Clin Infect Dis, 1995 Aug, 21(2), 380 - 9 Persistence of Borrelia burgdorferi sensu lato in resolved erythema migrans lesions; Strle F et al.; Erythema migrans skin lesions resulting from a tick bite and infection with Borrelia burgdorferi sensu lato eventually resolve, even without antibiotic therapy . The aim of the present study was to gauge the frequency of persistence of B . burgdorferi sensu lato in such lesions . Thus, the site of a previous lesion was biopsied and cultured in 48 patients: 39 with systemic or localized symptoms/signs and nine with no symptoms . B . burgdorferi sensu lato was isolated from biopsied skin from three symptomatic patients . Cultures of other tissues and fluids were negative . By genospecies-specific polymerase chain reaction (PCR) and pulsed-field gel electrophoretic (PFGE) analysis, two isolates were classified as Borrelia afzelii . The remaining isolate was a member of an unusual group of strains that type as B . burgdorferi sensu stricto by genospecies PCR but possess an atypical PFGE profile . All three patients had a dramatic clinical response to antibiotic treatment . These findings demonstrate the capacity of viable B . burgdorferi sensu lato organisms to persist in clinically normal-appearing skin at the site of a resolved erythema migrans rash for periods ranging from 2 months to 3.5 years . This observation may provide new insight into the organisms' ability to evade the host's immune response. J Antimicrob Chemother, 1995 Aug, 36(2), 403 - 9 Evaluation of an antibiotic prescribing protocol for treatment of acute exacerbations of chronic obstructive airways disease in a hospital respiratory unit; Boyter AC et al.; A prescribing protocol for infective exacerbations of chronic obstructive airways disease (COAD), specifying the use of oral amoxycillin 500 mg tid (or erythromycin 500 mg qid if allergic) as first line therapy, and oral ciprofloxacin 500 mg bd as second line treatment, was introduced in 1991 . Every third sequential admission was screened for the year preceding (1990) and the year after (1991) the protocol was implemented . Only those patients with a discharge diagnosis of infective exacerbation of COAD, but without pneumonia, were included in the analysis . The two groups (1990 and 1991) were matched in terms of age, sex and pre-treatment given by their General Practitioner (GP), but differed with respect to severity score, with 1991 being more severe . The outcome measures showed that duration of hospital stay was comparable as was duration of treatment . Response to first line therapy was 68% and 67% for 1990 and 1991, respectively . Of those who had received antibiotics from their GP, 67% responded to first line therapy, while of those who had not received antibiotics from their GP 75% responded . Duration of therapy was shorter in first line responders (mean and 95% CI: 7.3 (6.3-8.3) days vs 12.7 (10.1-15.3) days) . The mean cost per day antibiotic treatment was reduced by 54.6% (95% CI 52.3-56.9%) from 3.77 pounds to 1.71 pounds . In conclusion, the introduction of antibiotic prescribing guidelines for treatment of infective exacerbations of COAD showed no detrimental effect on outcome measures, but was associated with a significant reduction in the cost of antibiotic therapy. Ann Thorac Surg, 1995 Aug, 60(2 Suppl), S118 - 20; discussion S120-1 Viability studies of human valves prepared for use as allografts; Armiger LC; The preimplantation viability status of pulmonary and aortic valves prepared for use as allografts by the methods in current use at Green Lane Hospital, Auckland was determined by autoradiography and culture . The valves were obtained from cadaver donors, disinfected in antibiotic solution and stored by cryopreservation . A group of 45 banked valves considered unsuitable for clinical use was assayed initially and very few were found to have viable fibroblasts in their leaflets . A series of 29 valves collected at postmortem examination then was assayed sequentially after each phase of the preparation procedure . Valves obtained within 24 hours of donor death usually retained considerable viability . However, in all but a minority of cases this declined markedly after antibiotic treatment and further still after cryopreservation, so that most valves were nonviable when thawed. J Clin Oncol, 1995 Aug, 13(8), 2072 - 6 Recurrent chiasmatic-hypothalamic glioma treated with oral etoposide; Chamberlain MC et al.; PURPOSE: Chiasmatic-hypothalamic gliomas are not amenable to surgical resection and therefore are treated with either radiotherapy or chemotherapy . Here we report the use of etoposide (VP-16) administered on a chronic oral schedule as a novel chemotherapeutic approach . PATIENTS AND METHODS: Fourteen patients, aged 2 to 15 years, were treated with VP-16 after clinical and neuroradiographic tumor progression . Thirteen patients had received prior radiotherapy, and 12 received prior nitrosourea-based chemotherapy . VP-16 was administered orally, each cycle consisting of 50 mg/m2/d on day 1 through 21 and 36 through 57 . Clinical and neuroradiographic evaluations were performed during days 58 through 72 before initiation of each cycle of therapy . Complete blood counts were performed weekly . RESULTS: Treatment-related complications included the following: partial alopecia (seven patients); diarrhea (six); weight loss (five); neutropenia (four); and thrombocytopenia (four) . Three patients required transfusion (three RBC; two platelet), and one patient required antibiotic treatment of neutropenic fever . There were no treatment-related deaths . Fourteen patients were assessable, five of whom demonstrated a radiographic response (one complete and four partial); and three patients demonstrated stable disease, with a median duration of response of 8 months . CONCLUSION: Chronic oral VP-16 is well tolerated, produces modest toxicity, and has apparent activity in this small cohort of patients with recurrent chiasmatic-hypothalamic gliomas. J Neurol Neurosurg Psychiatry, 1995 Aug, 59(2), 175 - 7 Application of the polymerase chain reaction to monitor Mycobacterium tuberculosis DNA in the CSF of patients with tuberculous meningitis after antibiotic treatment; Lin JJ et al.; The polymerase chain reaction (PCR) was used to detect Mycobacterium tuberculosis DNA in 29 CSF specimens from seven patients with tuberculous meningitis after the start of antituberculous chemotherapy . Ten of the 13 CSF specimens taken from these patients with an initial treatment of three weeks were positive for the PCR study . By contrast, only one of the other 16 CSF specimens taken from patients treated for more than three weeks was positive . This study shows that M tuberculosis DNA can exist in the CSF of a patient with tuberculous meningitis for three weeks after treatment and that PCR can still be a sensitive method to detect M tuberculosis DNA in the CSF after the start of treatment in patients with tuberculous meningitis. Rev Esp Enferm Dig, 1995 Aug, 87(8), 597 - 600 {Acute pancreatitis associated with hepatotoxicity induced by amoxicillin-clavulanic acid}; Galindo C et al.; A 25-year old man suffered from acute pancreatitis and cholestatic acute hepatitis simultaneously after 4 weeks of an antibiotic treatment withdrawal (amoxicillin plus clavulanic acid) which was given for pharyngitis . Other potential etiological causes of both acute pancreatitis and liver disease, were excluded . The causal relationship between amoxicillin plus clavulanic acid and cholestatic hepatitis is well know, but no data has been reported regarding acute pancreatitis . The medical literature is reviewed and the mechanisms of toxicity are discussed. Arch Pediatr, 1995 Aug, 2(8), 742 - 6 {Frequency of gastroesophageal reflux in infants and in young children with cystic fibrosis}; Vic P et al.; BACKGROUND--Gastro-esophageal reflux (GER) is common in chronic bronchopulmonary diseases, and may aggravate them . The aim of this study was to study frequency and characteristics of GER in infants and toddlers with cystic fibrosis (CF) . POPULATION AND METHODS--Twenty-five CF patients, 45 to 954 days-old (mean 219 days) without clinical evidence of bronchopulmonary infection, were studied by prolonged pHmetry (19.45 +/- 1.89 hours) . Their pulmonary state was evaluated by the number of previous courses of antibiotic treatment and analysis of the X-rays . RESULTS--Nineteen children had GER (76%); four of them had no clinical sign of GER . All 19 patients had mild or moderate signs of pulmonary impairment . The reflux index (percentage of time with pH < 4) was 12.82% . The GER episodes were more frequent during walking time (p < 0.001), but longer during sleeping time (p < 0.001) . CONCLUSIONS--GER is frequent in CF patients, even the youngest . It seems primary, and not related to pulmonary impairment . Its frequency and its potential severity lead to suggesting a pHmetry to every new CF patient. Ann Hematol, 1995 Aug, 71(2), 65 - 70 Optimal timing of granulocyte colony-stimulating factor (G-CSF) administration after bone marrow transplantation . A prospective randomized study; Torres Gomez A et al.; The positive role of G-CSF in hastening the myeloid recovery of patients undergoing allogeneic bone marrow transplantation (ALLO-BMT) or autologous bone marrow transplantation (ABMT) has recently been established . Considerable knowledge about adequate doses and route of administration has been accumulated in the past few years . Nonetheless, the optimal time to start growth-factor administration remains undetermined . We have performed a stratified study according to the source of hematopoietic progenitors (ALLO-BMT or ABMT), underlying disease and its stage, and acute graft-versus-host disease (GVHD) prophylaxis regimen and randomized patients in two arms: group A, which started G-CSF on day 0 (36 patients), and group B, which started on day +7 post-BMT (39 patients) . The same dose (5 micrograms/kg/day) and route of administration were employed in both groups . We found no significant differences in the time to reach an absolute neutrophil count (ANC) of 0.1, 0.5, and 1 x 10(9)/l and 50 x 10(9) platelets/l (medians: 10 and 11, 14.5 and 14, 17 and 16, 23 and 24 days, respectively, in groups A and B) . We did not find differences in the days of fever or days on antibiotic treatment with less than 1 x 10(9)/l ANC, rate of bacteriemia, or days of hospitalization in both groups . In contrast, a considerable saving of G-CSF in B group was found (mean days of infusion in group A, 18, versus 11 in group B) (p < 0.0001) . This is equivalent to a saving of 1120 $US per patient.(ABSTRACT TRUNCATED AT 250 WORDS) Berl Munch Tierarztl Wochenschr, 1995 Jul, 108(7), 253 - 5 {Effectiveness of oral rifampicin against mycobacteriosis in tropical fish}; Boos S et al.; In vitro studies have shown that rifampicin is an effective antibiotic for mycobacteria infections . Two species of tropical fish, the Firemouth Cichild Cichlasoma meeki and the Congo Tetra Phenacogrammus interruptus, were used to determine whether oral application of rifampicin might serve as an effective treatment for mycobacteriosis in tropical fish . Fish of the two species were infected with M . marinum under controlled conditions . Six or twelve weeks after infection, treatment was begun with medicated fish food containing rifampicin in combination with tetracyclin . Histological examination of epithelial cell granuloma in the anterior and posterior kidneys, as well as in liver and spleen, showed that antibiotic treatment could somewhat reduce the intensity of, but could not successfully eliminate infection . In addition, after treatment, acid-resistant rods could still be isolated from histological samples and M . marinum could be cultured from organ samples. Am J Cardiol, 1995 Jul 1, 76(1), 97 - 100 A prospective study of the seroprevalence of Borrelia burgdorferi infection in patients with severe heart failure; Sonnesyn SW et al.; We conclude that Lyme disease is not a common cause of idiopathic heart failure in the Midwestern United States and that false-positive Lyme disease serologic results are not rare among patients with severe heart failure . Patients with significant cardiac disease who are found to be EIA seropositive should have confirmatory Western blots performed before consideration of treatment . Based on our findings, we cannot recommend either the routine serologic screening of patients with idiopathic cardiomyopathy or aggressive (e.g., parenteral) antibiotic treatment of seropositive patients unless the specific clinical history suggests antecedent Lyme disease. Rev Esp Enferm Dig, 1995 Jul, 87(7), 535 - 7 {Bacterial overgrowth secondary to intestinal diverticulosis}; Montalvo II et al.; Jejunal diverticulosis is an unusual finding . We present the case of 70-year-old man with bacterial overgrowth secondary to multiple diverticula of the small intestine . The diagnosis was based on clinical events, x-ray films and mainly on the optimal answer to antibiotic treatment. An Med Interna, 1995 Jul, 12(7), 340 - 2 {Splenic abscess following gynecologic infection with complete response to antibiotic treatment}; Fombuena Moreno M et al.; A 37 year old woman is presented with solitary splenic abscess, without involvement of other organs, in the context of septic abortion . Splenic abscess were effectively treated with 21 days of antibiotic administration, not was necessitated splenectomy and percutaneous drainage . Emphasis is laid on its rarity of solitary splenic abscess in the course of gynecologic infection, and complete response to antibiotic treatment. Ned Tijdschr Geneeskd, 1995 Jun 24, 139(25), 1291 - 5 {Treatment of acute ethmoiditis according to a protocol based on clinical stage}; Middelweerd MJ et al.; OBJECTIVE: To describe the results of application of a systematic treatment protocol, meant to reduce the risk of serious complications, when treating acute ethmoiditis . DESIGN: Prospective study . SETTING: Academic hospital of the 'Vrije Universiteit (VU)', Amsterdam, The Netherlands . METHOD: From January 1988 to March 1994, 25 children with acute ethmoiditis were admitted to the VU hospital . Eight of them had Chandler stage I, 8 stage II, 3 stage III, 3 stage IV and 3 stage V . The treatment protocol was stepwise, based on the Chandler stages and focused on intensive antibiotic treatment in combination with surgical drainage of the ethmoid complex and (or) the orbit . RESULTS: All children with ethmoiditis stages I-III were cured without rest symptoms . One patient with ethmoiditis stage IV and a pre-existent lymphatic leukaemia died of pulmonary complications of a massive fungal infection, 8 months after treatment . One patient with ethmoiditis stage V finally had permanent psychomotor retardation . CONCLUSION: The used treatment protocol offered the possibility to treat patients with acute ethmoiditis stepwise, depending on stage, with satisfying results . Especially the treatment result in patients with ethmoiditis stage V was good. Adv Ther, 1995 Jul-Aug, 12(4), 199 - 206 Cost considerations in oral antibiotic therapy; Ballow CH; The total cost of antibiotic treatment may be computed from basic treatment and indirect costs . Basic treatment costs represent the product of the per-dose acquisition cost and the number of doses . Agents with a high per-dose acquisition cost and an infrequent (eg, once daily), short duration of therapy may have lower total costs than agents with a low per-dose acquisition cost and a high-frequency (eg, four times daily), long-duration regimen . Indirect cost reflects expenditures associated with noncompliance, treatment failure, adverse events, and drug interactions . These costs result, in turn, from additional office visits, treatment with alternative or additional medications, hospitalization, and lost productivity . Older agents, though likely to have lower acquisition costs, may have reduced efficacy against clinically important pathogens, side effects, drug interactions, and the requirement for multiple daily doses and long dosage regimens--factors that may increase the probability of poor outcome and the overall treatment cost . Newer broad-spectrum agents are effective and generally well tolerated and may have fewer drug interactions; however, most require long and relatively complex dosage regimens . These limitations increase the basic treatment cost and influence indirect costs through negative effects on patient compliance . Broad-spectrum antibiotics with low acquisition costs, simple dosing regimens, and relatively favorable safety and tolerability profiles may provide benefits in the treatment of common infections. Am J Clin Pathol, 1995 Jun, 103(6), 761 - 6 Lymphocytosis of gamma/delta T cells in human ehrlichiosis; Caldwell CW et al.; The majority of T cells in peripheral blood express a T-cell receptor (TCR) comprised of alpha and beta chains . An alternate form of the TCR is comprised of gamma and delta chains . These gamma/delta T cells are associated with certain infectious lesions, and modestly elevated in peripheral blood in certain disease states . Human ehrlichiosis is characterized by hematologic abnormalities including multi-lineage cytopenias . In most cases reported, a lymphocytopenia has been present either at diagnosis, or at some time during the illness . Early in the course of antibiotic treatment (48-72 hours), the lymphocytopenia corrects itself and is rapidly followed by a lymphocytosis of T cells that express CD3, but are negative for CD4 and CD8, as well as the major form of the TCR formed by the alpha/beta heterodimer . Instead, these CD3+4-8- T cells express the gamma/delta heterodimer associated with V gamma 9 and V delta 2 chains, a population of cells usually the distinctive minority of peripheral blood T cells, but constituting the major phenotype of peripheral gamma/delta T cells. Drugs Aging, 1995 Jun, 6(6), 456 - 64 Bacteraemia in the very old . Features and treatment; Leibovici L; Bacteraemia is a common disorder in the elderly, and its prevalence and incidence increase with age . It carries a mortality rate of 20 to 40% . The signs and symptoms of bacteraemia are often blunted or nonspecific in the elderly, and the index of suspicion should therefore be high . Comparing underlying disorders of bacteraemia between older and younger patients, the percentage of past cerebrovascular accidents, dementia and decubitus ulcer increases sharply with age, while the percentage of neutropenia is lower . Elderly patients have a predilection for anaerobic bloodstream infections, and for multiresistant bacteria, although age is not an independent risk factor for resistance . Bacterial endocarditis in the old is caused mainly by gut bacteria . Appropriate empirical antibiotic treatment reduces mortality, regardless of age . To target antibiotic treatment, the physician should consider the patient's salient features, and the overall susceptibility of the micro-organisms in the local ecosystem . The most important supportive measure for treatment of sepsis or septic shock is fluid repletion . No non-antibiotic drug has been shown to be effective in sepsis. Spine, 1995 Jun 1, 20(11), 1304 - 6 Septic arthritis of a lumbar facet joint and a sternoclavicular joint; Dauwe DM et al.; STUDY DESIGN . This is a case report . OBJECTIVES . To the authors' knowledge, simultaneous septic arthritis of a lumbar facet joint and another joint has not been described as yet . Therefore, a patient is presented in whom both a lumbar facet joint (L4-L5 on the right) and a sternoclavicular joint were involved . SUMMARY OF BACKGROUND DATA . Septic arthritis of a lumbar facet joint is a rare condition, and only a few cases have been reported in the literature . METHODS . The etiology, clinical presentation, technical examinations, and treatment are reviewed . RESULTS . Antibiotic treatment was sufficient to heal these lesions . CONCLUSION . Antibiotic treatment was sufficient to heal these lesions. Anasthesiol Intensivmed Notfallmed Schmerzther, 1995 Jun, 30(4), 252 - 6 {Severe legionellosis after abuse of anti-inflammatory drugs--diagnostic and intensive care aspects based on a case report}; Bein T et al.; Legionella infections are getting increasingly important as causes of severe pneumonias or of acute respiratory insufficiency . Consumptive or immunosuppressive underlying diseases such as diabetes mellitus, cardiac insufficiency, alcohol-induced liver damage, malignant tumours or drug-induced immunosuppression after organ transplantation, are among the risk factors . Diagnosis is based on direct identification of the pathogen from body secretions by means of direct immunofluorescence . The serological immunoresponse often takes place long after outbreak of the disease or fails entirely to appear and is therefore only suitable for retrospective confirmation . Therapy of choice is an intravenous administration of erythromycin . There are now increasing pointers to the efficiency of fluoroquinolone antibiotics, such as ciprofloxacin . We report on the course of a severe case of legionnaire's disease with multiple organ failure occurring in a patient after bone marrow depression induced by anti-inflammatory drugs . Treatment erythromycin resulted in a marked cholestasis, so that antibiotic treatment was changed to ciprofloxacin . This therapy as well as the supportive intensive-care treatment eventually led to the patient's complete recovery . Based on the case report, fundamental aspects of diagnostics, antibiotic treatment, intensive-care treatment and prognosis of severe cases of legionellosis are discussed. Vet Hum Toxicol, 1995 Jun, 37(3), 243 - 4 Promethazine toxicity in a seven-month-old Doberman pinscher; Staley EC et al.; A 7-mo-old female Doberman Pinscher undergoing antibiotic treatment for tonsillitis was presented in near collapse with markedly low blood pressure, tachycardia, dilatation of pupils (non-responsive to light), and gastrointestinal distress . Since the owner could provide no history of significant toxin exposure, general supportive and non-specific toxicologic treatment protocols were initiated . Within 4 h marked improvement was observed . The owner's wife revealed that promethazine suppositories had been administered at a toxic level to control the vomition accompanying the tonsillitis. J Hosp Infect, 1995 Jun, 30 Suppl, 268 - 74 Antibiotic treatment of ophthalmic infection: new developments; Andrews V; The introduction of quinolones has dramatically altered antibiotic therapy for serious ophthalmic infections . The newer cephalosporins are also playing a more significant role . The recently introduced macrolides, particularly azithromycin, have great potential for treating not only serious infections, but also some of the less serious ones . These new developments are discussed, and the cost implications of new antibiotic treatment on ophthalmology is described. Eur J Surg, 1995 Jun, 161(6), 431 - 3 Timing of antibiotic treatment in non-perforated gangrenous appendicitis; Almqvist P et al.; OBJECTIVE: To assess whether antibiotic treatment with cefuroxime and tinidazole started during the operation was as effective as treatment started before operation in patients with gangrenous non-perforated appendicitis . DESIGN: Prospective randomised study . SETTING: University hospital, Sweden . SUBJECTS: 114 patients with gangrenous, non-perforated appendicitis who had had antibiotics started before operation and 120 whose treatment was started during operation out of a total of 575 who presented with a presumptive diagnosis of appendicitis . MAIN OUTCOME MEASURES: Morbidity and mortality . RESULTS: There were no deaths, and the rates of infective complications were 1/114 (0.9%) and 3/120 (3%), respectively . The median hospital stay was four days in both groups . CONCLUSION: Antibiotic treatment started during the operation is not significantly worse at preventing infective complications in non-perforated, gangrenous appendicitis than treatment started before the operation. BMJ, 1995 May 27, 310(6991), 1360 - 2 Oral versus intravenous antibiotics for community acquired lower respiratory tract infection in a general hospital: open, randomised controlled trial; Chan R et al.; OBJECTIVE--To see whether there is a difference in outcome between patients treated with oral and intravenous antibiotics for lower respiratory tract infection . DESIGN--Open controlled trial in patients admitted consecutively and randomised to treatment with either oral co-amoxiclav, intravenous followed by oral co-amoxiclav, or intravenous followed by oral cephalosporins . SETTING--Large general hospital in Dublin . PATIENTS--541 patients admitted for lower respiratory tract infection during one year . Patients represented 87% of admissions with the diagnosis and excluded those who were immunocompromised and patients with severe life threatening infection . MAIN OUTCOME MEASURES--Cure, partial cure, extended antibiotic treatment, change of antibiotic, death, and cost and duration of hospital stay . RESULTS--There were no significant differences between the groups in clinical outcome or mortality (6%) . However, patients randomised to oral co-amoxiclav had a significantly shorter hospital stay than the two groups given intravenous antibiotic (median 6 v 7 and 9 days respectively) . In addition, oral antibiotics were cheaper, easier to administer, and if used routinely in the 800 or so patients admitted annually would lead to savings of around 176,000 pounds a year . CONCLUSIONS--Oral antibiotics in community acquired lower respiratory tract infection are at least as efficacious as intraveous therapy . Their use reduces labour and equipment costs and may lead to earlier discharge from hospital. Rev Prat, 1995 May 15, 45(10), 1239 - 41 {Treatment of COPD (excluding acute distress)}; Fournier M et al.; There is no available drug which has been demonstrated to reverse the pathological lesions associated with chronic obstructive pulmonary disease, either at the bronchial or at the parenchymal level . Bronchodilators may improve dyspnea and exercise tolerance; in some patients, they may also decrease moderately airflow obstruction . Their benefit on the rate of decline of forced expiratory volume in one second has not been documented . In the same way, the regular use of inhaled steroids has not been shown to prevent or limit the degradation of pulmonary function . On the other hand, long term oxygen supply improves the life expectancy of patients with chronic hypoxemia . Antibiotic treatment of exacerbations is recommended; however, the rationale for its use is still a matter of debate. Pharmacoeconomics, 1995 Jun, 7(6), 543 - 54 The use of first- and second-line outpatient antibiotics under the Saskatchewan Drug Plan; McCombs JS et al.; The Saskatchewan Drug Plan proposed de-listing several second-line antibiotics from its formulary for reasons of potential overuse and expense . This study evaluated the use of second-line antibiotics as initial and secondary courses of therapy depending on the patient's prior use of other antibiotics and other factors . A total of 637,607 courses of therapy dispensed to Plan members for selected antibiotics between July 1989 and June 1990 were evaluated . Second-line antibiotics were used in 5.0% of all initial courses of therapy . This use was correlated with patient characteristics that may warrant use of second-line antibiotics as initial therapy: age, rural residence, the use of bronchodilators or inhaled steroids, and the number of prior courses of antibiotic therapy . The potential savings from de-listing second-line antibiotics from the formulary are limited because of their use in only 5% of all initial courses of therapy . Savings would be further reduced by administrative costs and physician time required to process prior authorisation requests, and the costs of treating any additional antibiotic treatment failures that may result from reduced access. Dtsch Med Wochenschr, 1995 May 5, 120(18), 636 - 40 {Agranulocytosis caused by infectious-toxic bone marrow damage after Borrelia infection}; Kamp T et al.; A 19-year-old girl developed a fever of up to 40 degrees C and, during an episode of high fever, generalized seizures . Physical examination on admission was unremarkable, except for several small lymph nodes . Differential blood count showed a leukopenia (1700/microliters) with 14% stab and 7% segmented neutrophils . After initial clinical improvement she again became feverish and the differential count now showed agranulocytosis with a total white cell count of 1400/microliters . Because of the time of year and the geographic location borreliosis was now considered in the differential diagnosis . The antibody titre against Borrelia was raised to 1:64 (IgM) and 1:256 (IgG) . Her condition and the differential blood count rapidly improved on intravenous antibiotic treatment with cefotiam (2 g two times daily) and gentamicin (120 mg two times daily), as well as filgrastim (granulocyte-colony stimulating factor) subcutaneously . Antibiotic treatment was continued after 6 days with oral ampicillin (1 g three times daily) for 3 weeks . Follow-up examination six weeks later found the patient to be symptom-free. Ophthalmology, 1995 May, 102(5), 713 - 7 Proptosis as the initial presentation of fungal sinusitis in immunocompetent patients; Heier JS et al.; BACKGROUND: Fungal sinusitis typically occurs in immunocompromised patients . The authors report four cases of fungal sinusitis in immunocompetent young adults, all of whom had proptosis . METHODS: The diagnosis in all four patients was determined after orbital imaging and sinus biopsies . RESULTS: All four patients required surgical removal of the fungal source and anti-fungal chemotherapy postoperatively . CONCLUSION: Patients with proptosis, ocular pain, or other symptoms suggestive of orbital cellulitis unresponsive to antibiotic treatment should undergo radiographic imaging . If sinus disease is present, biopsy and culture may lead to the diagnosis of fungal disease . Surgical debridement and the appropriate systemic antifungal therapy usually lead to cure. Am J Emerg Med, 1995 May, 13(3), 333 - 6 Clinical indicators of childhood retropharyngeal abscess; Gaglani MJ et al.; Retropharyngeal abscess is a rare but distinctive cause of airway obstruction in childhood . Early recognition permits emergent airway management and surgical drainage . Even when the presentation is insidious and does not include respiratory compromise, early clinical diagnosis of retropharyngeal cellulitis and appropriate medical treatment may halt progression to an abscess . Delay in the diagnosis and management of a retropharyngeal abscess may lead to potentially lethal complications involving vital structures . A case of an infant whose diagnosis of retropharyngeal abscess was delayed because of absence of respiratory compromise is reported . Relapse of retropharyngeal abscess despite surgical drainage and appropriate antibiotic treatment was a complication of infection in this patient . Clinical indicators providing an early diagnosis of retropharyngeal infection, and aspects of evaluation, management, and outcome, are discussed. Am J Respir Crit Care Med, 1995 May, 151(5), 1491 - 6 Efficacy, safety, and therapeutic relevance of transthoracic aspiration with ultrathin needle in nonventilated nosocomial pneumonia; Dorca J et al.; In order to determine the potential indications of transthoracic needle aspiration (TNA) using the ultrathin 25G needle for the diagnosis of nonopportunistic lung infections, we prospectively analyzed the diagnostic efficacy, safety, and therapeutic implications of its results in 97 patients with nonventilated nosocomial pneumonias (NVNP) . The sensitivity of TNA was 60.9% . Specificity and positive predictive value (PPV) were 100% . Negative predictive value (NPV) was 34.1% . The complications in the studied cases were nil in 89 cases (91.8%), transient hemoptoic expectoration (< 10 ml) in five (5.2%), and self-limited partial pneumothorax in three (3.1%) . No complications needing treatment were observed . On the basis of a positive TNA result, the initial antibiotic treatment was modified in 29 of 97 (29.9%) cases . In twelve of these, the empirical antibiotic regimen was demonstrated to be ineffective . We conclude that, using the 25G needle, TNA has a good diagnostic efficacy and is a safe procedure for the etiologic investigation of NVNP . A positive TNA result has significant therapeutic relevance, even in cases where broad-spectrum antibiotics are empirically prescribed. Arch Neurol, 1995 May, 52(5), 509 - 13 Recurrent chiasmatic-hypothalamic glioma treated with oral etoposide; Chamberlain MC; BACKGROUND: Chiasmatic-hypothalamic gliomas are not amenable to surgical resection and therefore are treated with either radiotherapy or chemotherapy . Etoposide (VP-16), administered on a long-term oral schedule, represents a novel chemotherapeutic approach . PATIENTS AND METHODS: Fourteen patients (age range, 2 to 15 years) were treated with etoposide following tumor progression as determined by clinical and neuroradiographic examinations . Thirteen patients had received prior radiotherapy, and 12 received prior nitrosourea-based chemotherapy . Etoposide was administered orally; each cycle consisted of 50 mg/m2 per day on days 1 to 21 and days 36 to 57 . Clinical and neuroradiographic examinations were performed from days 58 to 72 prior to the start of each cycle of therapy . Complete blood cell counts were performed weekly . RESULTS: Treatment-related complications included partial alopecia (n = 7), diarrhea (n = 6), weight loss (n = 5), neutropenia (n = 4), and thrombocytopenia (n = 4) . Three patients required a transfusion (ie, red blood cell {n = 3} and platelet {n = 2} transfusions), and one patient required antibiotic treatment of neutropenic fever . There were no treatment-related deaths . Fourteen patients were evaluable; in eight of these 14 patients, a response was demonstrated radiographically (complete response {n = 1}, partial response {n = 4}, and stable disease {n = 3}), with a median duration of response of 8 months . CONCLUSIONS: Long-term treatment with oral etoposide was well tolerated by the patients in this study, and etoposide was a relatively nontoxic chemotherapeutic agent with apparent activity in this small cohort of patients who had recurrent chiasmatic-hypothalamic gliomas. Am Surg, 1995 May, 61(5), 403 - 6 Interaction of vecuronium with piperacillin or cefoxitin evaluated in a prospective, randomized, double-blind clinical trial; Condon RE et al.; Interactions between beta-lactam antibiotics, particularly acylaminopenicillins, and vecuronium, a widely used muscle relaxant, leading to prolonged neuromuscular blockade have been reported in studies of experimental animals and in a few clinical case reports . In the clinical reports, however, confounding factors always existed . A clinical trial to evaluate interactions between vecuronium and cefoxitin or piperacillin was conducted . Patients having major operations requiring both muscle relaxants as part of general anesthesia and prophylactic antibiotics were entered into the trial and randomly assigned to receive either cefoxitin or piperacillin . The electromyographic twitch response was measured before and after administration of the antibiotic . Five of 27 evaluable patients had minor prolongation of the time to recovery of baseline twitch . No prolonged neuromuscular blockade was observed . There were no differences in responses between the two antibiotic treatment groups . Cefoxitin and piperacillin administered pre- or intra-operatively are not associated with clinically important prolongation of muscle relaxation induced by vecuronium . The potential for prolongation of neuromuscular blockade induced by vecuronium through concomitant administration of piperacillin or cefoxitin as antibiotic prophylaxis was investigated in a clinical trial of 30 patients having major abdominal operations . Quantitative measurement of neuromuscular blockade was done using the electromyographic twitch response to a supramaximal current stimulus. Rev Esp Enferm Dig, 1995 May, 87(5), 357 - 61 {A comparative study of 2 technics of percutaneous endoscopic gastrostomy}; Fernandez I et al.; OBJECTIVE: To compare the two most frequently used methods of percutaneous endoscopic gastrostomy: Pull-string Ponsky-Gauderer type and Push-over-wire Sachs-Vine gastrostomy . PATIENTS AND METHODS: Forty-four patients with oral feeding incapacity were prospectively randomized to one of the two methods of percutaneous endoscopic gastrostomy . In 22 patients the Ponsky-Gauderer type were used and in the other 22 the Sachs-Vine gastrostomy were employed . In every case the gastrostomy tube was replaced 4-5 months after its placement by a Flexiflo tube . The mean follow-up of the patients was 7.3 months (range: 4-18) . RESULTS: Gastrostomy was successful in every case . No differences were found between the two procedures in technical difficulties or complications during gastrostomy placement . Wound infection occurred in 6 patients (13%), 3 in each group, and in all cases it was cured with topic antibiotic treatment administered through the gastrostomy . Tube dislodgement was observed in 3 patients in the Ponsky-Gauderer group (soft internal with-holder) . The only significant difference between the two procedures was found at the removal of the gastrostomy tube . In the Sachs-Vine type the removal of the tube was always endoscopically performed (due to the presence of a rigid internal with-holder), while the Ponsky-Gauderer type was always done by traction (soft internal with-holder) . No related procedure mortality was found with any of the two techniques . CONCLUSION: Both percutaneous endoscopic gastrotomy techniques are similar in efficacy, safety and morbidity and they prove to be a valid alternative to surgical gastrostomy in patients with oral feeding incapacity. Leber Magen Darm, 1995 May, 25(3), 122, 125 - 7 {Short-term triple therapy with pantoprazole, clarithromycin and metronidazole in eradication of Helicobacter pylori}; Labenz J et al.; In a prospective study, thirty consecutive patients presenting with either H.pylori positive (histology and/or culture) ulcer disease (n = 17; acute ulcer: n = 11) or functional dyspepsia (n = 13) were treated over one week with pantoprazole 40 mg bd, clarithromycin 250 mg bd and metronidazole 400 mg bd . Four weeks after discontinuation of the study medication H.pylori eradication was assessed by means of an urease test, culture and histology . One patient had to be withdrawn from the study after one day because of a concomitant infectious disease requiring long-term antibiotic treatment . Another patient refused the final follow-up endoscopy . 28 patients completed the study without contravening the protocol . H.pylori infection was eradicated in 24 out of 28 patients (eradication rate: 86%; 95%-confidence interval: 57%-96%) . Cure of bacterial infection was more frequently obtained in ulcer patients as compared to patients suffering from functional dyspepsia (94% vs 75%; p = 0.28) . In 2 patients, treatment failure was associated with pretherapeutic resistance of H . pylori to either clarithromycin or metronidazole . Without antiulcer treatment beyond eradication therapy, ulcer healing was endoscopically confirmed after 5 weeks in 9 out of 10 patients available for follow-up (healing rate: 90%; 95%-confidence interval: 56%-100%) . Seven patients reported mild adverse events that did not lead to discontinuation of the study medication (rate: 23%; 95%-confidence interval: 10%-42%) . After cure of the infection, histology demonstrated a statistically highly significant improvement (p < 0.001) of both grade and activity of antrum and body gastritis.(ABSTRACT TRUNCATED AT 250 WORDS) Hautarzt, 1995 May, 46(5), 319 - 24 {In vitro and in vivo studies of local disinfection and wound healing}; Hagedorn M et al.; Wound healing represents a dynamic process of increasing scientific interest, especially with the detection of the different growth factors . Economic aspects are also of importance in the investigation of substances used for wound healing . In Germany 25% of all patients (ca . 1 million) with severe chronic venous insufficiency have crural ulcers . The influence of bacterial infection of crural ulcers is controversial . There is no doubt that the quantity of bacteria is of importance . Local antibiotic treatment is difficult, as most of the substances used are known to inhibit wound healing . In vivo and in vitro investigations showed, that chiniofon-containing antiseptic has a bacteriostatic function . Additionally it was shown, using cultures of fibroblasts, that chiniofon-containing antiseptic does not inhibit the growth of fibroblasts, whereas PVP-iodine solution, a widely used antiseptic, clearly reduces the growth of fibroblasts . The good clinical results in the treatment of acute and chronic radiation damage indicate that chiniofon-containing antiseptic may have antiflammatory activity. J Clin Periodontol, 1995 May, 22(5), 380 - 4 Bacterial resistance following subgingival and systemic administration of minocycline; Preus HR et al.; The aim of the present study was to compare total numbers of cultivable bacteria and prevalence of resistance to minocycline among periodontal bacteria following subgingival or systemic application of minocycline in patients suffering from periodontal disease . 10 adult patients were administered 2% minocycline ointment subgingivally into their periodontal pockets at baseline, week 2 and months 1, 3, 6 and 9 . Patients had scaling/root planing at baseline and month 6 . In addition, 10 patients undergoing scaling/root planing followed by a 10-day course of systemic minocycline therapy, were studied and compared with the subgingival application group . Bacterial samples were taken from the 4 deepest pockets before each subgingival application of the drug . The systemic administration group was sampled at baseline and at week 2, as well as months 1 and 3 after completing the antibiotic treatment . For each patient at each sampling, bacterial samples were pooled, diluted, seeded on parallel blood agar plates and incubated aerobically and anerobically . After incubation, 30 colonies were picked at random and transferred to blood agar plates supplemented with 10 micrograms/ml minocycline, to estimate prevalence of minocycline-resistant bacteria . The results of this study indicate that subgingival application of minocycline ointment resulted in an initial reduction in total numbers of cultivable bacteria, which then remained depressed during the full year of the study . No such observation was made in the systemic administration . Both in the subgingival and the systemic administration group, the % of cultivable aerobic and anaerobic minocycline-resistant bacterial strains increased transiently following administration of the drug, but returned to baseline levels within 3 months post-treatment.(ABSTRACT TRUNCATED AT 250 WORDS) Am J Med, 1995 Apr 24, 98(4A), 30S - 37S; discussion 37S-43S Early disseminated Lyme disease: Lyme meningitis; Pachner AR; Lyme meningitis is the direct result of invasion of the nervous system by Borrelia burgdorferi . Occurring within the first few months of infection, it initially presents as a chronic basilar meningitis . Much about the pathogenesis of Lyme meningitis has been learned from animal models, the best being the adult Rhesus macaque . Injection of these animals with a highly infective strain of B . burgdorferi has led to a very predictable course of events: erythema migrans within the first few weeks after injection, development of anti-B . burgdorferi antibody, detection of spirochetemia in weeks 3 and 4, and central nervous system (CNS) invasion within 1 month with cerebrospinal fluid (CSF) pleocytosis . In humans, facial palsy is the earliest clinical indicator . Headache and meningismus are symptoms of inflammation of the subarachnoid space . Severe fatigue and arthralgia are common extra-CNS symptoms . Culture is not generally useful for detecting or confirming Lyme meningitis . False-positive serologic tests may occur in patients with other infections, inflammatory processes, or malignancies . Immunoblotting will differentiate true-from false-positive antibody reactivity . Lack of a consistently positive serum antibody titer should make the diagnosis of Lyme meningitis suspect . Positive CSF antibody is almost universal in patients with Lyme meningitis . Polymerase chain reaction is a direct test that is highly specific and sensitive . The antibiotic treatment of choice is intravenous (i.v.) cephalosporins or penicillin for 2-3 weeks . If the clinical picture is anything less than absolutely classic, a lumbar puncture and Western blot of serum should be obtained in a seropositive patient before initiating intravenous antibiotic therapy . There is no role at this time for long-term (> 1 month) intravenous antibiotics . Nonsteroidal antiinflammatory agents can also be of benefit. J Rheumatol, 1995 Apr, 22(4), 695 - 701 Lyme arthritis--a common manifestation in a highly endemic area in Sweden; Berglund J et al.; OBJECTIVE . To study the prevalence and the clinical features of Lyme arthritis in a Swedish area highly endemic for Lyme borreliosis . METHODS . Sera from 480 of 540 individuals living in a tick endemic area on an island in southern Sweden were tested by ELISA for IgG antibodies against Borrelia burgdorferi . A questionnaire was completed at the time serum was obtained . Antibody positive individuals who reported joint pain were examined by the authors one year later . RESULTS . Of 90 seropositive individuals, 34 (38%) reported symptoms of chronic or recurrent arthralgia . Of seronegative individuals from the same area 48/390 (12%) reported such complaints (p < 0.001) . One year later one of the 34 seropositive patients with arthralgia had died and, of the remaining, 32 still had arthralgia . Lyme arthritis was diagnosed in 11/32 (35%) of these individuals corresponding to a prevalence of 2.3% (95% confidence interval: 1.0-3.6) in the population . The prevalence of other rheumatic disorders did not differ from that found in other areas in South Sweden . Clinical and laboratory findings were in agreement with previous reports of Lyme arthritis . Other manifestations of Lyme borreliosis were found in 6 of the 11 patients with Lyme arthritis . After antibiotic treatment 9/11 (82%) remain free of complaints followed for 6 months or more . CONCLUSION . Our results indicate that arthritis and musculoskeletal symptoms of Lyme borreliosis are as common in highly endemic areas for Lyme borreliosis in Sweden as in similar areas in North America. Am J Trop Med Hyg, 1995 Apr, 52(4), 325 - 7 Eradication of Rickettsia tsutsugamushi from patients' blood by chemotherapy, as assessed by the polymerase chain reaction; Murai K et al.; The presence of Rickettsia tsutsugamushi DNA in peripheral blood mononuclear cells of eight patients with tsutsugamushi disease was determined by the polymerase chain reaction during antibiotic treatment with minocycline or doxycycline . Rickettsia tsutsugamushi DNA was detectable in all samples from these patients collected the day before treatment began . After the initiation of chemotherapy, all samples tested positive on the third or fourth day, and one sample tested positive on the eighth day, showing a slow action of the drugs against the rickettsia within cells . Immune responses against R . tsutsugamushi also seemed to be important for eradication of the pathogens, as suggested by patients' high antibody titers. J Clin Psychiatry, 1995 Apr, 56(4), 161 - 6 Bacillary angiomatosis: a treatable cause of acute psychiatric symptoms in human immunodeficiency virus infection; Baker J et al.; BACKGROUND: Bacillary angiomatosis is a systemic infection that has been most commonly reported in the setting of immunosuppression, especially human immunodeficiency virus (HIV) disease . METHOD: We report two patients who had bacillary angiomatosis who presented with psychiatric symptoms . RESULTS: The first patient presented with marked exacerbation of previous depressive disease . The second patient presented with new psychotic symptoms . In both cases psychiatric symptoms did not resolve until antibiotic treatment was given . CONCLUSION: Our report expands the clinical spectrum of bacillary angiomatosis and identifies a new cause of treatable psychiatric disease in HIV-infected persons. Stroke, 1995 Apr, 26(4), 696 - 8 Brain abscess as a complication of stroke; Chen ST et al.; BACKGROUND: Systemic infection is a common complication of stroke . However, brain abscess as a complication of stroke has never been reported . CASE DESCRIPTIONS: We report two patients, one with a hypertensive intracerebral hemorrhage and the other with nonseptic cerebral infarction . In both patients, brain abscess developed at the stroke lesion site after an infectious complication . After surgical aspiration and antibiotic treatment, one patient recovered and the other died . CONCLUSIONS: These two cases demonstrate that brain abscess may occur in a previous hemorrhage or infarction area as a complication of systemic infection . Recognition of the risk is important for early diagnosis and proper treatment of this potentially fatal complication of stroke. Chest, 1995 Apr, 107(4), 1028 - 31 C-reactive protein in simple community-acquired pneumonia; Smith RP et al.; STUDY OBJECTIVE: To assess whether C-reactive protein (CRP) is a sensitive marker of pneumonia and to evaluate whether it may be used as an index of treatment response . DESIGN: A retrospective casenote review was carried out on 40 patients admitted with simple community acquired pneumonia and 20 patients admitted with purulent bronchitis (infective exacerbations of chronic obstructive airways disease) . Serum CRP levels, in addition to other traditional markers of infection, were measured in all patients on the first day . In 21 cases of pneumonia, a second CRP measurement was available after 3 to 7 days of antibiotic therapy . RESULTS: Temperature and WBC count showed considerable overlap between the pneumonia and bronchitic groups, whereas there was no overlap in serum levels of CRP . C-reactive protein levels were above 100 mg/L in all but two cases . In the bronchitic group only 7 out of 20 had levels above the normal range (< 10 mg/L) . Mean +/- Standard Error of the Mean and lower/upper quartiles for CRP (mg/L) were as follows: pneumonia 217 +/- 16 mg/L, 130/275; purulent bronchitis, 18 +/- 3 mg/L, 10/18; {95% confidence interval (CI) for difference 153, 244 mg/L} . A CRP above 70 mg/L in pneumonia on day 1 occurred in association with a WBC count < 12 x 10(9)/L in 45% of cases and with a temperature < 37.0 degrees C in 32% . CRP levels fell to < 100 mg/L in all cases of pneumonia after antibiotic treatment: pretreatment 213 +/- 21 mg/L +/- 2, 138/270; posttreatment 31 +/- 5 mg/L, 14/47; {95% CI for difference 141, 221 mg/L} . CONCLUSION: Serum CRP may be a useful adjunctive test in pneumonia, both in terms of distinguishing parenchymal from endobronchial infection, as well as being a marker of treatment response. J Hepatol, 1995 Apr, 22(4), 410 - 5 Transarterial embolization for hepatocellular carcinoma . Antibiotic prophylaxis and clinical meaning of postembolization fever; Castells A et al.; BACKGROUND/AIMS: The aim of this prospective randomized controlled trial was to investigate the need for prophylactic antibiotherapy in patients with cirrhosis and hepatocellular carcinoma who underwent transarterial embolization and to establish the parameters that determine the development of fever > 38 degrees C after this procedure . METHODS: Sixty-one consecutive patients with cirrhosis undergoing 75 procedures were randomized into Group I {(n = 37) allocated to receive prophylactic antibiotics (Cefotaxime + Metronidazole)} and Group II {(n = 38) allocated to receive no antibiotic treatment} . RESULTS: Twelve of the 37 patients (32%) in Group I and 13 of the 38 patients (34%) in Group II developed fever > 38 degrees C after treatment . However, none of them developed bacterial infection, and all biological fluid cultures were negative . A logistic regression analysis disclosed that the obtention of an extensive tumor necrosis was the unique parameter independently associated with the development of fever . CONCLUSIONS: Antibiotic prophylaxis is therefore not necessary in patients with cirrhosis and hepatocellular carcinoma undergoing transarterial embolization . The appearance of fever after this procedure does not indicate bacterial infection; it rather represents a clinical marker of extensive tumor necrosis and thus of a favorable response to treatment. AJNR Am J Neuroradiol, 1995 Apr, 16(4), 745 - 8 Endocarditis-related cerebral aneurysms: radiologic changes with treatment; Corr P et al.; PURPOSE: To document the response of mycotic aneurysms to antibiotic therapy and correlate these findings with patient outcome . METHODS: Clinical findings, CT studies, and serial cerebral angiograms of patients with endocarditis related aneurysms seen over 10 years were retrospectively reviewed . RESULTS: In 14 patients infective endocarditis was diagnosed . The patients presented with subarachnoid haemorrhage (4 patients), stroke (9 patients), and seizure (1 patient) . CT findings were intracerebral hematoma (5 patients), infarcts (4 patients), subarachnoid hemorrhage (4 patients), and aneurysms (2 patients) . On angiography, 10 (71%) patients had single aneurysms, and 4 (29%) patients had multiple aneurysms . Eighteen aneurysms were detected, of which 6 (33%) were centrally located, and 12 (66%) were located peripherally . The most common site was the peripheral middle cerebral artery (56%) . Serial angiography during antibiotic treatment demonstrated complete resolution of 6 aneurysms (33%), with 12 aneurysms remaining after 6 weeks of treatment . Of the latter, there was no change in size in 6 aneurysms (33%), a decrease in size in 3 aneurysms (17%) and an increase in size in 3 aneurysms (17%) . No new aneurysms appeared . Surgery was performed on 10 patients with residual aneurysms, 11 aneurysms being excised or clipped . After 6 weeks' treatment, there was complete recovery in 7 (50%) patients, permanent neurologic deficits in 6 patients, and death from aneurysm rebleed in 1 patient . CONCLUSION: Follow-up angiography is recommended in all patients with mycotic aneurysms to assess response to antibiotic therapy, to detect new aneurysms, and to identify those aneurysms with no response or with enlargement. AJNR Am J Neuroradiol, 1995 Apr, 16(4), 669 - 71 Isolated Castleman disease of the neck: MR findings; Glazer M et al.; Castleman disease in an 11-year-old girl appeared as a neck mass that grew despite antibiotic treatment . MR showed a well-defined solid mass, isointense with muscle on short-repetition-time/short-echo-time images, with a stellate area of central hypointensity on long-repetition-time/long-echo-time images, that did not enhance with gadolinium. J Spinal Disord, 1995 Apr, 8(2), 136 - 44 Low-velocity gunshot wounds to the spine with an associated transperitoneal injury; Lin SS et al.; Twenty-nine patients who incurred a transperitoneal low-velocity gunshot wound to their spine were evaluated for the occurrence of spinal infectious complications . All patients underwent an exploratory laparotomy to determine the extent of viscera involvement . No attempt was made to debride the involved spinal area, and the bullet was not removed unless it was easily accessible . Of the 21 patients with a parenchymal and/or noncolonic viscous injury, 17 (77%) were treated with intravenous (i.v.) antibiotics for a minimum of 5 days the remainder received treatment for a maximum of 48 h . All 8 patients with colonic injuries received a minimum of > or = 5 days of antibiotic treatment . Follow-up averaged 44.9 months (range 3-144 months) . Only 1 (4.7%) patient with either a noncolonic or parenchymal perforation developed an infectious complication (subdiaphragmatic abscess); two patients (25%) with colonic perforations developed a psoas abscess . No patient developed a spinal infection . This study suggests that patients who sustain a transperitoneal low-velocity gunshot wound to their spine do not need to undergo spinal debridement and may be treated with parenteral antibiotics . Any course of broad-spectrum antibiotics for 5 days appears to minimize infectious complications . Bullet removal and missile tract debridement of the spine is not routinely necessary. Fortschr Med, 1995 Mar 20, 113(8), 97 - 101 {Acute meningoencephalitis--diagnosis and therapy}; Zahner B et al.; Meningoencephalitis is still associated with a mortality rate of up to 30% and early selective treatment is extremely important . Whenever the disease is suspected, lumbar puncture should be performed immediately with the aim of differentiating on the basis of the cell count and cell picture between the various forms of inflammation namely bacterial, viral, and other special forms (tuberculous, leptospiral, spirochaete-associated or fungus-associated infections) . Bacterial meningoencephalitis requires immediate antibiotic treatment . The present article discusses the choice of suitable medication . When herpes encephalitis is suspected, acyclovir should be administered immediately . The diagnosis and treatment of tuberculous meningoencephalitis are also briefly discussed . Infections with less common pathogens are not considered in the present article. J Am Geriatr Soc, 1995 Mar, 43(3), 245 - 51 Effectiveness of oral antibiotic treatment in nursing home-acquired pneumonia; Degelau J et al.; OBJECTIVE: To determine factors associated with success or failure of oral antibiotic treatment for nursing home-acquired pneumonia (NHAP) . DESIGN: Retrospective study of outcomes for all identifiable NHAP cases in 1991 . SETTING: The Nursing Home Services Program of St . Paul Ramsey Medical Center and 31 metropolitan St . Paul, Minnesota, community nursing homes . PARTICIPANTS: Nursing home (NH) cohort: 124 patients (mean age 85.2 years) with a new respiratory symptom and new infiltrate on portable chest X-ray for whom oral antibiotics were prescribed . Hospital cohort: 74 NH patients (mean age 84.3 years) admitted to hospital with new X-ray infiltrate and pneumonia diagnosis . Supportive care status patients were excluded . Forty-three physician/nurse practitioner (MD/NP) teams were represented . MEASUREMENTS: Nursing home cohort: Outcomes of hospitalization within 14 days or 30-day mortality . A discriminant model was applied to predict outcome and discriminant rule performance was analyzed . Hospital cohort: 30-day mortality . RESULTS: Of 198 episodes of NH pneumonia, 63% were treated in the facility; 30.6% (38) failed NH treatment . Thirty-day mortality was 13% . There was no examination by the MD or NP for 59% of NH-treated episodes . The hospital cohort had a higher mean pulse (P < .05) but a similar frequency of feeding dependence . Hospital cohort mortality was 17.6% . The NH treatment failure group had significantly higher proportions of pulse > 90/min, temperature > 100.5 degrees F, respirations > 30/min, feeding dependence, and mechanically altered diets . A discriminant model using these factors was significant (P = .002) . The NH treatment failure rate was 11% for no factors present, 23% for two or fewer factors, and 59.5% for three or more (likelihood ratio 3.1) . Thirty-two percent of the hospital cohort had zero or one factor present and were alive at 30 days . CONCLUSION: The majority of NHAP episodes were treated successfully with oral antibiotics, but 31% failed treatment in the NH . Patients with a mechanically altered diet or requiring feeding assistance by staff had significantly higher failure rates . Feeding dependence and need for a mechanically altered diet as well as abnormal vital signs are associated with oral antibiotic treatment failure . These factors should be considered in treatment decisions for NHAP. Fertil Steril, 1995 Mar, 63(3), 571 - 7 Low-dose glucocorticoids after in vitro fertilization and embryo transfer have no significant effect on pregnancy rate; Moffitt D et al.; OBJECTIVE: To determine the effect on pregnancy rate (PR) of low-dose glucocorticoid treatment in cycles without micromanipulation . DESIGN: Randomized, prospective, double-blinded, placebo-controlled trial . SETTING: One university-based tertiary infertility center and two private infertility centers . PATIENTS: All patients receiving standard stimulation IVF-ET or transfer of cryopreserved embryos at the participating facilities from January to September 1993 were asked to participate in this study . Patients having micromanipulation were excluded from this study . INTERVENTIONS: Participating patients were randomized to either 16 mg oral 6-alpha-methylprednisolone for four evenings starting the evening of retrieval or the evening before thawing cryopreserved embryos or to placebo administered in an identical fashion . Both groups were treated with 250 mg oral tetracycline four times per day starting with initiation of the study medication and continuing for 4 days . Cryopreservation and stimulation cycles were managed according to pre-established protocols for all patients . A clinical pregnancy was confirmed by an appropriately rising hCG titer and a gestational sac on ultrasound . RESULTS: A total of 206 stimulation patients and 61 cryopreservation patients were randomized and had an ET . Patient characteristics were similar between groups . The clinical pregnancy and implantation rates between placebo and glucocorticoid groups were 35.9% versus 40.8% and 12.8% versus 11.7% for stimulation cycles and 30.3% versus 25% and 9.9% versus 7.4% for cryopreservation cycles, respectively . None of these differences were statistically significant . CONCLUSIONS: Glucocorticoid plus antibiotic treatment at these doses for transfers of nonmicromanipulated embryos does not appear to have a significant effect on pregnancy or implantation rates. Gastroenterol Clin Biol, 1995 Mar, 19(3), 252 - 8 Antibiotic versus maintenance therapy in the prevention of duodenal ulcer recurrence . Results of a multicentric double-blind randomized trial; Sobhani I et al.; OBJECTIVES--Reduction of gastric acid secretion by maintenance therapy and eradication of Helicobacter pylori by antibiotic treatment have been shown to reduce duodenal ulcer relapse . This study compared the effect of two regimens, a 6-month maintenance on an H2 receptor antagonist versus a one-week antibiotic therapy, on the rate of duodenal ulcer relapse in duodenal ulcer patients with gastric H . pylori infection . METHODS--We conducted a 30-week, double-blind, double-dummy, multicentric clinical trial involving 119 patients (97 M, 22 F, mean age 39 +/- 14 years) randomly assigned to a daily dose of 40 mg famotidine for 6 weeks supplemented with, during the first week, either antibiotics (500 mg amoxicillin q.i.d . and 500 mg tinidazole t.i.d.-antibiotic group) or their placebo (maintenance group) . Healed patients after 6 weeks entered the 6-month maintenance phase: the maintenance group received 20 mg famotidine at bedtime and the antibiotic group, a placebo . Endoscopy with antral biopsies was performed to allow a rapid urease test, culture and histological examination upon entry, after 6 weeks, 3 months, and 6 months and, whenever symptoms recurred . H . pylori status was regarded as positive if any one of these three tests was positive, and negative if all tests were negative . RESULTS--The 2 treatment groups were well balanced for all baseline characteristics . After 6 weeks, H . pylori was eradicated in 25 (45%) patients in the antibiotic group, and in 1 (2%) in the maintenance group (P < 0.01) . In term of intention-to-treat, there was no significant difference in the healing rate after 6 weeks (93 and 83% in the antibiotic and maintenance groups, respectively; P = 0.15) or in the relapse rate after 6 months (13 and 28% in the antibiotic and maintenance groups, respectively; P = 0.17 Log-rank test) . However, the overall failure rate (absence of healing, relapse) was lower (P = 0.04, Log-rank test) in the antibiotic group in which all relapses but one were observed in H . pylori positive patients . The rate of ulcer relapse (1/20) in patients of antibiotic group who remained free of H . pylori during the study, was significantly (P < 0.01) lower compared with that of H . pylori positive patients in the maintenance group (11/44) . During the first 6-week period, more side effects were observed in the antibiotic group than in the maintenance group (4 vs 1 patient, respectively) . CONCLUSIONS--Our results indicate no significant difference between ulcer relapse rates after 6 months following a one-week antibiotic therapy or long-term maintenance therapy . Short-term antibiotic therapy should be considered as a valuable alternative to the long-term maintenance therapy. Eur J Pediatr, 1995 Mar, 154(3), 236 - 8 Kartagener syndrome: an uncommon cause of neonatal respiratory distress? Losa M, Ghelfi D, Hof E, Felix H, Fanconi S. We report a newborn with respiratory distress and situs inversus totalis . The diagnosis of primary ciliary dyskinesia was confirmed by both ultrastructural and functional investigations . The immotile cilia syndrome was suspected because of respiratory distress, situs inversus, abnormal nasal discharge and hyperinflated chest X-ray . We suggest that ultrastructural and functional investigations of the respiratory mucosa should be done in any newborn with respiratory distress without explanation for the respiratory problems . Establishment of the correct diagnosis at an early stage may allow to improve the prognosis provided prophylactic physiotherapy, vaccinations, and aggressive antibiotic treatment of intercurrent respiratory infections are instituted . CONCLUSION Despite its rarity, primary ciliary dyskinesia should be considered in unexplained cases of neonatal distress. Unfallchirurg, 1995 Mar, 98(3), 139 - 44 {Chronic treatment refractory osteomyelitis of long tubular bones--possibilities and risks of intramedullary boring}; Pape HC et al.; Osteomyelitis of long bones is a severe complication of fracture healing . If on-going infection occurs despite reoperation and if antibiotic treatment is of no benefit, reaming of the medullary canal has been considered beneficial . We investigated long-term follow-up (minimum 2 years) in patients submitted to reaming of the medullary canal to evaluate the efficacy of this method . Criteria for success were: no recurrence and no further antibiotic treatment necessary . Of 37 patients, 32 were followed up (mean duration after reaming, 3.7 years) . The mean number of surgical operations for osteomyelitis prior to reaming was 3.2 . In 88% of patients a full range of motion was observed upon reexamination, while in the others stiffness attributable to articular injuries that had been sustained preoperatively was still present . We found that 84.3% of patients were working in the same profession as prior to the fracture, 72% were involved in sport again, and 97% of patients were pain free . One otherwise healthy patient suffering from sclerosing osteitis (Garre) died of bone marrow embolism into the lung during reaming of the femur . Reaming of the medullary canal has a high cure rate in osteomyelitis even after several previous treatment attempts with surgical revision and/or antibiotic medication . The mechanism is most probably based on improvement of local perfusion . During surgery care must be taken not to provoke pulmonary embolization . Intraoperative monitoring by pulmonary artery catheter should be performed; reaming should be discontinued immediately, if a rise in of pulmonary artery pressure occurs.(ABSTRACT TRUNCATED AT 250 WORDS) Headache, 1995 Mar, 35(3), 125 - 30 Headache characteristics in hospitalized patients with Lyme disease; Scelsa SN et al.; We reviewed 49 patients consecutively hospitalized for neurologic Lyme disease to determine the frequency and characteristics of recent onset headaches in this group . All patients had positive serum Lyme ELISAs and other neurologic illness excluded . Recent-onset headache occurred in 26 of 49 patients (53%) . Patients with headaches more commonly had central nervous system involvement (54% vs 19%, P < .05) and flu-like illness (58% vs 19%, P < .0005) . Eight of 26 (31%) met criteria for meningitis or encephalitis with abnormal CSF examinations . All 8 had focal findings (6), cognitive dysfunction (1), or both (1) . The remaining 18 patients had recent-onset headaches resembling migraine (9), tension-type headache (5), or neither (4) . Antibiotic treatment resulted in complete headache resolution in 11 of 14 patients with available follow-up data . Based on these findings, we conclude that recent-onset headaches are common in patients hospitalized with Lyme disease . Of those with meningitis or encephalitis requiring intravenous antibiotics, all had focal neurologic findings or cognitive abnormalities, not just headaches. Acta Radiol, 1995 Mar, 36(2), 173 - 7 Ultrasonographic findings after conservative treatment of acute appendicitis and open appendicectomy; Eriksson S et al.; In a randomized study we investigated the effects of antibiotics as the only treatment in acute appendicitis . Forty patients were examined, 19 after antibiotic treatment (one operated due to perforation) and 21 after surgery . All patients were examined prior to randomization, after 10 days and after 30 days . Of the positive ultrasonographic (US) findings, 18 (86%) of the 21 operated patients had histologically proven acute appendicitis . At the 10th day, 9 patients had a seroma under the scar, which had disappeared a month after surgery in all patients . In the 19 patients conservatively treated with antibiotics, the appendix could be visualized in 8 symptom-free cases on the 10th day . In 5 of the 8 patients the appendix was still visualized after 1 month . Three of these 5 had recurrent appendicitis within a year . It is concluded that US can be used not only in diagnosing acute appendicitis, but also in the evaluation of treatments such as antibiotics. J Formos Med Assoc, 1995 Mar, 94(3), 127 - 31 Trichosporon beigelii fungemia in patients with acute leukemia: report of three cases; Hung CC et al.; Trichosporon beigelii fungemia with localized visceral involvement or dissemination is a life-threatening infection in patients with granulocytopenia . We report three cases of T . beigelii fungemia in patients with acute leukemia seen at the National Taiwan University Hospital . Two patients were in the granulocytopenic state after cytoreductive chemotherapy, while one was in complete remission . Fever persisted or recurred despite conventional antibiotic treatment when fungemia developed . Cutaneous trichosporonosis was noted in one patient, which was misdiagnosed as candidiasis . An indwelling catheter constituted the likely portal of entry in two patients . Therapeutic response to amphotericin B is generally not achieved in patients without recovery of neutrophil counts and in those with retained catheters. Pol Arch Med Wewn, 1995 Mar, 93(3), 216 - 21 {The diagnostic value of cytology in children on continuous ambulatory peritoneal dialysis (CAPD)}; Sieniawska M et al.; Peritonitis is a common clinical problem that occurs in patients undergoing CAPD . Early diagnosis of this complication is difficult in some cases and elevated peritoneal cell count may be a misleading factor in diagnosis . The aim of the study was to determine the cell count in consecutive dialysate exchanges after starting CAPD . Elevated peritoneal cell count was found in 17 of 21 (80%) analyzed periods at the beginning of CAPD . Peritonitis was diagnosed in 5 of these patients and confirmed by culture in 4 and clinical observation in 1 . In the remaining 12 cases (70%) the elevated cell count normalized during consecutive exchanges of dialysate . The coexistence of such nonspecific symptoms as fever, abdominal pain of varying intensity, cloudy fluid with or without the presence of fibrin can be the cause of diagnostic mistake and institution of unnecessary antibiotic treatment . In doubtful case, the reduction of the dwell time to 2 hours and observation of the cell count in consecutive exchanges is very helpful, especially if rapid culture diagnosis is not available. Dermatol Surg, 1995 Feb, 21(2), 136 - 44 The role of surgery in the management of uncommon skin infections; Glorioso L et al.; BACKGROUND . Some infections do not respond readily to antibiotic therapy . In particular, fungi and mycobacteria often require prolonged treatment, which is expensive and prone to adverse effects . OBJECTIVE . To investigate the role of surgery in the treatment of skin infections . METHODS . Literature review . RESULTS . Infections caused by atypical mycobacteria, certain fungi, and those involving joints often respond well to surgical treatments . In several situations excision produces a higher cure rate than antibiotic treatment . CONCLUSION . Excision, drainage, or debridement has been shown to be superior to drug therapy in several infections and a reasonable alternative in others. Aliment Pharmacol Ther, 1995 Feb, 9(1), 33 - 9 Efficacy of rifaximin in the treatment of symptomatic diverticular disease of the colon . A multicentre double-blind placebo-controlled trial; Papi C et al.; BACKGROUND AND AIMS: In a recent open trial we have shown the efficacy of long term intermittent administration of a poorly absorbable antibiotic (rifaximin) in obtaining symptomatic relief in uncomplicated diverticular disease of the colon . The aim of this double-blind placebo-controlled trial was to test our previous observations . METHODS: One hundred and sixty-eight outpatients with symptomatic uncomplicated diverticular disease were treated with fibre supplementation (glucomannan 2 g/day) plus rifaximin 400 mg b.d . for 7 days every month (84 patients), or with glucomannan 2 g/day plus placebo two tablets b.d . for 7 days every month (84 patients) . Clinical evaluation was performed at admission and at three-month intervals for 12 months . RESULTS: After 12 months, 68.9% of the patients treated with rifaximin were symptom-free or mildly symptomatic, compared to 39.5% in the placebo group (P = 0.001) . Symptoms such as bloating and abdominal pain or discomfort were primarily affected by antibiotic treatment when compared with placebo (P < 0.001) . CONCLUSION: Rifaximin appears to be of some advantage in obtaining symptomatic relief in diverticular disease of the colon when compared with fibre supplementation alone. Br J Surg, 1995 Feb, 82(2), 166 - 9 Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis; Eriksson S et al.; In a prospective controlled study the effect of antibiotics as the only treatment in acute appendicitis was evaluated . Of 40 patients admitted with a duration of abdominal pain of less than 72 h, 20 received antibiotics intravenously for 2 days followed by oral treatment for 8 days and 20 considered as controls were randomized to surgery . All patients treated conservatively were discharged within 2 days, except one who required surgery after 12 h because of peritonitis secondary to perforated appendicitis . Seven patients were readmitted within 1 year as a result of recurrent appendicitis and underwent surgery, when appendicitis was confirmed . The diagnostic accuracy within the operated group was 85 per cent . One patient had perforated appendicitis at operation . Antibiotic treatment in patients with acute appendicitis was as effective as surgery . The patients had less pain and required less analgesia, but the recurrence rate was high. J R Coll Surg Edinb, 1995 Feb, 40(1), 42 - 5 Longterm follow-up of biliary stents for retained common bile duct stones in elderly patients; Lauri A et al.; Common bile duct (CBD) stones in elderly patients are best treated by endoscopic sphincterotomy (ES) . If CBD clearance cannot be achieved endoscopically a biliary stent may be inserted . Although satisfactory short-term results have been reported, few reports on their longterm outcome are available . Over a 3-year period, January 1987 to December 1989, 100 patients with CBD stones were referred for endoscopic stone removal . In 14 of these patients (3 men, 11 women; median age 83 years, range 79-97 years) the CBD could not be cleared endoscopically and a stent was inserted . Twelve of the 14 patients were jaundiced and 5 had acute cholangitis (AC) . The maximum diameter of the retained stones ranged from 10-42 mm with a median of 17 mm . Stent insertion resolved jaundice and sepsis in all cases and all patients were discharged from hospital . In-patient stay ranged from 1-82 days (median 12 days) and was significantly increased by the presence of acute cholangitis (P = 0.03, Mann-Whitney U-test) . Longterm follow-up was obtained in 13 of the 14 patients (93%) by referral to their general practitioner and out-patient notes . Seven patients are alive and well (median follow-up 43 months, range 34-60 months) . One of these 7 developed further jaundice owing to stent migration and had further ES and stone removal . Six patients died at 1, 3, 12, 32, 36 and 42 months following stent insertion from unrelated causes . One patient developed further AC requiring antibiotic treatment and another patient required stent replacement.(ABSTRACT TRUNCATED AT 250 WORDS) Spine, 1995 Feb 1, 20(3), 373 - 4 Multiple psoas abscesses after posterior spinal fusion; Thomas E et al.; STUDY DESIGN: A case of multiple psoas abscesses after Dove lumbar spine fixation is reported . OBJECTIVES: To review the diagnosis and treatment of deep infection after internal spinal fixation . METHODS: The possibility of septic complications after spinal surgery that may present with a degenerative pattern is examined . The clinical and computed tomographic findings of a psoas abscess are recalled . RESULTS: Surgical drainage of the purulent collection was performed along with prolonged parenteral antibiotic treatment . CONCLUSION: Infection should be considered as a cause of recurrence of pain after internal fixation of the lumbar spine. Eur J Pediatr, 1995 Feb, 154(2), 138 - 44 Comparison of C-reactive protein and white blood cell count with differential in neonates at risk for septicaemia; Berger C et al.; We prospectively compared the diagnostic value of C-reactive protein (CRP) and white blood cell counts for detection of neonatal septicaemia . Sensitivity and specifity in receiver operating characteristics, and positive and negative predictive value of CRP and white blood cell count were compared in 195 critically ill preterm and term newborns clinically suspected of infection . Blood cultures were positive in 33 cases . During the first 3 days after birth CRP elevation (sensitivity 75%, specifity 86%), leukopenia (67%/90%), neutropenia (78%/80%) and immature to total neutrophil count (I/T) ratio (78%/73%) were good diagnostic parameters, as opposed to band forms with absolute count (84%/66%) or percentage (79%/71%), thrombocytopenia (65%/57%) and toxic granulations (44%/94%) . Beyond 3 days of age elevated CRP (88%/87%) was the best parameter . Increased total (84%/66%) or percentage band count (79%/71%) were also useful . Leukocytosis (74%/56%), increased neutrophils (67%/65%), I/T ratio (79%/47%), thrombocytopenia (65%/57%) and toxic granulations had a low specifity . The positive predictive value of CRP was 32% before and 37% after 3 days of age, that of leukopenia was 37% in the first 3 days . CONCLUSION: During the first 3 days of life CRP, leukopenia and neutropenia were comparably good tests while after 3 days of life CRP was the best single test in early detection of neonatal septicaemia . Serial CRP estimations confirm the diagnosis, monitor the course of infection and the efficacy of antibiotic treatment. Br J Rheumatol, 1995 Feb, 34(2), 178 - 81 Primary nocardial meningitis in systemic lupus erythematosus; Mok CC et al.; Nocardia is an important but often overlooked opportunistic infection agent in immunocompromised hosts . Nocardiosis is primarily pulmonary; central nervous system involvement, usually in the form of brain abscess, is less common . Primary nocardial meningitis without associated brain abscess and pulmonary lesion is extremely rare and poses a formidable diagnostic challenge . We report on a patient with systemic lupus erythematosus who presented with a clinical picture of chronic meningitis which failed to respond to empirical antibiotic treatment . She deteriorated and succumbed . Post-mortem examination showed nocardial meningitis without associated brain abscesses . Nocardial meningitis should be considered a differential diagnosis of subacute meningitis in immunocompromised hosts. Mol Cell Probes, 1995 Feb, 9(1), 19 - 24 Detection of rifampin-resistant bacteria using DNA probes for precursor rRNA; Britschgi TB et al.; Ribosomal RNA precursor (pre-rRNA) molecules have terminal domains (tails) which are removed during late steps in rRNA processing, to yield the mature rRNA subunits . Transcriptional inhibitors such as rifampin can deplete pre-rRNA in sensitive cells by inhibiting de novo pre-rRNA synthesis while allowing maturation to proceed . We developed direct DNA probe assays for pre-rRNA tail sequences of Escherichia coli, and evaluated their ability to rapidly distinguish rifampin-resistant from rifampin-sensitive strains in cultures treated with the drug . Pre-rRNA became undetectable in sensitive cells less than a generation time after rifampin exposure, but remained abundant in resistant cells . Resistant cells were detectable by this method against a 100-fold excess of sensitive cells, showing that this method can detect resistant mutants even when present as a small percentage of a pathogen population . Our data indicate that the response of pre-rRNA to antibiotic treatment is sufficient in rate and magnitude to make it a useful metabolic marker for antibiotic sensitivity. Arch Surg, 1995 Feb, 130(2), 204 - 7 Endoscopic stenting for malignant biliary obstruction; Cheung KL et al.; OBJECTIVE: To evaluate the results of endoscopic stenting in patients with malignant biliary obstruction . DESIGN: Retrospective review . SETTING: Surgical endoscopy unit at a tertiary referral center . PATIENTS AND INTERVENTION: Plastic endoprosthetic stents were inserted for the relief of biliary obstruction in 131 consecutive patients . Among the 104 patients with malignant biliary obstruction, 60 underwent stenting as definitive palliative treatment . MAIN OUTCOME MEASURES: Data on the type and size of stents employed, their effectiveness in relieving jaundice, their complications, and the quality of survival were analyzed . RESULTS: Median survival was 1.93 months . The majority of the stents (88.3%) were placed endoscopically, and single straight stents were most frequently used (96.7%) . Jaundice was relieved in 35 patients . Early (< or = 14 days) and late acute cholangitis were found in four and 11 patients, respectively . Early and late stent migration was noticed in two and six patients, respectively . Pancreatitis occurred in one patient, and no papillotomy site bleeding was encountered . When compared with the 18 patients with proximal obstruction at or above the common hepatic duct, the 42 patients with distal ductal obstruction had longer median survival (P = .03) and more effective relief of jaundice (P = .005) and required less antibiotic treatment (P = .03) . These 42 patients also enjoyed better quality of survival when it was analyzed with reference to six objective parameters (P = .0018) . CONCLUSIONS: Stenting offers palliation of malignant biliary obstruction, and the results are particularly encouraging in distal obstruction. Schweiz Med Wochenschr, 1995 Jan 28, 125(4), 120 - 4 {Diagnostic value of C-reactive protein in comparison with erythrocyte sedimentation as routine admission diagnostic test}; Buess T et al.; In a prospective study the diagnostic relevance of C-reactive protein (CRP) as a screening parameter for inflammatory diseases was compared to the erythrocyte sedimentation rate (ESR) . At time of hospitalization CRP, ESR and other routine laboratory tests were performed . After taking history and clinical examination, the responsible physician had to answer a first questionnaire and a second at the time of patient discharge . At the time of admission, elevation of CRP was expected by the treating physician in 40.3% of patients, and elevation of ESR in 43.2% . An unexpected elevation of CRP or ESR was found in 38/303 cases (12.5%) . In 22/38 patients only CRP was elevated, but ESR only was elevated in 13/38 cases . In summary, measurement of CRP and/or ESR was felt by the treating physician to have been helpful in 25.1% of all patients . Due to the fast rise of CRP, all patients with bacterial pneumonia showed increased CRP at the time of hospitalization (23/23), but the ESR was still in normal range in some of these patients (normal ESR in 5/23) . Also in patients with COPD or asthma and clinical evidence for infection, or patients with bacterial gastroenteritis, CRP turned out to be the more sensitive parameter . In conclusion, CRP is a valuable screening test in acutely ill patients, has a higher sensitivity and (as shown by other authors) higher specificity than ESR . In addition, the short half-life of CRP makes it a useful parameter for the follow-up of patients with e.g . infections under antibiotic treatment. Lancet, 1995 Jan 21, 345(8943), 155 - 8 Impact of face-washing on trachoma in Kongwa, Tanzania; West S et al.; Observational studies have suggested that the prevalence of trachoma is lower in children with clean faces than in those with ocular or nasal discharge or flies on the face . We carried out a community-based randomised trial in three pairs of villages to assess the impact on trachoma of a face-washing intervention programme following a mass topical antibiotic treatment campaign . Six villages in Kongwa, Tanzania, were randomly assigned mass treatment plus the face-washing programme or treatment only . 1417 children aged 1-7 years in these villages were randomly selected and followed up for trachoma status and observations of facial cleanliness at baseline and 2, 6, and 12 months . At 12 months, children in the intervention villages were 60% more likely to have had clean faces at two or more follow-up visits than children in the control villages . The odds of having severe trachoma in the intervention villages were 0.62 (95% Cl 0.40-0.97) compared with control villages . A clean face at two or more follow-up visits was protective for any trachoma (odds ratio 0.58 {0.47-0.72}) and severe trachoma (0.35 {0.21-0.59}) . This community-based participatory approach to face-washing intervention had variable penetration rates in the villages and was labour intensive . However, we found that, combined with topical treatment, community-based strategies for improving hygiene in children in trachoma-endemic villages can reduce the prevalence of trachoma. Bull Soc Belge Ophtalmol, 1995, 259, 205 - 14 Retinal vasculitis in Lyme borreliosis; Leys AM et al.; We observed retinal vasculitis in seven patients with clinical and serologic evidence of Borrelia burgdorferi infection . Three patients presented with abrupt loss of vision due to acute retinal vasculitis . Funduscopy demonstrated engorged veins, hemorrhages, perivenous infiltrates and retinal white spots . Fluorescein angiography showed leakage from the veins, from the white spots and from the optic disc . Moreover arterial occlusions were observed in two patients . Four patients had signs of chronic uveitis with vitritis, cystoid macular oedema and retinal vasculitis, which was associated with neovascularization and vitreous hemorrhage in one patient, and with optic neuritis in another patient . Six patients received antibiotic treatment and three patients received systemic corticosteroids . Marked improvement in the three acute retinal vasculitis cases occurred within several weeks, the fundus changes disappeared in another few months, and no recurrences were observed . The final visual acuity was excellent in these patients, although optic disc pallor and visual field loss persisted in one case . In the four patients with chronic uveitis visual blurring improved following antibiotic treatment and the retinal vasculitis and vitritis slowly regressed . The proliferative retinopathy of one patient required panretinal laser treatment. QJM, 1995 Jan, 88(1), 61 - 8 Acute infective exacerbations of chronic bronchitis; Ball P et al.; Patients with an acute infective exacerbation of chronic bronchitis (AECB) (n = 471) were enrolled into a computer-based general-practice study to determine whether features of past history, presenting symptoms, or findings on examination were predictive of failure to recover . The median age was 68, 56.3% were male, and 82% were current or ex-smokers . All had daily sputum production and 57.5% had moderate or severe airflow obstruction . During the AECB 11.5% were pyrexial, and 80.7% had abnormal auscultatory findings; about half had moderate to severe increases in dyspnoea and airflow obstruction, and the majority had increases in sputum volume and/or purulence . The median number of AECBs in the previous year was three, and one-third of patients had cardiopulmonary disease . The only factors significantly (p < 0.05) predicting failure to recover from an AECB were historical . Neither clinical features at presentation nor antibiotic treatment affected recovery . Coexistent cardiopulmonary disease was a risk factor for returning with a chest problem and for being referred to hospital . The number of chest infections in the previous 12 months was a risk factor for returning with a chest problem . The higher the number of chest infections, the higher the odds of returning with a chest problem . The best combination predicting return with a chest problem was history of cardiopulmonary disease and more than four previous AECBs in the last 12 months . The sensitivity was 75% and specificity 47%. Semin Thorac Cardiovasc Surg, 1995 Jan, 7(1), 13 - 9 Surgical treatment of prosthetic valve endocarditis; Lytle BW; Despite advances in the diagnosis and treatment of prosthetic valve endocarditis (PVE) it remains a serious complication of prosthetic valve replacement . Antibiotic treatment alone can be successful for late infections that involve the prosthesis only (particularly for patients with bioprothesis), but it rarely cures infections involving the valve-native annulus interface . Combined antibiotic and surgical treatment of PVE often is successful; more accurate diagnosis (usually based on echocardiography), more effective myocardial protection at reoperation, and improved surgical experience have improved the short-term and long-term outcomes for patients with PVE . For 146 patients of Cleveland Clinic Foundation who underwent reoperation for PVE from 1975 through 1992, the overall in-hospital mortality rate was 13%, 10% from 1985 to 1992 . In this more recent surgical period, active infection and early PVE did not appear to be factors that increase in-hospital mortality . The mean in-hospital stay of survivors was 25 days, which highlights the fact that even successful treatment of PVE uses enormous resources . The late survival rate of in-hospital survivors was 82% at 5 years, and the reoperation-free survival rate was 75% at 5 postoperative years. Enferm Infecc Microbiol Clin, 1995 Jan, 13(1), 40 - 3 {Retropharyngeal abscess in adults}; Pintado V et al.; BACKGROUND: Retropharyngeal abscess is a rare disorder usually seen in children as a result of upper respiratory tract infections . In adults, retropharyngeal abscess can occur as a result of local trauma (such as foreign body ingestion or instrumental procedures) and odontogenic infections . PATIENTS AND METHODS: We report two cases of retropharyngeal abscess in adults . The clinical features, diagnostic procedures and treatment of the disease are discussed . RESULTS: Foreign body ingestion (fish bone) was the predisposing factor in one patient and no underlying cause was found in the other . Diagnosis was established by computed tomography of the neck . S . mitis and S . oralis were isolated in the culture of the abscess secondary to foreign body ingestion . Antibiotic treatment was successful in both cases without evidence of complications . Surgical drainage was not required . CONCLUSIONS: Antibiotic therapy is a useful alternative treatment to surgery in the management of non-complicated retropharyngeal abscess. Gut, 1995 Jan, 36(1), 121 - 5 Deoxycholic acid in gall bladder bile does not account for the shortened nucleation time in patients with cholesterol gall stones; Noshiro H et al.; The relations between the concentration of deoxycholic acid (DCA), the cholesterol saturation index, and the nucleation time in gall bladder bile were measured to determine the role of DCA in bile in the pathogenesis of cholesterol gall stone disease . Bile was obtained from patients with cholesterol gall stones (n = 30), subjects without gall stones (n = 35), and patients with pigment gall stones (n = 9) . Three of 30 cholesterol gall stone patients and 10 of 35 gall stone free subjects were treated with antibiotics by mouth to decrease the concentration of bile DCA and determine the effect of DCA on biliary lithogenecity . Both the percentage and concentration of DCA in bile were similar in patients with and without cholesterol gall stones despite significant differences in their cholesterol saturation indices and nucleation times . Neither the percentage nor the concentration of DCA in bile correlated with either the cholesterol saturation index or the nucleation time . Analysis of subgroups with matching cholesterol saturation indices showed no correlation between the proportion of DCA in the bile and the cholesterol nucleation time . The proportion of DCA in bile was decreased by antibiotic treatment, but this had no effect on the cholesterol saturation index or nucleation time . These results suggest that DCA in bile is not responsible for biliary cholesterol saturation or cholesterol nucleation time. Acta Cytol, 1995 Jan-Feb, 39(1), 73 - 5 Phenotypic analysis of cerebrospinal fluid cells over the course of Lyme meningoradiculitis; Sindern E et al.; Cytologic cerebrospinal fluid abnormalities that most distinctly point to the diagnosis of Lyme meningoradiculitis are pronounced mononuclear pleocytosis composed mainly of T lymphocytes, large amounts of plasma cells and IgM-positive B cells . In this study, repeat examinations revealed decreasing cell numbers and almost normal cell counts 100-130 days after the onset . B cells persisted over the whole observation period in five of six patients and were not related to any clinical symptoms or signs indicative of persistent meningitis or central nervous system involvement . The CD4/CD8 ratio of the helper/inducer and suppressor/cytotoxic lymphocyte subsets declined in all the patients after antibiotic treatment . It might be useful as a marker of the disease activity. Chest, 1995 Jan, 107(1), 201 - 3 Reversal of 'refractory septic shock' by infusion of amrinone and angiotensin II in an anthracycline-treated patient; Ryding J et al.; A 53-year-old granulocytopenic woman with malignant lymphoma treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy, including doxorubicin (Adriamycin) and autologues bone marrow transplantation, presented in the clinical state of "refractory septic shock" caused by Escherichia coli . Despite inotropic treatment with dopamine, dobutamine, and norepinephrine infusion, the patient's condition did not improve, but during treatment with amrinone and angiotensin II infusion, the septic shock was reversed . The patient was monitored with a pulmonary artery catheter and underwent repeated echocardiographic examinations . Antibiotic treatment with thienamycin and floxacillin was given . The initial reduction in cardiac performance in this patient may be explained by a state of true down-regulation of the myocardial beta-receptors . Apparently these beta-receptors were bypassed via the enzymatic action of amrinone upon cyclic monoadenosine phosphate . This is, to our knowledge, the first doxorubicin-treated patient with septic shock refractory to conventional vasopressor therapy whose condition reversed by inotropic treatment with amrinone and angiotensin II . This treatment may prove to be an alternative choice for patients developing "refractory septic shock" unresponsive to treatment with norepinephrine, dobutamine, and dopamine. J Antimicrob Chemother, 1995 Jan, 35(1), 205 - 12 Antibiotic treatment of community-acquired pneumonia in clinical practice: a European perspective; Ortqvist A; The prescription pattern of empirical antibiotic treatment of community-acquired pneumonia (CAP) in seven European countries was studied based on data from published studies and prescription surveys . Overall, the three most commonly used compounds for outpatient treatment were aminopenicillins, aminopenicillins with clavulanic acid, macrolides and cephalosporins . The relative order of these three compounds varied very much between the different countries . Aminopenicillin was the first or second choice in four of seven countries . Cephalosporins were used mainly in Germany and in Southern Europe . In Italy parenteral treatment with third-generation cephalosporins or imipenem was the commonest choice (nearly 40%) . Tetracyclines were used most in Northern and Central Europe . In contrast to the others, penicillin was the commonest choice in Sweden . Also for hospitalised patients the choice of initial antibiotic, as well as the use of mono- or combination therapy, varied significantly between countries . The varying treatment policies cannot be explained by scientific reason, such as differences in the aetiology of infection, frequency of penicillin-resistant pneumococci, pharmacokinetics, safety, nor by ecological or economic considerations . It is probable that local therapy traditions, and marketing factors, are equally important as the scientific rationale for the doctors' choice of empirical therapy for CAP. Acta Derm Venereol, 1995 Jan, 75(1), 46 - 9 Topical antimycotic treatment of atopic dermatitis in the head/neck area . A double-blind randomised study; Broberg A et al.; In order for us to evaluate the effect of topical antimycotic treatment in patients with atopic dermatitis affecting the head and neck area, 60 patients (36 females and 24 males; median age 28 years; range 14-53 years) were included in a double-blind study during 6 weeks . Of the 53 evaluable patients, 55% had positive skin prick tests to Pityrosporum ovale . In addition to oral antibiotic treatment, patients in group A (n = 26) were given miconazole-hydrocortisone cream and ketoconazole shampoo, whereas patients in group B (n = 27) were given hydrocortisone cream and placebo shampoo . At the start of the study P . ovale cultures were positive in 83% of all patients (no significant difference between the groups) . After 4 weeks of treatment, there was a decrease in P . ovale colonisation in group A (p < 0.001) but not in group B . Patients in both groups improved (p < 0.001) . The decrease in eczema score did not differ between group A and group B after 4 weeks' treatment . A further decrease of the eczema score was seen in both groups at the end of the study, but no difference was found between the groups. J Am Vet Med Assoc, 1995 Jan 1, 206(1), 53 - 5 Disseminated subcutaneous Mycobacterium fortuitum infection in a dog; Fox LE et al.; A 15-month-old 27.7-kg sexually intact male Doberman Pinscher was examined because of multiple subcutaneous abscesses on the neck, trunk, and limbs that developed 2 months after a dog bite and were refractory to antibiotic treatment . Incubation of a biopsy specimen at 37 C on a Lowenstein-Jensen agar slant for 8 days yielded growth of a Runyon's Group IV mycobacterium, and disseminated subcutaneous Mycobacterium sp infection was diagnosed . The organism was identified as M fortuitum, and was susceptible to amikacin, doxycycline, cefoxitin, minocycline, trimethoprim/sulfadiazine, and sulfisoxazole . Lesions resolved after 8 months of treatment with doxycycline (5 mg/kg of body weight, PO, q 12 h) . The cause of dissemination was unknown; however, delay in debridement of the bite wound and corticosteroid use in initial wound management may have potentiated dissemination. Eur Urol, 1995, 27(2), 170 - 3 Pseudoneoplastic xanthogranulomatous pyelonephritis . A typical clinical presentation but unusual diagnosis and treatment; Mollier S et al.; Xanthogranulomatous pyelonephritis is a rare disease that may mimic various renal lesions, especially renal tumors, in its focal form . We report a case of pseudoneoplastic xanthogranulomatous pyelonephritis in a young woman . This case is unusual, because it was diagnosed by a percutaneous renal puncture and furthermore total renal recovery was achieved by antibiotic treatment alone. J Heart Valve Dis, 1995 Jan, 4(1), 35 - 9 Mitral allograft with chordal support: echocardiographic evaluation in sheep; Vetter HO et al.; The in vivo echocardiographic behavior of a new mitral allograft design that incorporates ePTFE patches and chordae to enhance durability has been evaluated in sheep . A strip of pericardium was sewn around the anulus margin and an ePTFE patch of 0.4 mm thickness placed over the truncated papillary muscle tip . In four out of ten cases, 5/0 ePTFE sutures were used additionally to reinforce the native chordae of the anterior leaflet . The allografts were cold-stored at 4 degrees C after antibiotic treatment and implanted in weanling sheep . Valvular function was first examined intraoperatively by transesophageal echocardiography and again after a mean follow up of 153 +/- 8 days by epicardial echo . In all six long term survivors, valve motion was unimpaired and similar to that of the natural mitral valve . There was sufficient coaptation and concentric opening action of the leaflets . Ventricular contraction was enhanced by maintaining the annulo-ventricular connection of the native valve . Color and pulsed Doppler revealed a physiologic biphasic flow pattern and only minor regurgitation in one case . Mean transvalvular pressure gradient was 3.3 +/- 2.1 mmHg on average which correlates well with values obtained from subsequent cardiac catheterization . In conclusion, this new design of a mitral allograft shows excellent in vivo echocardiographic behavior after five months of implantation . Therefore, human allografts of this type could be recommended for clinical application. Arch Pediatr, 1995 Jan, 2(1), 39 - 42 {Acute lipid pneumopathy}; Duvaltier I et al.; BACKGROUND--Lipid pneumonia in children has rarely been described in Europe . In some countries, due to local customs, the course is chronic . This study describes an acute lipid pneumonia in a young boy . CASE REPORT--A 12 year-old boy, previously treated for a rhabdomyosarcoma, developed acute fever with thoracic pain . A chest radiograph revealed heterogenous consolidation . The patient was given oral antibiotics, although no improvement was observed . The diagnosis of lipid pneumonia was made by a bronchoscopy with bronchoalveolar lavage . Treatment with corticosteroids was started . Clinical manifestations improved rapidly . One month later, chest radiograph and biological findings were normal . CONCLUSION--Diagnosis of lipid pneumonia should be considered in children with an acute febrile pneumonitis non resolving with antibiotic treatment . Examination of the fluid obtained by bronchoalveolar lavage confirms the diagnosis. Clin Podiatr Med Surg, 1995 Jan, 12(1), 75 - 86 Imaging techniques in the diabetic foot; Newman LG; Osteomyelitis underlies the majority of diabetic foot ulcers, and it is usually not detected clinically . Leukocyte scanning with indium oxyquinoline has greater sensitivity than radiographs, bone scans, and MR imaging in diagnosing osteomyelitis in diabetic foot ulcers . All ulcers that expose bone, and perhaps moderately deep ulcers as well, should be treated for osteomyelitis because of the high prevalence of this infection (100% and 82%, respectively) . Osteomyelitis should be evaluated for in shallow ulcers by radiographs, followed by leukocyte scans if the former tests are negative . Bone biopsies should be performed if possible because cultures may guide antibiotic treatment. Scand J Infect Dis, 1995, 27(2), 179 - 82 Chlamydia pneumoniae and chronic pharyngitis; Falck G et al.; Chlamydia pneumoniae has been implicated as an etiological agent for both upper and lower respiratory tract infections . We describe 4 cases of chronic pharyngitis where Chlamydia pneumoniae appears to be the etiological agent . All the patients were non-smokers, and had symptoms of more than 6 months' duration . Disease symptoms seemed to resolve following appropriate antibiotic treatment. Chir Organi Mov, 1995 Jan-Mar, 80(1), 21 - 7 The spacer block technique in revision of total knee arthroplasty with septic loosening; Gusso MI et al.; Five cases of septic loosening of total knee arthroplasty were treated by two-stage revision using a cement mixed with antibiotic . The spacer block was responsible for greater mechanical stability of the joint in the interval between the two stages of the operation, and the association of the antibiotic favored resolution of septic complications, allowing at the same time for systemic antibiotic treatment at doses lower than usual . In all of the cases treated reimplantation was performed in conditions of apparent sterility . The minimum amount of time between the first operation and reimplantation was 3 months, maximum was 5 months . Four to 18 months after reimplantation there was no recurrence of infection . Despite the short follow-up, the technique used appears to constitute a valid solution for septic complications in total knee arthroplasty. Wien Med Wochenschr, 1995, 145(7-8), 196 - 8 {Lyme borreliosis and cardiomyopathy}; Bergler-Klein J et al.; According to current opinion there is acute, self-limiting Lyme carditis, and chronic Lyme carditis . Acute Lyme carditis manifests mostly as transient conduction disorders of the heart (e.g . AV-blocking I to III), and as supraventricular and ventricular rhythm disturbances, pericarditis, myocarditis, and pancarditis in single cases . Chronic Lyme carditis is defined as a case of chronic heart failure confirmed by positive serology and endomyocardial biopsy . Anamnestic aid is rare . Neither tick-bites nor preceding or accompanying erythema chronicum migrans are constantly reported . Seropositivity and control of its specificity by western blot are indicative but no etiological proof . Even histological detection of spirochetes in endomyocardial tissue or cultivation of borrelia from endomyocardial biopsy are no final etiological proof of the respective cardial disorder . Those findings, however, are an indication for antibiotic treatment . According to the severity of the disorder, antibiotics are administered orally (penicillin or derivatives) or parenterally with penicillin or cephalosporins of the 3rd generation over 4 and 2 weeks, respectively. Wien Med Wochenschr, 1995, 145(7-8), 155 - 61 {Lyme borreliosis}; Stanek G; In Europe and in other parts of the world, Lyme borreliosis is recognized increasingly by physicians and serodiagnostic laboratories . However, it is currently difficult to present conclusive epidemiologic data . There are no widely accepted case definitions for the numerous clinical features due to or supposed to be linked to infection with Borrelia burgdorferi . Clinical diagnosis of suspected cases of Lyme borreliosis requires confirmation by the demonstration of the aetiologic agent and the recognition of its causative role in the respective disorder . The specificity of serological tests for Lyme borreliosis is impaired by several phenomena including cross-reacting antibodies . Interpretation of serological test results may lead to the clinical diagnosis of Lyme borreliosis and in consequence to antibiotic treatment . Complications in order to treat suspected disseminated Lyme disease may be severe, as recently reported (45) . No reliable data of Lyme borreliosis prevalence can be offered so far . This is partly due to incomplete reporting of Lyme borreliosis cases to specialized institutions, and partly due to the insufficiency of the diagnostic process . The true incidence and prevalence of this disease cannot be determined and one must wait for the results of the development of specific and dependable methods to identify actual infection. J Neuropsychiatry Clin Neurosci, 1995 Summer, 7(3), 345 - 7 Rapidly progressive frontal-type dementia associated with Lyme disease; Waniek C et al.; The authors report a case of fatal neuropsychiatric Lyme disease (LD) that was expressed clinically by progressive frontal lobe dementia and pathologically by severe subcortical degeneration . Antibiotic treatment resulted in transient improvement, but the patient relapsed after the antibiotics were discontinued . LD must be considered even in cases with purely psychiatric presentation, and prolonged antibiotic therapy may be necessary. Fortschr Kiefer Gesichtschir, 1995, 40, 166 - 9 {Surgical tooth reconstruction in conjunction with irradiation of malignant tumors}; Henrich GM et al.; An infected osteoradionecrosis (IORN) is one of the most problematic sequelae of radiation in the course of cancer treatment in the head and neck . To prevent this, prophylactic dental extractions have been demanded before radiation, as well as specific measures (epiperiostalplastic cover, perioperative antibiotic treatment) if a tooth has to be extracted after the radiation treatment has been carried out . From 1980 until 1993, 812 Patients who had to be irradiated underwent a prophylactic dental extraction programme . Only in 0.5% of these cases an infected osteoradionecrosis developed later on . 167 patients were treated after the radiation had been applied, using perioperative antibiotic treatment and meticulous soft tissue cover following epiperiostal preparation of the gingiva . In spite of 25% of localised dehiscences no immediate infection of the bone was observed . At the same time 53 infected osteoradionecrosis were treated, 43% of which were of dental origin . Most of these were seen in the lower molar area . The results show the high value of prophylactic dental extractions before radiation as well as the benefit of careful extractions with epiperiostal gingival cover, after the radiation treatment, especially in the area of the posterior lower alveolus. Am J Nephrol, 1995, 15(5), 436 - 8 Glomerulonephritis associated with permanent pacemaker endocarditis; Barnes E et al.; Two patients with permanent transvenous cardiac pacemakers were seen with a history of pyrexia of unknown origin and renal failure . After extensive investigation both were found to have pacemaker endocarditis . A renal biopsy of one patient revealed changes characteristic of glomerulonephritis associated with this condition . Both patients underwent thoracotomy for open removal of their pacemaker and appropriate antibiotic treatment . One patient made a good recovery of renal function . Unfortunately the second patient died . These reports emphasize the need for vigilance for these two uncommon complications and the difficulty in their diagnosis. Rev Pneumol Clin, 1995, 51(4), 253 - 6 {Disappearance of emphysematous bullae after infectious episodes}; Guimard Y et al.; The authors report 3 cases of peri-emphysematous lung infection associated with the development of air-fluid level in pre-existing emphysematous bullae . Prolonged observation revealed that both bullae and fluid disappeared completely or partially after short antibiotic treatment . The review of literature show that this favourable evolution has not often been described and that these pictures must be to differentiate from lung abscess. Khirurgiia (Sofiia), 1995, 48(1), 23 - 9 {The postoperative complications and risk factors in heart operations with extracorporeal circulation}; Kozhukharov B et al.; The analysis covers 150 patients subjected to open-heart surgery in the "St . Catherine"