61%) experienced recurrent, short-lived pain compared with 63/210 (30%) who had not had an episode of prolonged pain . More specifically, 12/17 (71%) who received antibiotic treatment for presumed acute diverticulitis during their bout of prolonged pain experienced recurrent pain compared with 82/244 (34%) who did not experience such an episode . Study 2: 18/26 patients hospitalized for acute diverticulitis developed new, recurrent, short-lived abdominal pain following discharge, with a median duration of 4 h . CONCLUSION: Episodes of prolonged, presumed inflammatory pain due to diverticulitis are frequently followed by recurrent, short-lived pain similar to that seen in irritable bowel syndrome. Beijing Da Xue Xue Bao, 2003 Apr 18, 35(2), 123 - 7 {Analysis of 37 pathological and clinic data of extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT)}; Ke X et al.; OBJECTIVE: To provide pathological and clinical evidences in order to establish standardized diagnosis and treatment for MALT lymphoma . METHODS: Pathological characters, grade, stage, prognostic factors and treatment of 37 cases of MALT lymphoma were analyzed which were diagnosed from January 2000 to June 2002 . RESULTS: The 39 patients(8.82%) were diagnosed as MALT lymphoma out of 442 NHL patients(37 patients were followed up, and two missing) . Median age was 52 years . The percentage of patients older than 50 was 63.6% . The marjority of tumors were found in stomach, intestinal, thyroid, parotid gland, orbit and lung . Among 28 (71.8%) of 37 patients with gastro-intestinal(GI) Maltoma, low-grade was 70.3%, median-grade 27.0%, stage I 53.6%, stage II 28.6%, stage III 14.3%, and stage IV 3.6% . Of phenotype 35 cases were CD20 positive, and 4 cases were diagnosed as MALT lymphoma supported by PCR detecting IgH re-arrangement . Among 13 patients with gastric MALToma, 46.15% were helicobacter pylori (HP) positive . Patients with GI MALT lymphoma received 3-cycle antibiotic treatment . Most of GI patients received surgical operations . Most of patients received chemotherapy, with 4 plus local radiotherapy . Only one patient received antibiotic treatment alone . No one received radiation treatment alone . CONCLUSION: MALT lymphoma was often seen in older patients, most of whom were in low-grade with slow disease progression . The site, grade, stage and molecular genetic change are important prognostic factors, which can help us to make decision in choosing suitable treatment. Cochrane Database Syst Rev . 2003;(3):CD003038. Beta-lactam versus beta-lactam-aminoglycoside combination therapy in cancer patients with neutropaenia; Paul M et al.; BACKGROUND: Chemotherapy treated cancer patients are prone to neutropaenia and life-threatening infections . Early, empirical antibiotic treatment is therefore administered routinely to febrile neutropaenic patients . Currently, either beta-lactam-aminoglycoside combination treatment or beta-lactam monotherapy are recommended . OBJECTIVES: We compared beta-lactam monotherapy versus beta-lactam-aminoglycoside combination therapy for cancer patients with fever and neutroepaenia . SEARCH STRATEGY: We searched the Cochrane Cancer Network Register (searched July, 2000), the Cochrane Controlled Trials Register (Cochrane Library Issue 4, 2001), EMBASE (January 1980 to December 2000), LILACS (January 1982 to August 2001), MEDLINE (January 1966 to August 2001), and ICAAC conference proceedings (1995 to 2000) . We scanned references of all included studies, pertinent reviews, and contacted the first author of each included trial and the pharmaceutical companies . SELECTION CRITERIA: Randomised controlled trials comparing any beta-lactam antibiotic monotherapy to any combination of a beta-lactam and an aminoglycoside antibiotic, for the initial, empirical treatment of febrile neutropaenic cancer patients . DATA COLLECTION AND ANALYSIS: Data concerning mortality, treatment failure (including treatment modifications), superinfections, adverse effects and study quality measures were extracted independently by two reviewers . Relative risks with their 95% confidence intervals (CI) were estimated . Outcomes were extracted by intention-to-treat analysis whenever possible . MAIN RESULTS: Forty-six trials and 7642 patients were included . All cause mortality was the primary outcome assessed . For all mortality comparisons, no significant difference between monotherapy and combination therapy was seen, relative risk 0.85 (95% CI 0.72-1.02) for all studies combined . Treatment failure was the outcome reported in all included trials . No significant difference between study groups was shown for studies comparing the same beta-lactam, relative risk 1.12 (95% CI 0.96-1.29) . A significant advantage to monotherapy was observed for studies comparing different beta-lactams, relative risk 0.86 (95% CI 0.80-0.93) . Bacterial and fungal superinfections developed with similar frequencies in the monotherapy and combination treatment groups . Adverse events were significantly more common in the combination treatment group, relative risk 0.83, (95% CI 0.72-0.97) . These included events associated with significant morbidity, primarily renal toxicity . Results were consistent for subgroup and sensitivity analyses . REVIEWER'S CONCLUSIONS: We have shown an advantage to broad-spectrum beta-lactam monotherapy over beta-lactam-aminoglycoside combination therapy for febrile neutropaenia . This advantage comprises of 1) a similar, if not better, survival, 2) a significantly lower treatment failure rate, 3) comparable probability for secondary infections and, 4) most importantly, a lower rate of adverse events associated with significant morbidity . Monotherapy can be regarded, therefore, as the standard of care for febrile neutropaenic patients. Cochrane Database Syst Rev . 2003;(3):CD001127. Recombinant human deoxyribonuclease for cystic fibrosis; Jones AP et al.; BACKGROUND: Recombinant human deoxyribonuclease (rhDNase) is currently used to treat pulmonary disease (the major cause of morbidity and mortality) in cystic fibrosis . OBJECTIVES: To determine whether the use of rhDNase in cystic fibrosis is associated with improved mortality and morbidity compared to placebo or other mucolytics and to identify any adverse events associated with its use . SEARCH STRATEGY: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group trials register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and abstracts from conferences.Date of the most recent search of the Group's register: January 2003 . SELECTION CRITERIA: All randomized and quasi-randomized controlled trials where rhDNase was compared to either placebo, standard therapy or another mucolytic . DATA COLLECTION AND ANALYSIS: Trials were independently assessed for inclusion criteria and the lead reviewer and a colleague carried out analysis of methodological quality and data extraction . MAIN RESULTS: The searches identified 38 trials, of which 12 trials met our inclusion criteria, including a total of 2294 participants . Three additional studies examined the health care cost from one of the clinical trials . Ten studies compared rhDNase to placebo; one compared daily rhDNase with hypertonic saline and alternate day rhDNase; and one compared daily rhDNase to hypertonic saline . Study duration varied from six days to two years . The number of deaths was not significant between treatment groups . Lung function improved in the treated groups, with significant differences at one month, three months, six months and two years . The mean percentage change in FEV1in the two largest trials were 5.80 (95% CI 3.99 to 7.61) and 3.24 (95% CI 1.03 to 5.45) . There was no excess of adverse effects except voice alteration (and rash, which were reported more frequently in one trial in the treated groups . Insufficient data wer