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Anaerobic sepsis due to multidrug-resistant Bacteroides fragilis: microbiological cure and clinical response with linezolid therapy.

We describe the first reported case of anaerobic sepsis due to Bacteroides fragilis with simultaneous resistance to metronidazole, beta-lactams, beta lactam/beta-lactamase inhibitors, carbapenems, macrolides, and tetracyclines. Microbiological cure and clinical improvement was achieved with linezolid therapy, an agent that may be useful for the treatment of multidrug-resistant anaerobic infections.

Acetamides↗

Fusobacterium necrophorum infections in England and Wales 1990-2000.

In response to a marked increase in both the number of Fusobacterium necrophorum bacteraemia reports to the PHLS Communicable Disease Surveillance Centre and the number of F. necrophorum isolates referred to the PHLS Anaerobe Reference Unit in 1999, the data from both sources on F. necrophorum infections were reviewed for the decade 1990-2000. There were 208 reports of F. necrophorum bacteraemia (average 19/year; range 14-34/year) with a peak in incidence in the late winter months; 68% were from male patients and the peak age range was 16-23 years. Of 205 referred isolates of F. necrophorum, 122 (59%) were from blood cultures and these represented 58% of the bacteraemia reports; the others were from brain and soft tissue abscesses, pleural and joint fluids, eyes, ears and lymphatic tissue. The average number of referrals was 19/year (range 9-37/year). The peak year for bacteraemia reports (34) and isolate referrals (37) was 1999; this increase was not sustained in 2000. All isolates were susceptible to metronidazole, but 2% were resistant to penicillin and 15% to erythromycin. F. necrophorum continues to be a regular but uncommon cause of bacteraemia and metastatic abscesses following an acute sore throat, especially in young, otherwise healthy adults.

Abscess↗

Quinacrine does not prolong survival in a murine Creutzfeldt-Jakob disease model.

Paramount among issues relating to the transmissible spongiform encephalopathies (also known as prion diseases) is the absence of any effective therapy. This need has been heightened by the substantial European and emerging global problem of bovine spongiform encephalopathy and consequent variant Creutzfeldt-Jakob disease. Stimulated by the recent reports of a potent antiprion effect in cell culture-based clearance assays, we studied the utility of quinacrine in a well-characterized in vivo model of mouse-adapted transmissible spongiform encephalopathy. Our results failed to show any evidence that quinacrine is effective when using the simple but objective measure of survival prolongation.

Animals↗

Information on marketed drugs for doctors and patients. Experience in six European countries.

This article describes a project that looked at the availability of information on marketed pharmaceutical products to doctors and patients in six European countries. It examines the legal status of the drug compendia published in each country and reports on the implementation of EC Directive 92/27/EEC on labeling and packaging. A small survey showed that it is hard to compare patient information because it is difficult to obtain copies of pack inserts available in each country. However, a limited analysis revealed some differences in the content and presentation of data for doctors and patients.

Drug Industry↗

A comparison of generic, indirect utility measures (the HUI2, HUI3, SF-6D, and the EQ-5D) and disease-specific instruments (the RAQoL and the HAQ) in rheumatoid arthritis.

Rheumatoid arthritis (RA) is a common, chronic disease where health-related quality of life (HRQL) is one of the main goals of therapy. As such, instruments used to measure HRQL in RA must be able to discriminate across RA severity. The two basic categories of instruments used to measure HRQL are generic instruments and disease-specific instruments. Generic instruments can be further subdivided into preference-based measures which yield both single and multi-attribute utility values anchored at zero (death) and 1.00 (perfect health) as a measure of HRQL. The scores from these types of instruments can be integrated into cost-utility analyses as the weightings for quality adjusted life years. We assessed the construct validity of utility scores from four generic preference-based measures (the Health Utilities Index 2 and 3 (HUI2, HUI3), the EuroQol 5D (EQ-5D), and the Short Form 6-D (SF-6D) and disease specific measures (the Rheumatoid Arthritis Quality of Life Questionnaire (RAQoL) and the Health Assessment Questionnaire (HAQ)) in a sample of 313 RA patients in British Columbia, Canada. We also estimated the minimally important differences (MID) for each of the measures. Generally, as anticipated, the disease-specific measures were better able to discriminate across groups with higher RA severity; however, utility scores from each of the scales also appeared to discriminate well across RA severity categories. The MID values agreed with those previously reported in the literature for the HUI2, SF-6D and the HAQ and provided new information for the HUI3, EQ-5D and the RAQoL. We conclude that the all of the preference-based utility measures that were evaluated appear to adequately discriminate across levels of RA severity.

Adult↗

[Influence of tobacco on the serum levels and pharmacokinetics of phenylbutazone and oxyphenbutazone].

The serum levels of a number of drugs are reduced by smoking. The authors wanted to see whether this phenomenon occurred with phenylbutazone. With this objective, they compared the changes in serum levels of phenylbutazone and oxyphenbutazone, the hydroxylated metabolite of phenylbutazone, during ten days of administration, in 9 smokers and in 6 non-smokers. Blood samples were taken every day at 8:00 a.m. and the PB and OPB were assayed by high performance liquid chromatography. The comparison of the mean serum levels of PB in smokers and non-smokers revealed a statistically significant reduction (p less than or equal to 0.05) of this level in the smoker, between D5 and D10. Comparison of the mean serum levels of OPB in smokers and non-smokers revealed a statistically significant reduction of this level in the smoker, but only on days 9 and 10. When we compare these results with those reported in the literature for other drugs, it would appear that tobacco smoke accelerates the metabolism of phenylbutazone and oxyphenbutazone by a mechanism of enzyme induction. It is proposed that the therapeutic activity of phenylbutazone is reduced in the smoker, but this has not been confirmed by a reliable clinical evaluation in this initial study.

Adult↗

Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain.

OBJECTIVE: To determine whether a short course of traditional acupuncture improves longer term outcomes for patients with persistent non-specific low back pain in primary care. DESIGN: Pragmatic, open, randomised controlled trial. SETTING: Three private acupuncture clinics and 18 general practices in York, England. PARTICIPANTS: 241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration. INTERVENTIONS: 10 individualised acupuncture treatments from one of six qualified acupuncturists (160 patients) or usual care only (81 patients). MAIN OUTCOME MEASURES: The primary outcome was SF-36 bodily pain, measured at 12 and 24 months. Other outcomes included reported use of analgesics, scores on the Oswestry pain disability index, safety, and patient satisfaction. RESULTS: 39 general practitioners referred 289 patients of whom 241 were randomised. At 12 months average SF-36 pain scores increased by 33.2 to 64.0 in the acupuncture group and by 27.9 to 58.3 in the control group. Adjusting for baseline score and for any clustering by acupuncturist, the estimated intervention effect was 5.6 points (95% confidence interval -0.2 to 11.4) at 12 months (n = 213) and 8.0 points (2.8 to 13.2) at 24 months (n = 182). The magnitude of the difference between the groups was about 10%-15% of the final pain score in the control group. Functional disability was not improved. No serious or life threatening events were reported. CONCLUSIONS: Weak evidence was found of an effect of acupuncture on persistent non-specific low back pain at 12 months, but stronger evidence of a small benefit at 24 months. Referral to a qualified traditional acupuncturist for a short course of treatment seems safe and acceptable to patients with low back pain. TRIAL REGISTRATION: ISRCTN80764175 [controlled-trials.com].

Acupuncture Therapy↗

Synthetic putative transmembrane region of minimal potassium channel protein (minK) adopts an alpha-helical conformation in phospholipid membranes.

Minimal potassium channel protein (minK) is a potassium channel protein consisting of 130 amino acids, possessing just one putative transmembrane domain. In this study we have synthesized a peptide with the amino acid sequence RDDSKLEALYILMVLGFFGFFTLGIMLSYI, containing the putative transmembrane region of minK, and analysed its secondary structure by using Fourier-transform IR and CD spectroscopy. The peptide was virtually insoluble in aqueous buffer, forming intermolecular beta-sheet aggregates. On attempted incorporation of the peptide into phospholipid membranes with a method involving dialysis, the peptide adopted a predominantly intermolecular beta-sheet conformation identical with that of the peptide in aqueous buffer, in agreement with a previous report [Horvàth, Heimburg, Kovachev, Findlay, Hideg and Marsh, (1995) Biochemistry 34, 3893-3898]. However, by using an alternative method of incorporating the peptide into phospholipid membranes we found that the peptide adopted a predominantly alpha-helical conformation, a finding consistent with various proposed structural models. These observed differences in secondary structure are due to artifacts of aggregation of the peptide before incorporation into lipid.

Amino Acid Sequence↗

Ethical dilemma: is this elder abuse?

Elder abuse, neglect, and exploitation are major problems today (Marshall, Benton, & Brazier, 2000). Most elder abuse occurs at home and is committed by spouses, children, or other family members. Abuse may go undetected until observant professionals intervene ( AOA, 1998). Sometimes the abuse is a continuation of existing dysfunctional family dynamics. More often, however, the abuse is a result of changes brought about by an older person's growing dependency and need for increased care.

Aged↗

Analysis of the porphyrin content of fluorescent pus by absorption spectrophotometry and high performance liquid chromatography.

Extracts of 19 samples of pus which showed red fluorescence with ultraviolet light were screened for the presence of porphyrins by absorption spectrophotometry. All those which showed spectra typical of metal-free porphyrins were analysed by high performance liquid chromatography to identify the porphyrins present. These were predominantly the di-carboxylic porphyrins, deuteroporphyrin and mesoporphyrin, and another which was thought to be pemptoporphyrin. This combination matched those reported previously in normal stools. Protoporphyrin IX was shown not to be the most common fluorescent pigment in pus and was never present alone. However, the di-carboxylic porphyrins may be produced by bacterial metabolism of its labile vinyl side-chains. Black-pigmented bacteroides (the melaninogenicus group of Bacteroides spp. and Porphyromonas spp.) were isolated from 12 (63%) of the 19 pus samples; these may produce protoporphyrin IX by the demetallation of haem.

Bacterial Infections↗

Nurse prescribing: radicalism or tokenism?

The creation of The Medical Products (Prescription by Nurses, etc.) Act 1992 has been generally welcomed by the nursing profession. This article seeks to introduce a note of scepticism about the assumed motivations for its introduction through an analysis of various legal, ethical, economic and political dimensions. In reviewing the position of nursing vis-à-vis medicine it is argued that one of the ways that nursing has sought to improve its professional position is to take on work previously done by doctors, and nurse prescribing can be seen in the context of the concurrent de-regulation of medicines, allowing greater access to medicines and therefore greater consumer choice. This de-regulation stems from the liberation ideology of the previous Conservative government. Viewed in this way nurse prescribing, particularly with reference to the limited nature of the nursing formulary, can be seen to be anomalous. In the light of this analysis, the reasons generally put forward (notably in the Crown Report 1989) for the introduction of nurse prescribing could be seen to be peripheral to its real purpose. It is argued that the most convincing reasons for its introduction relate to the medical profession as a social institution. It is proposed that the three primary aims behind the introduction of nurse prescribing are: the saving of money; the transfer of routine medical work to nursing; and a challenge to the professional monolith of medicine.

Community Health Nursing↗

Searching for the evidence in pre-hospital care: a review of randomised controlled trials. On behalf of the Ambulance Response Time Sub-Group of the National Ambulance Advisory Committee.

OBJECTIVES: To identify randomised controlled trials (RCTs) which evaluate aspects of pre-hospital care; to perform categorisation by theme; to compare the sensitivity and precision of the search databases. DATA SOURCES: August 1997 updates of MEDLINE and EMBASE databases, using the Datastar online system. Papers published in 1987 or later were included, with no language restrictions. STUDY SELECTION: A trial was eligible for inclusion if it was judged, by two independent and blinded assessors, that participants followed up in the trial were definitely or possibly assigned prospectively to one of two or more alternative forms of healthcare with random allocation or a quasi-random method of allocation. RESULTS: The literature search retrieved 849 papers, of which 569 (67%) were in MEDLINE and 486 (57%) in EMBASE. Forty one (5%) were confirmed as reports of RCTs or quasi-RCTs, and the total number of individual trials was 38. Ten of these trials dealt with thrombolytic drugs; 14 were concerned with other drugs, 12 with equipment, and two with other interventions. Four trials were based on a sample size of more than 1000, and seven reported a statistically significant effect on mortality. All 41 papers were in EMBASE, and all but one were also in MEDLINE. CONCLUSIONS: Evidence based policy making with respect to the organisation of pre-hospital services cannot depend on RCTs. In the current relative absence of such evidence, practitioners and decision makers must use alternative information sources. A future review could examine a broader range of literature and be based on a wider search of published and unpublished material.

Abstracting and Indexing↗

Potent inhibitory effect of naturally occurring flavonoids quercetin and kaempferol on in vitro osteoclastic bone resorption.

Several recent studies have suggested that flavonols, a class of phytochemicals with many biological activities, might exert a protective effect against post-menopausal bone loss. In the present study, we investigated the effects of quercetin and kaempferol, two of the major naturally occurring flavonols on the in vitro bone resorbing activity of osteoclasts. Our results indicate that both compounds, at concentrations ranging from 0.1 to 100 microM reduce bone resorption in a time and dose-dependent manner. Significant inhibitory effects were observed at concentrations as low as 0.1 microM especially with kaempferol. The IC(50)s, or concentration inhibitory of 50% of basal resorption, calculated for quercetin and kaempferol were 1.6 and 5.3 microM, respectively. Using highly purified rabbit osteoclasts, we showed that both flavonols directly induce apoptosis of mature osteoclasts in the same dose-range effective for inhibiting bone resorption. When osteoclasts were treated with 50 microM of quercetin and kaempferol, intracellular reactive oxygen species levels decreased significantly by 75 and 25%, respectively, indicating these molecules keep their antioxidant properties at this concentration. However, at concentrations below 50 microM, neither quercetin nor kaempferol exerted antiradical action, suggesting that antioxidant properties cannot fully explain the inhibitory effect on bone resorption. Finally, we report that kaempferol-, but not the quercetin-induced inhibition of bone resorption was partially abolished by the presence of the pure anti-estrogen ICI 182780 suggesting that kaempferol's estrogenic effect could be involved in the inhibition of bone resorption. The present study demonstrates that flavonols widely distributed in human diet such as quercetin and kaempferol, exert a potent inhibitory effect on in vitro bone resorption.

Animals↗

Clostridium difficile: an update on its epidemiology and role in hospital outbreaks in England and Wales.

Data from the surveillance system of general outbreaks of infectious intestinal disease and from laboratory reports collated by the Communicable Disease Surveillance Centre (CDSC) and requests for outbreak investigation by the PHLS Anaerobe Reference Unit were used to evaluate the current epidemiology of Clostridium difficile infection in England and Wales. Between January 1992 and December 1996, CDSC received 10,220 laboratory reports of C difficile isolation from patient's faeces and 26,873 of toxin in faeces. Over 75% of all reports were of people aged 64 years and over. The surveillance system captured a minimum data set on 694 hospital outbreaks of infectious intestinal disease. C. difficile was responsible for 109 (15%) outbreaks affecting 1625 people, of whom 1152 were found to have a C. difficile toxin producing strain. The median duration of outbreaks was 11 days. Fingerprinting by Pyrolysis Mass Spectrometry (PMS) was performed by the PHLS Anaerobe Reference Unit in 60 outbreaks, and typing by Polymerase Chain Reaction ribotyping (PCR) in 14.

Adolescent↗

Propionibacterium propionicum and infections of the lacrimal apparatus.

Analysis of the clinical details associated with 26 referred isolates of Propionibacterium propionicum revealed the marked propensity of this anaerobe to be involved with infections of the lacrimal apparatus; 18 (69%) of the 26 referred isolates were from cases of canaliculitis in which this organism was regarded as the significant pathogen. Further analysis of data showed a significant correlation with the sex of the patient. Of the 18 cases of canaliculitis, the sex of the patient was reported in 16; 14 (88%) of these 16 patients were females (P < .005). The age of 13 of the 18 patients with canaliculitis was known (mean, 61.6 years; range, < 1-80 years); it appears from these cases that P. propionicum lacrimal infections are more common in later life. None of the referred isolates were identified as Actinomyces species. Despite the fact that infection of the lacrimal apparatus is known as ocular actinomycosis, it appears that P. propionicum is more frequently associated with the condition than are true Actinomyces species.

Actinomyces↗

Using rank data to estimate health state utility models.

In this paper we report the estimation of conditional logistic regression models for the Health Utilities Index Mark 2 and the SF-6D, using ordinal preference data. The results are compared to the conventional regression models estimated from standard gamble data, and to the observed mean standard gamble health state valuations. For both the HUI2 and the SF-6D, the models estimated using ordinal data are broadly comparable to the models estimated on standard gamble data and the predictive performance of these models is close to that of the standard gamble models. Our research indicates that ordinal data have the potential to provide useful insights into community health state preferences. However, important questions remain.

Health Status Indicators↗

School nursing: costs and potential benefits.

BACKGROUND: Previous reports that variations in school nursing resources across the UK had no relationship to deprivation; controversy about the changing role of the school nursing service. OBJECTIVES: To measure the resources allocated to school nursing, determine whether the variations can be explained by deprivation, and assess whether the allocation of school nursing time to a range of tasks is in line with current evidence and perceptions of changing needs. STUDY DESIGN: Quantitative economic analysis; qualitative descriptive study. SETTING: Detailed study of four English districts with diverse characteristics; staffing and service questionnaire and telephone survey of 62 districts. MAIN MEASURES: Staff resources and their salaries; measures of population and deprivation; activity statistics. RESULTS: There were wide variations in the cost of the school nursing service, but in contrast to previous reports 24% of the variance was explained by deprivation. There were no clear associations with any other social or educational variables. The greatest allocation of time was in routine screening and surveillance tasks. Relatively little time was allocated to other activities such as health promotion, support of special needs or unwell children, or teenage clinics. The expenditure on school nursing is only loosely related to deprivation and the results of this study offer guidance on what districts should spend to achieve equity of provision. CONCLUSIONS: The current allocation of resources to school nursing in between districts comparisons is not equitable and the use of school nursing time is out of step with current evidence of need and effectiveness.

Adolescent↗

In vitro and in vivo enhancement of ddI activity against Rauscher murine leukemia virus by ribavirin.

Ribavirin has been reported to enhance the activity of ddI against HIV. We explored this enhancement of antiviral activity in Rauscher murine leukemia virus (RMuLV) models in vitro and in vivo. The significant finding in these studies was that combinations of the drugs exhibited virus titer reductions that were greater than would be expected if the drug interactions were simply additive. These effects were designated synergistic by the method of Prichard and Shipman (Prichard, M.N. and Shipman, C., Jr. (1990). A three-dimensional model to analyze drug-drug interaction, Antiviral Res. 14, 181-206). In addition to the antiviral synergy, we also observed some synergistic toxicity in the animal model.

Animals↗