Anterior cruciate ligament insufficiency: does delay in index surgery affect outcome in recreational athletes

The aim of the study was to see if delay in anterior cruciate ligament (ACL) reconstruction affects post-reconstruction outcome in recreational athletes. Sixty-two recreational athletes who had arthroscopic ACL reconstructions using quadruple hamstring grafts between 1997 and 2000 were retrospectively evaluated. Patients with less than 2 years' follow-up, those with multi-ligament injuries, reconstructions for previous failed repairs, those whose injury date was unknown, those with pre-injury Tegner activity level greater than 7 (competitive athletes) and those lost to follow-up were all excluded. Forty-six patients (38 males) were entered. The mean follow up was 38 months and the mean time from injury to index ACL reconstruction was 27 months. Apart from two revisions there were no other significant complications. Forty-one (89%) patients were evaluated in a review clinic. There was a significant improvement in the post-reconstruction Lysholm scores and an improvement in the Tegner scores. The Spearman's correlation coefficient between postoperative Lysholm score and the delay until surgery was -0.18 and the correlation coefficient between postoperative Tegner scores and the delay until surgery was 0.14. Thirty-five patients returned to sporting activity. Thirty-seven rated their knee as being normal or nearly normal and 35 said that their knee function was as they had expected it to be. Late ACL reconstruction does not adversely affect the outcome in recreational athletes. ACL reconstruction should be offered to these patients as there is a significant improvement in the knee function and patients are satisfied with the results.

Comparison of piperacillin/tazobactam and imipenem/cilastatin, both in combination with tobramycin, administered every 6 h for treatment of nosocomial pneumonia

This randomized, double-blind, multicenter study compared the efficacy and safety of piperacillin/tazobactam (P/T) and imipenem/cilastatin (IMP), both in combination with an aminoglycoside, in hospitalized patients with acute nosocomial pneumonia (NP). Patients with acute NP, defined as pneumonia with symptoms > or = 48 h after admission or < or =7 days after hospital discharge, received infusions of 4 g/500 mg P/T or 500 mg/500 mg IMP every 6 h. Endpoints were clinical cure and microbiological response rates; pathogen eradication rates; length of hospital stay; hospital readmissions; and adverse events (AEs). Of 437 patients in the intent-to-treat population, 197 were efficacy evaluable. At test-of-cure, response rates were similar between groups. Within the efficacy evaluable population, 68% of P/T patients and 61% of IMP patients were clinically cured (P = 0.256). Microbiological responses for P/T and IMP patients were: eradication, 64% versus 59%; persistence, 29% versus 21%; relapse, 0% versus 5%; and superinfection, 7% versus 15%, respectively. Gram-positive isolates were eradicated in 83% of P/T patients and 75% of IMP patients; Gram-negative pathogens were eradicated in 72% of P/T patients and 77% of IMP patients. Treatment groups had similar number of mean hospital days, readmission rates, and frequency of AEs. This study showed that P/T administered four times per day was as safe and efficacious as IMP in treating hospitalized patients with NP.

Laparoscopic total extraperitoneal repair versus anterior preperitoneal repair for inguinal hernia

Laparoscopic inguinal hernia repair is still not the gold standard for repair although mesh implantation is unequivocally accepted as an integral part of any groin hernia repair. The aim of the study was to compare the results of anterior preperitoneal (APP) mesh repair with totally extra peritoneal (TEP) repair for inguinal hernias. The prospective study was conducted on 241 patients with 247 hernias (from January 2000 to June 2004). Anterior preperitoneal repair was done in 121 patients and 120 patients were subjected to TEP repair. Repair in both groups was done by using Prolene mesh of size 6x4 in. or 6x6 in. intraoperative and postoperative parameters and complications were recorded and the patients were followed up to 1 year post-surgery. For both unilateral and bilateral inguinal hernias, mean operative time was significantly more in patients of TEP repair as compared to APP repair (P<0.001) and significantly more patients had peritoneal tears in the TEP group (P<0.001). Patients undergoing TEP repair, however, had significantly less postoperative pain (P<0.05) and postoperative hospital stay (P<0.05) and return to work was significantly earlier is this group (P<0.01 and P<0.001). There was no difference in the recurrence rate between the two groups. Patients with inguinal hernias undergoing laparoscopic repair recover more rapidly, and have less incidence of postoperative pain. But it takes significantly more time to perform than APP repair and also the incidence of peritoneal tear is higher.

Incidence and Impact of Risk Factors in Critically Ill Trauma Patients

There is a paucity of data describing the incidence of pre-existing diseases or risk factors and their effects in trauma patients. We conducted a prospective study to determine the incidence of such factors in critically ill trauma patients and to evaluate their impact on outcome. The study, performed over a 2-year period, examined the hospital course of all trauma patients admitted to the ICU. Multiple risk factors were evaluated and analyzed via multivariate regression analysis. Outcome was evaluated by infection rate, hospital length of stay, ventilator days, and mortality matched for age and Injury Severity Score (ISS). A total of 1172 patients (73% blunt injury) were enrolled over the study period. Of these, 873 (74.5%) were male. The mean age was 42.5 years with an ISS of 19.8. Tobacco use (24%) was the most common risk factor identified, followed by hypertension (HTN, 17%), coronary artery disease (9%), chronic obstructive pulmonary disease (COPD)/reactive airway disease (4%), non-insulin-dependent diabetes (NIDDM) (4%), insulin-dependent diabetes (IDDM) (3.2%), cancer (3%), liver disease (2%), and HIV/AIDS (1.4%). Of these risk factors, IDDM was found to be an independent risk factor for infection (0.004) and ventilator days (0.047), increasing age was found to be an independent risk factor for hospital length of stay (0.023) and mortality (<0.001), and HTN was found to be an independent risk factor for increased ventilator days (0.04). In addition, COPD/reactive airway disease was found to be an independent predictor of ventilator days, infection, and ICU days (P < 0.05). Thus, increased age, IDDM, COPD, and HTN are most predictive of outcome in critically ill trauma patients. With our aging population it is becoming increasingly important to identify pre-existing risk factors on admission in order to minimize their effects on outcome.

Prevalence of HCV and HIV/HCV co-infection among volunteer blood donors and VCT clients

OBJECTIVE

To determine the prevalence of HCV infection and HCV/HIV co-infection among voluntary blood donors at the National Blood Transfusion Centre and clients at the Kenyatta National Hospital HIV-Voluntary Counseling and Testing (VCT) Centre.

DESIGN

A prospective cross-sectional descriptive study.

SETTING

Kenyatta National Hospital, a tertiary referral and teaching hospital and the National Blood Transfusion Services Centre, Nairobi.

SUBJECTS

Volunteer blood donors and VCT attendants.

RESULTS

The prevalence of HCV/HIV co-infection among 6154 blood donors in the NBTSC was very low, at 0.02. The HIV prevalence among the 353 KNH HIV-VCT clients was 9.3%, none of the clients tested positive for HCV. The incidence of risk factors in the persons with HCV and/or HIV infection(s) was low.

CONCLUSION

The prevalence of HCV infection among pre-screened volunteer blood donors was low. However the current practice of screening all donated blood for HCV remains indispensable to prevent its transmission to blood recipients.

Prevalence of HCV and HCV/HIV co-infection among in-patients at the Kenyatta National Hospital

OBJECTIVE

To determine the prevalence of HCV and HCV/HIV co-infection among medical in-patients at the Kenyatta National Hospital.

DESIGN

Prospective cross-sectional descriptive study.

SETTING

Kenyatta National Hospital, a tertiary referral and teaching hospital, in-patient department

SUBJECTS

HIV/AIDS and HIV negative in-patients at KNH medical wards.

RESULTS

Among 458 HIV/AIDS medical in-patients, the prevalence of HCV was 3.7% while in the 518 HIV negative patients, it was 4.4%. The prevalence of co-infection with HCV and HIV was 3.7%. The incidence of risk factors in persons with HCV and/or HIV infection(s) was low.

CONCLUSION

This study found the prevalence of HCV infection among medical in-patients to be similar in HIV positive and HIV negative group of patients. The co-infection rates were low, as were the risk factors for transmission of these infections.

Admission hyperglycemia is predictive of outcome in critically ill trauma patients

OBJECTIVES

There is a paucity of data evaluating whether hyperglycemia at admission is associated with adverse outcome in trauma patients. Our objectives were to determine whether admission hyperglycemia was predictive of outcome in critically ill trauma patients.

METHODS

Prospective data were collected daily on 1,003 consecutive trauma patients admitted to the intensive care unit over a 2-year period. Diabetics were excluded. Patients were stratified by admission serum glucose level (<200 mg/dL vs. > or =200 mg/dL) age, gender, Injury Severity Score, and other preexisting risk factors. Outcome was measured by incidence of infection, ventilator days, hospital length of stay and intensive care unit length of stay, and mortality. Multiple linear regression models were used to determine level of significance.

RESULTS

Two hundred fifty-five of 1,003 (25%) patients were admitted with hyperglycemia over the study period. The majority (78%) of the admissions were caused by blunt injury. Male patients accounted for the majority of the study population (73%); however, female patients were more likely to be hyperglycemic at admission (p = 0.015). Patients with hyperglycemia had an overall greater infection rate and hospital length of stay. The hyperglycemic group had a 2.2-times greater risk of mortality when adjusted for age and Injury Severity Score.

CONCLUSION

Hyperglycemia at admission is an independent predictor of outcome and infection in trauma patients. Future investigation on the effects of hyperglycemia are warranted.

Minimal access surgery in children - 5 years institutional experience

Context:

Minimal access surgery (MAS) in children are common place and performed worldwide with gratifying results as the learning curve of the surgeon attains plateau. We share our experience of this technically evolving modality of surgery, performed at our setup over a period of 5 years. We also review and individually compare the data for commonly performed procedures with other available series. Author also briefly discuss potential advantages of MAS in certain debatable conditions performed quickly and with cosmesis as open procedure.

Materials and methods:

We performed 677 MAS in children aged between 7 days and 12 years. Five hundred and sixty-eight of these were Laparoscopic procedures and 109 were Video assisted thoracoscopic surgeries (VATS). In all laparoscopic procedures, the primary port placement was by the Hasson's open technique. We have used 5, 3 and 2 mm instruments. Our study include 259 inguinal hernia, 161 Appendectomies, 95 VATS for empyema, 51 orchiopexies, 49 diagnostic laparoscopy, 29 cholecystectomies, 22 adhesionlysis and other uncommonly performed procedures.

Results:

The ultimate outcome of all the performed procedures showed gratifying trend, the data of which are discussed in detail in the article. Conclusion: As we gained experience the operating time showed a decreasing trend, the complication rates and conversion rate also reduced. The advantages we came across were better postoperative appearances, less pain and early return to unrestricted activities.

Persistent hyperglycemia is predictive of outcome in critically ill trauma patients

OBJECTIVES

Our objectives were to determine whether persistent hyperglycemia was predictive of outcome in critically ill trauma patients.

METHODS

Prospective data were collected daily on 942 consecutive trauma patients admitted to the ICU over a 2-year period. Patients were stratified by serum glucose level from day 1 to day 7 (low = 0-139 mg/dL, medium = 140-219 mg/dL, and high >220 mg/dL) age, gender, and ISS. Patients were further stratified by pattern of glucose control (all low, all moderate, all high, improving, worsening, highly variable (HV). Outcome was measured by ventilator days, infection, hospital (HLOS) and ICU (ILOS) length of stay and mortality. Multiple linear regression models were used to determine level of significance.

RESULTS

71% were victims of blunt trauma. The majority (74%) were male with a mean ISS of 21.3 +/- 15. 41% of patients acquired an infection. Patients with medium, high, worsening, and highly variable hyperglycemia were found to have increased ILOS, HLOS, ventilator days, infection rate and mortality by univariate analysis (p < 0.01). When controlling for age, ISS, and glucose pattern, patients with high, worsening and HV hyperglycemia were most predictive of increased ventilator days, ILOS, HLOS, infection and mortality. (p < 0.01).

CONCLUSION

Trauma patients with persistent hyperglycemia have a significantly greater degree of morbidity and mortality. A prospective randomized controlled study instituting aggressive hyperglycemic control is warranted.

Nutritional status and wound healing in open fractures of the lower limb

Forty-three patients averaging 28.2 (range 16--74) years with open fractures of the lower limbs were studied prospectively for 40 weeks using anthropometrical, biochemical and haematological parameters to ascertain their relationship to wound healing following injury. Nearly half (21/43) of the patients were malnourished at admission and the number increased to 22 a week after injury. Dietary advice and better food intake improved nutritional status with only 13 patients remaining malnourished at the 40th week. Wound healing was earlier when creatinine-height index was normal throughout the course of treatment and was delayed when serum albumin level was low.

Admission Preoperative Glucose is Predictive of Morbidity and Mortality in Trauma Patients who Require Immediate Operative Intervention

Although there have been reports in the surgical literature regarding the negative effects of preoperative hyperglycemia on outcome, the impact of elevated preoperative serum glucose levels in trauma patients is unknown. Our objectives were to determine whether preoperative hyperglycemia was associated with a greater morbidity and mortality in trauma patients who underwent surgical intervention upon admission. Prospective data was collected on 252 consecutive nondiabetic trauma patients admitted for ≥3 days who went directly to the OR from the resuscitation area. Patients were stratified by preoperative serum glucose level (<200 vs. ≥200 mg/dL) age, gender, Injury Severity Score (ISS), and other preexisting risk factors. Outcome was measured by incidence of infection, hospital (HLOS) and ICU (ILOS) length of stay, and mortality. Multiple linear regression models were used to evaluate serum glucose in relation to other preoperative risk factors. Blunt trauma accounted for the majority (86%) of the injuries. Orthopedic procedures were the most common (36%) followed by neurosurgical (22%), abdominal (22%), and thoracic (6%). Patients with elevated serum glucose had a significantly greater incidence of infection, HLOS, ILOS, and mortality matched per age and ISS. Elevated serum glucose on admission is an accurate predictor of postoperative infection, HLOS, ILOS, and mortality. A randomized prospective trial evaluating the impact of preoperative glucose control is warranted.

Admission serum albumin is predicitve of outcome in critically ill trauma patients

There is a paucity of data evaluating serum albumin on admission as a predictor of outcome in adult trauma patients. Our objectives were to evaluate whether or not hypoalbuminemia on admission is a predictor of adverse outcome in trauma patients. Prospective data was collected daily on 1023 patients over a 2-year period. Patients were stratified by serum albumin level on admission, age, gender, injury severity, and comorbid conditions. Outcome was measured by ICU and hospital length of stay, ventilator days, incidence of infection, and mortality. Student t test, chi2, and multilinear regression analysis were used to determine level of significance. Blunt injuries accounted for the majority (78%) of the admissions. The mean age of the study population was 43+/-21 years with a mean Injury Severity Score (ISS) of 21.4+/-12. The majority of patients were male (74.5%). The mean albumin level on admission was 2.9+/-1.8. Five hundred ninety-three (58%) patients were admitted with a serum albumin level of > or =2.6 as compared to 430 patients (42%) with an admission albumin level of <2.6. Patients with a lower serum albumin level were found to have a significantly greater ICU (17.1 vs 14.2 days) and hospital length of stay (17.3 vs 20.1 days, P'< 0.05), ventilator days (11.1 vs 13.5 days, P < 0.05), and mortality (P = 0.008) when matched for age and injury severity. The relative risk of infection and mortality increased greater than 2.5-fold in patients with increased age and low serum albumin when analyzed by multilinear regression analysis, P < 0.001. An admission serum albumin level of <2.6 g/dL is a significant independent predictor of morbidity and mortality in trauma patients. The combination of increased age and low albumin level was most predictive of infection and mortality. Early nutrition should be considered in these high-risk patients.

Admission Serum Albumin is Predicitve of Outcome in Critically Ill Trauma Patients

There is a paucity of data evaluating serum albumin on admission as a predictor of outcome in adult trauma patients. Our objectives were to evaluate whether or not hypoalbuminemia on admission is a predictor of adverse outcome in trauma patients. Prospective data was collected daily on 1023 patients over a 2-year period. Patients were stratified by serum albumin level on admission, age, gender, injury severity, and comorbid conditions. Outcome was measured by ICU and hospital length of stay, ventilator days, incidence of infection, and mortality. Student t test, χ2, and multilinear regression analysis were used to determine level of significance. Blunt injuries accounted for the majority (78%) of the admissions. The mean age of the study population was 43 ± 21 years with a mean Injury Severity Score (ISS) of 21.4 ± 12. The majority of patients were male (74.5%). The mean albumin level on admission was 2.9 ± 1.8. Five hundred ninety-three (58%) patients were admitted with a serum albumin level of ≥2.6 as compared to 430 patients (42%) with an admission albumin level of <2.6. Patients with a lower serum albumin level were found to have a significantly greater ICU (17.1 vs 14.2 days) and hospital length of stay (17.3 vs 20.1 days, P < 0.05), ventilator days (11.1 vs 13.5 days, P < 0.05), and mortality ( P = 0.008) when matched for age and injury severity. The relative risk of infection and mortality increased greater than 2.5-fold in patients with increased age and low serum albumin when analyzed by multilinear regression analysis, P < 0.001. An admission serum albumin level of <2.6 g/dL is a significant independent predictor of morbidity and mortality in trauma patients. The combination of increased age and low albumin level was most predictive of infection and mortality. Early nutrition should be considered in these high-risk patients.

The Importance of Bactericidal Drugs: Future Directions in Infectious Disease

BACKGROUND

Although a considerable amount of research has gone into the study of the role of bactericidal versus bacteriostatic antimicrobial agents in the treatment of different infectious diseases, there is no accepted standard of practice.

METHODS

A panel of infectious diseases specialists reviewed the available literature to try to define specific recommendations for clinical practice.

RESULTS

In infections of the central nervous system, the rapidity with which the organism is killed may be an important determinant, because of the serious damage that may occur during these clinical situations. The failure of bacteriostatic antibiotics to adequately treat endocarditis is well documented, both in human studies and in animal models.

CONCLUSION

The bulk of the evidence supports the concept that, in treating endocarditis and meningitis, it is important to use antibacterial agents with in vitro bactericidal activity. This conclusion is based on both human and animal data. The data to support bactericidal drugs' superiority to bacteriostatic drugs do not exist for most other clinical situations, and animal models do not support this concept in some situations. Clinicians should be aware that drugs that are bacteriostatic for one organism may in fact be bactericidal for another organism or another strain of the same organism.

Cardiovascular risk factor profile of black Africans undergoing coronary angiography

BACKGROUND

Coronary artery disease (CAD) is a growing epidemic on the African continent. It remains uncertain whether the risk factors identified as contributing to CAD in white populations contribute to a similar extent to CAD incidence in black populations. No data of the local population exists that is based on the coronary angiogram (CA).

OBJECTIVES

To analyse the relationship of conventional cardiovascular risk factors with presence of CAD in black Africans.

DESIGN

This was a dual-armed study, consisting of retrospective and prospective comparative arms.

SUBJECTS

Black Africans who underwent coronary angiography.

SETTING

Nairobi Hospital, Cathereterization laboratory.

MAIN OUTCOME MEASURES

The conventional risk factors: age, male gender, hypertension, obesity, smoking, diabetes mellitus, dyslipidaemia, alcohol use and interventricular septum (IVS) hypertrophy, as a marker of LVH.

RESULTS

One hundred and sixty nine patients fulfilled the inclusion criteria; 144 in the retrospective arm and 25 in the prospective. The larger retrospective arm showed that the group with CAD, compared to the normal group, was significantly older, with a higher mean age of 54.4 years compared to 49.8 years (P=0.005); had significantly more males, with a male to female ratio of 5.5:1 compared to 2.3:1 (P=0.045); had a very significantly larger proportion of diabetics (38.5% compared to 12%, P=0.0002), and also had a significantly larger proportion of patients with dyslipidaemia (67.3% compared to 35.9%, P=0.0003). The percentage of hypertensives was high in both groups, with (65.4%) in the CAD group and 62% in the Normal group being hypertensive (P=0.68). The percentage of smokers was small in both groups, being 15.4% and 13% respectively. Smoking, increased BMI, alcohol use, and increased IVS were each found to be distributed equally in both groups. In addition, the Waist hip ratio (WHR) and waist circumference (WC) did not differ significantly between the two groups studied.

CONCLUSIONS

The risk factors found to be most strongly associated with presence of angiographically-detected CAD in the population studied were diabetes mellitus, dyslipidaemia, age and male gender. There was a high prevalence of hypertension, with equal distribution in both groups under study; hence this risk factor was not discriminatory for CAD. There was a low prevalence of cigarette smoking in this particular study; it was not predictive of presence of CAD.

Analgesic effect of expressed breast milk in procedural pain in term neonates: a randomized, placebo-controlled, double-blind trial

AIM

To assess the effectiveness of expressed breast milk (EBM) in reducing pain due to venepuncture, in term neonates, as measured by behavioural and physiological observations.

METHODS

This randomized, placebo-controlled, double-blind trial involved 81 full-term neonates, up to 4 wk of postnatal age, who needed venepuncture for blood investigations. Two minutes before the venepuncture, in the intervention arm, 40 babies received 5 ml of EBM, while 41 babies in control group received 5 ml of distilled water (DW) as placebo. Two observers who were blinded to the intervention recorded the physiological (heart rate and oxygen saturation) and behavioural parameters [duration of crying and modified Neonatal Facial Coding Scores (NFCS)] after the venepuncture.

RESULTS

There was no difference in the baseline characteristics of the neonates in the two groups. The duration of crying was significantly shorter in babies fed EBM [median 38.5 s, interquartile range (IQR) 9.5-57.5 s] than in those fed DW (median 90 s, IQR 28-210 s). The mean duration of crying in EBM group was shorter by 70.7 (95% confidence interval 36.6-104.9) s. The modified NFCS at 0, 1 and 3 min was significantly lower (p < 0.01) in the EBM than in the DW group. The change in heart rate and oxygen saturation was significantly lower in the EBM group and returned to baseline values sooner than in the DW group.

CONCLUSION

Feeding 5 ml of EBM before venepuncture is effective in reducing symptoms due to pain in term neonates.

A time-dependent analysis of intensive care unit pneumonia in trauma patients

BACKGROUND

Appropriate and timely antibiotic therapy to treat pneumonia in trauma patients is extremely important. We evaluated the incidence and microbiology of pneumonia stratified by days postadmission and risk factors.

METHODS

Prospective data were collected on 714 trauma patients admitted to the intensive care unit over a 1-year period. Pneumonia was classified as community acquired (CAP) (< or = 3 days), early nosocomial (ENP) (4-6 days), or late nosocomial (LNP) (> or = 7 days). In addition, pneumonia was classified as CAP only, nosocomial only (NI), or combination (CAP and NI, or ENP and LNP) pneumonia. Strict institutional guidelines were followed for diagnosis.

RESULTS

One hundred eighty-two patients (25%) were diagnosed with 204 pneumonias over the study period. One hundred twenty-five (61%) of these pneumonias were ventilator associated. Staphylococcus aureus and Haemophilus influenzae were the most common pathogens isolated. Twenty-one percent of patients with CAP acquired an LNP (p < 0.025), in which Pseudomonas was the most common organism. Haemophilus caused LNP in 12% of patients. Cancer (p < 0.01), liver failure (p < 0.05), and age (p < 0.01) were predictive of nontypical pathogens in patients with CAP and ENP (p < 0.05). Obesity was most predictive of increased ventilator days (p < 0.001) and intensive care unit length of stay (p < 0.001). Increased age, alcohol abuse, and field airway were most predictive of mortality.

CONCLUSION

Unanticipated pathogens were isolated in each class of pneumonia. The clinician must be aware of significant risk factors that may predispose patients to pathogens that are not ordinarily covered with standard antibiotic therapy.

Reclassification of Urinary Tract Infections in Critically Ill Trauma Patients: A Time-Dependent Analysis

BACKGROUND

Successful treatment of urinary tract infections (UTIs) in the trauma ICU requires early recognition and timely, appropriate antibiotic therapy. We evaluated the incidence and microbiology of UTIs stratified by days post-admission and risk factors.

METHODS

Prospective data were collected on 1,172 trauma patients admitted to the ICU over a two-year period. Infections were classified as Community Acquired (CA, < or = 3 days), Early Nosocomial (EN, 4-6 days), Mid-Nosocomial (MN, 7-10 days) and Late Nosocomial (LN > 10 days). Criteria of the U.S. Centers for Disease Control and Prevention (CDC) were used for diagnosis.

RESULTS

Two hundred twenty patients (19%) were diagnosed with a total of 235 UTIs. Thirtysix patients were diagnosed with multiple UTIs. Escherichia coli, Enterococcus sp. and Candida sp. were the most common pathogens isolated. One thousand one hundred fifty-one patients had a Foley catheter placed (mean duration, 1 +/- 11 days) with a CDC device-related infection rate (no. of catheter-associated UTIs/1000 catheter days) of 18. Patients admitted with a CA infection were significantly older (p < 0.001) and had a higher mortality rate (39% vs. 15%, p = 0.001). Unanticipated pathogens in this group included Enterococcus, Candida, and Pseudomonas. Women were more likely to be admitted with a CA infection (5% vs. 1%, p < 0.001) or acquire an NI infection (23% vs. 15%, p < 0.001). Obesity was highly predictive of increased Foley catheter days, and thus UTI, by multivariate analysis (p < 0.001).

CONCLUSIONS

Escherichia coli was the most common pathogen in all nosocomial infection categories. Increased age, gender, and obesity, in addition to catheter-days, were significant risk factors for UTI in trauma patients. Specific risk factors may predispose patients to pathogens that are not ordinarily covered by usually-chosen antibiotic therapy.

In vitro propagation of Saussurea obvallata (DC.) Edgew.--an endangered ethnoreligious medicinal herb of Himalaya

This is the first report of a micropropagation protocol for Saussurea obvallata (DC.) Edgew. (Asteraceae), a rare, threatened and near-endemic medicinal herb of the Indian Himalayan region. Multiple shoots were formed from epicotyle explants on Murashige and Skoog (MS) medium supplemented with 1.0 microM kinetin and 0.25 microM alpha-naphthaleneacetic acid. A maximum of five shoots were obtained from one explant in a 75-day culture period. The effect of subsequent subcultures on shoot formation was also studied. After 100% in vitro rooting was obtained in half-strength MS supplemented with 2.5 microM indole-3-butyric acid, the plantlets were transferred to ex vitro conditions. Following a 15-day in vitro rooting period and 12 days of ex vitro acclimatization, 66.7% of the plantlets had established in the field. Application of this protocol has the potential to substantially reduce the pressure on natural populations.

Impact of community-acquired infection on acquisition of nosocomial infection, length of stay, and mortality in adult blunt trauma patients

The incidence of community-acquired infections (CA) and how it relates to the incidence of nosocomial infections (NI) in the adult blunt trauma population is unknown. We evaluated this incidence and assessed the impact of age on morbidity and mortality. Prospective data were collected on blunt trauma patients admitted >48 h over a 2-year period. Each patient was screened for infection by an infectious disease specialist. The Centers for Disease Control and Prevention (CDC) guidelines were used to diagnose infection. Of the 2,645 patients admitted, 86% were <65 years of age and 14% were > or =65 years of age. There was not a significant difference in Injury Severity Score (ISS) between the two groups. A total of 201 (8.8%) of the younger patients were diagnosed with CA; of these, 52.2% acquired a NI. Additionally, 65 (17.4%) of the older patients were diagnosed with a CA; of these, 57% acquired a NI. The combination of CA and NI led to the most significant increases in intensive care (ILOS), hospital (HLOS) length of stay, and mortality. Patients with the CA had a significantly greater risk of obtaining an NI in both age groups. The relative risk (RR) of an older patient presenting with a CA was two times greater than in patients <65 years old. The greatest relative risk of mortality (RRM) was demonstrated with the combination of CA and NI, and age. However, once infected with both CA and NI, younger patients had a greater RRM (5.0 vs. 3.9) in the group-specific comparison. CA significantly increases the risk of blunt trauma patients acquiring an NI. The combination of CA and NI led to the most significant increases in HLOS, ILOS, and mortality. Increased age is associated with a significantly higher incidence of CA, ILOS, HLOS, and mortality. Once infected with both CA and NI, younger patients have a greater risk of mortality.

Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury

OBJECTIVES

There is an absence of prospective data evaluating the impact of prehospital intubation in adult trauma patients. Our objectives were to determine the outcome of trauma patients intubated in the field who did not have an acutely lethal traumatic brain injury (death within 48 hours) compared with patients who were intubated immediately on arrival to the hospital.

METHODS

Prospective data were collected on 191 consecutive patients admitted to the trauma center with a field Glasgow Coma Scale score < or = 8 and a head Abbreviated Injury Scale score > or = 3 who were either intubated in the field or intubated immediately at admission to the hospital. Patients who died within 48 hours of admission and transfers were excluded from the study.

RESULTS

Of the 191 patients, 176 (92%) sustained blunt trauma and 25 (8%) were victims of penetrating trauma. Seventy-eight (41%) of the 191 patients were intubated in the field and 113 (59%) were intubated immediately at admission. There was no significant difference in age, Glasgow Coma Scale score, head Abbreviated Injury Scale score, or Injury Severity Score between the two groups. Patients who were intubated in the field had a significantly higher morbidity (ventilator days, 14.7 vs. 10.4; hospital days, 20.2 vs. 16.7; and intensive care unit days, 15.2 vs. 11.7) compared with patients intubated on immediate arrival to the hospital and nearly double the mortality (23% vs. 12.4). Field-intubated patients had a 1.5 times greater risk of nosocomial pneumonia compared with hospital-intubated patients.

CONCLUSION

Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. A randomized, prospective study is warranted to confirm these results.

Use of the injury severity score to predict nosocomial bloodstream infections among critically ill trauma patients

Nosocomial bloodstream infections (NBSI) are associated with increased hospital length of stay (LOS), mortality, and costs. At this writing, no available reports describe the association between injury severity and NBSI among critically ill adult trauma patients. This study aimed to examine the use of the Injury Severity Score (ISS) as a predictor of NBSI among critically ill adult trauma patients. A case-control design was used to compare the mean ISS of 190 critically ill trauma patients equally divided between those with positive test results for NBSI and those with negative results. The mean hospital LOS (34.8 days versus 16.5 days) and the mean intensive care unit LOS (28.1 days versus 13 days) were significantly higher among the patients with NBSI than among the control subjects without such infection (P <.001 and P <.001, respectively). The mean LOS until the diagnosis of NBSI was significantly lower than the total LOS of the control subjects (odds ratio [OR], 0.959; 95% confidence interval [CI], 0.93-0.99). The ISS score and age were found to be independent predictors of NBSI. The findings provide a means for using the ISS score as a predictor of NBSI in the critically ill adult trauma population.

Persistent systemic inflammatory response syndrome is predictive of nosocomial infection in trauma

BACKGROUND

Admission systemic inflammatory response syndrome (SIRS) score has been previously reported to be an accurate predictor of infection and outcome in trauma. However, these data were limited to only one SIRS score at admission. A prior study in surgical intensive care unit (ICU) patients reported that the SIRS score on ICU day 2 declined after completion of resuscitation, and was a more accurate predictor of outcome. Our objective in this follow-up study was to prospectively evaluate the utility of daily SIRS scores in prediction of nosocomial infection and outcome in high-risk trauma patients.

METHODS

Prospective data were collected on 702 consecutive trauma patients admitted over a 12-month period to the ICU. SIRS scores were calculated daily. Centers for Disease Control and Prevention guidelines were used for the diagnosis of infection. Multivariate linear regression was used for statistical analysis.

RESULTS

Five hundred seventy-three (82%) patients sustained blunt injuries and 129 (18%) sustained penetrating injuries. The mean age was 43 +/- 21 years, with an overall mortality of 11.4%. Two hundred ninety (41.3%) of the study patients acquired a nosocomial infection (respiratory site most common), with an associated mortality rate of 12.4%. SIRS (defined as SIRS score >/= 2) on hospital days 3 through 7 was a significant predictor of nosocomial infection and hospital length of stay. Persistent SIRS to hospital day 7 was associated with a significant risk for increased mortality (relative risk, 4.7; 95% confidence interval, 1.41-12.87; p = 0.047).

CONCLUSION

Persistent SIRS is predictive of nosocomial infection in trauma. Daily monitoring of SIRS scores is easily accomplished and should be considered in all high-risk trauma patients. Persistent SIRS in trauma should initiate early diagnostic interventions for determination of source of infection, and consideration of early empiric antimicrobial therapy.

Auditory function following spinal analgesia. Comparison of two spinal needles

BACKGROUND AND OBJECTIVE

Auditory impairment is among the lesser known complications of spinal analgesia. The aim of the present study was to determine the degree of vestibulocochlear dysfunction in patients undergoing spinal analgesia for lower abdominal surgery.

METHODS

Eighty patients who had received spinal analgesia for lower abdominal surgery were studied. Males were undergoing inguinal herniorraphy and the females tubectomy. Audiograms were performed before operation and on the second and seventh postoperative days. Hearing levels were measured from 250 Hz-8 kHz. In Group 1 (n = 40) a 22-gauge, cutting type of spinal needle (Howard Jones) was used. In Group 2 (n = 40) a 25-gauge, non-cutting spinal needle (Whitacre) was used.

RESULTS

Hearing loss >10 dB was noticed in three patients in Group 1 and none in Group 2. The mean hearing level was more reduced in Group 1 patients.

CONCLUSIONS

Use of cutting type spinal needle is associated with a greater decrease in mean hearing levels compared to the non-cutting type.

Pulmonary disposition of budesonide from liposomal dry powder inhaler

The Purpose of this study was to establish the use of a developed dry powder inhaler of budesonide liposomes in pulmonary drug delivery. Budesonide liposomes composed of egg phosphatidyl choline (EPC) and cholesterol were prepared using a lipid-film hydration technique. The liposomal dispersion was freeze dried and formulated to a dry powder inhaler. The entrapped drug values (91.79% to 78.99%) of freeze dried liposomes were estimated in prepared batches after purification from the free drug by centrifugation of the rehydrated vesicles. In vitro drug retention was evaluated using methanolic phosphate buffer saline and bronchoalveolar lavage, following incubation at 37 degrees C. All batches were found to retain more than 63.54% of budesonide within liposomes at the end of 24 h. Rehydrated budesonide liposomes or nonencapsulated budesonide was delivered to rat lungs by intratracheal administration. The pulmonary drug disposition was assessed by simultaneous monitoring of drug levels in the bronchoalveolar lavage and lung tissue. After intratracheal administration, cumulative drug levels in the lung tissue indicated that the targeting factor was at least 1.66 times higher in liposomes. The maximal drug concentration in the lung homogenate for the liposomal dry powder inhaler was 36.64 micrograms as compared to 78.56 micrograms with the plain drug. Similarly, the time for maximum drug concentration in the lung homogenate for the liposomal dry powder inhaler was 9-12 h as compared to 3 h for that of the plain drug. Hence, the use of a developed liposomal budesonide dry powder inhaler was found to provide desired drug levels in the lungs for a prolonged period of time, which is expected to enhance the therapeutic index of the drug and probably reduce the dose and cost of therapy as well.

Group A Streptococcus (GAS) soft-tissue infections: a lethal organism on the rise

Several reports over the past decade have suggested that there has been an increase in the number of invasive streptococcal infections with young children and the elderly being at the highest risk. We evaluated the incidence of group A Streptococcus (GAS) and compared it with historic data collected at our institution. Prospective data were collected on patients diagnosed with GAS (with and without shock) admitted to a tertiary-care center from July 1995 to July 2000. Each patient was followed by an infectious disease specialist throughout the hospital stay. Definitions of streptococcal toxic shock syndrome (STSS) developed by the Centers for Disease Control and Prevention were used. Thirty-eight patients (mean age of 39+/-12) presenting with GAS soft-tissue infections were admitted to our institution over a 5-year period (7.6 patients per year). Fourteen (37%) were diagnosed with STSS. This represents a greater than fourfold increase in the average number of cases per year of patients diagnosed with GAS and a nearly 4.5 times greater increase in the annual number of patients diagnosed with STSS. The overall mortality of patients diagnosed with GAS was 13 per cent, which increased to 36 per cent in patients diagnosed with STSS. We conclude that there has been a significant increase in the incidence of GAS soft-tissue infections over the past 5 years at our institution. This may represent a new virulent strain, as the majority of these infections did not occur in typical high-risk patients at the extremes of their lives. Further epidemiologic population-based studies are needed to further delineate the severe nature of this problem.

Group A Streptococcus (GAS) Soft-tissue Infections: A Lethal Organism on the Rise

Several reports over the past decade have suggested that there has been an increase in the number of invasive streptococcal infections with young children and the elderly being at the highest risk. We evaluated the incidence of group A Streptococcus (GAS) and compared it with historic data collected at our institution. Prospective data were collected on patients diagnosed with GAS (with and without shock) admitted to a tertiary-care center from July 1995 to July 2000. Each patient was followed by an infectious disease specialist throughout the hospital stay. Definitions of streptococcal toxic shock syndrome (STSS) developed by the Centers for Disease Control and Prevention were used. Thirty-eight patients (mean age of 39 ± 12) presenting with GAS soft-tissue infections were admitted to our institution over a 5-year period (7.6 patients per year). Fourteen (37%) were diagnosed with STSS. This represents a greater than fourfold increase in the average number of cases per year of patients diagnosed with GAS and a nearly 4.5 times greater increase in the annual number of patients diagnosed with STSS. The overall mortality of patients diagnosed with GAS was 13 per cent, which increased to 36 per cent in patients diagnosed with STSS. We conclude that there has been a significant increase in the incidence of GAS soft-tissue infections over the past 5 years at our institution. This may represent a new virulent strain, as the majority of these infections did not occur in typical high-risk patients at the extremes of their lives. Further epidemiologic population-based studies are needed to further delineate the severe nature of this problem.

Apoptosis versus necrosis during cold storage and rewarming of human renal proximal tubular cells

BACKGROUND

A recent clinical study demonstrated that in renal allografts preserved in the cold apoptosis occurred soon after reperfusion. The mode of cell death during cold storage is generally considered necrotic. Whether apoptosis occurs as a part of cold storage is uncertain. The objective was to determine in human renal tubular cells whether apoptosis is specific for rewarming or it also occurs during cold storage and whether it could be modified.

METHODS AND RESULTS

Cold storage (4 degrees C) of primary human renal proximal tubular epithelial (RPTE) in University of Wisconsin (UW) solution up to 48 hr caused a time-dependent increase in cell death measured by lactic dehydrogenase (LDH) release and vital dye exclusion methods. Transmission electron microscopy (TEM) demonstrated that cell death in the cold was necrotic, involving considerable mitochondrial disruption, and was not apoptotic. The TUNEL assay that provides a specific, quantitative measure for apoptosis showed no increase in TUNEL-positivity during flow cytometry of cells stored in cold: 37 degrees C, 0.23+/-0.14%; 24 hr cold, 0.23+/-0.1%; 48 hr cold, 1.79+/-0.58%. Annexin-V staining, a sensitive method for detecting early apoptosis, similarly showed no increase in positively stained cells during cold storage. Addition of antioxidants 2-methyl aminochroman and deferoxamine to UW solution inhibited necrotic cell death and preserved mitochondrial structure. In contrast to cold storage alone, rewarming (37 degrees C for 24 hr) of cold stored cells, however, resulted in significant apoptosis (TUNEL positive: 48 hr cold: 2+/-0.6%, 48 hr cold and 24 hr rewarming: 54+/-17%), which was confirmed by the TEM based on typical apoptotic features. Addition of 2-MAC and DFO significantly inhibited rewarming-induced apoptotic cell death (plus 2-MAC: 3+/-1%, plus DFO: 3+/-2%).

CONCLUSION

Our study in human tubular cells provides evidence that cold storage per se does not result in apoptosis, but is primarily necrotic. However, rewarming is associated with significant apoptosis in the presence of ongoing necrosis, speculatively due to the activation of the apoptotic enzymic process of sublethally injured cells. Inclusion of antioxidants in the storage solution confers protection against both cold storage and rewarming-induced necrosis and apoptosis.

Dry powder inhalation of liposomal Ketotifen fumarate: formulation and characterization

The purpose of the experiment was to formulate and characterize the dry powder inhalation (DPI) formulation of liposomally entrapped anti-asthmatic drug, Ketotifen fumarate (KF). Liposomes composed of saturated egg phosphatidyl choline (EPC) and cholesterol (CHOL) were prepared by lipid film hydration and sonicated to have the desired size (<5 microm). Process variable such as vacuum, presonication hydration, postsonication hydration, purification and lamellae composition, were optimized for encapsulation efficiency of KF. Liposomal dispersion was blended with cryoprotectant (sugar) in varying bulk and mass ratios and assessed for its influence on retention of encapsulated drug on lyophilization. Characterization of liposomal dispersion was done for size, lamellarity, entrapped volume and oxidation index. DPI formulation was characterized for angle of repose, compressibility index, dispersibility and respirable fraction (British Pharmacopoeia, apparatus A). Process optimization revealed that a vacuum, 20 in.; presonication hydration, 60 min; postsonication hydration, 2 h and purification by dialysis gave maximum encapsulation efficiency. Sucrose was found to be the most suitable cryoprotectant at bulk strength of 500 mM and mass ratio of lipid/sugar, 1/12. Blending of sorbolac before lyophilization showed better retention of encapsulated KF (97.92+/-0.54%). In the preparation of sonicated MLVs, the presence of nitrogen atmosphere, alpha-tocopherol and EDTA could not totally eliminate EPC oxidation, expressed as the change in oxidation index from 0.427+/-0.01 to 1.510+/-0.01. The respirable fraction of the developed formulation (21.59+/-1.53%) is comparable with the control (26.49+/-1.52%). From studies, it may be concluded that an optimal bulk and mass ratio of sucrose, relative to the size of liposomes is necessary for effective cryoprotection. In this investigation, DPI of liposomal KF was successfully prepared and delivered to the required site in the lungs.

Atypical ductal hyperplasia in stereotactic breast biopsies: enhanced accuracy of diagnosis with the mammotome

There is little literature assessing the incidence of subsequent carcinoma in patients diagnosed with atypical ductal hyperplasia (ADH) by mammotome. We reviewed 216 stereotactic mammotome biopsies (SMBs) and compared the results to the 121 automated tru-cut biopsies (ATC) performed at our breast care center from June 1994 to July 1998. The median age in the mammotome series was 57 years, compared to 56 years in the ATC group. An increase in biopsies for microcalcifications (49% versus 41%) was noted in the SMB series. This was accompanied by an increase in the number of cases with a diagnosis of pure ductal carcinoma in situ (DCIS) (10% versus 4%). Compared to the tru-cut, in which 38% (3 of 8) of the cases diagnosed as atypical hyperplasia (AH) showed DCIS and/or invasive carcinoma on open biopsy, none of the cases diagnosed as AH on mammotome revealed carcinoma on open biopsy. ADH is more accurately diagnosed with SMB than by the ATC method and may not be an indication for subsequent open biopsy.

Systemic inflammatory response syndrome score at admission independently predicts infection in blunt trauma patients

BACKGROUND

Systemic inflammatory response syndrome (SIRS) score has been demonstrated to be an accurate predictor of outcome in critical surgical illness. To our knowledge, there is a paucity of data using SIRS score as a tool to predict posttraumatic infection. Our goal was to determine whether the severity of SIRS score at admission is an accurate predictor of infection in trauma patients.

METHODS

Prospective data were collected on 4,887 blunt trauma patients admitted to a primary adult resource center designated trauma center over an 18-month period. Patients were stratified by age and Injury Severity Score (ISS). SIRS score was calculated at admission. SIRS was defined as an SIRS score > or = 2. Each patient was screened for infection by an infectious disease specialist. Those at high risk for infection were then monitored daily throughout their hospitalization. Centers for Disease Control and Prevention guidelines were used to diagnose infection.

RESULTS

Of the 4,887 patients, 1,850 (38%) were admitted > 24 hours and evaluated for subsequent infection (mean ISS, 16 +/- 9; mean age, 43 +/- 19, SD). Thirty-one percent (577) of the patients acquired an infection. The mean hospital length of stay (20.2 days vs. 6.5 days) and mortality (7.8% vs. 2.7%) were significantly greater in the infected group (p < 0.001). Of the four SIRS variables (temperature, heart rate, white blood cell count, and respiratory rate), hypothermia and leukocytosis were the most significant predictors of infection (p < 0.001) when adjusted for age and ISS. SIRS scores of > or = 2 were increasingly predictive of infection when analyzed by multiple logistic regression analysis.

CONCLUSION

An admission SIRS score of > or = 2 is a significant independent predictor of infection and outcome in blunt trauma. Daily SIRS scores may be a meaningful method of assessing postinjury risk of infection, and may initiate earlier diagnostic intervention for determination of infection.

Impact of nosocomial infections in trauma: does age make a difference?

BACKGROUND

The effect of age and infection on outcome after trauma is unknown. We evaluated the incidence and impact that nosocomial infection (NI) and age have on morbidity and mortality. Several risk factors were identified and analyzed for correlation with infection.

METHODS

Prospective data were collected on patients admitted for > or = 3 days over a 2-year period. Each patient was followed by an infectious disease specialist throughout their hospitalization. Centers for Disease Control and Prevention guidelines were used to diagnose infection.

RESULTS

Of the 3,254 patients admitted, 88% were < 65 and 12% were > or = 65 years of age. Injury Severity Score was not significantly different (older vs. younger). Five hundred one (17.4%) of the younger patients developed an NI with a significantly higher hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality compared with the noninfected group. One hundred forty-seven (39%) of the older group developed an NI and also had significant increases in hospital LOS, ICU LOS, and mortality. Older infected patients had the highest hospital LOS, ICU LOS, and mortality. The greatest relative risk of mortality was demonstrated with the combination of increased age and NI. Once infected, however, younger patients with penetrating trauma had a greater relative risk of mortality in the group-specific comparison. Many risk factors were associated with infection. Only chronic obstructive pulmonary disease in elderly trauma patients was a significant independent risk factor for infection.

CONCLUSION

NI significantly increases hospital LOS, ICU LOS, and mortality after injury. Age increases risk of infection matched for injury severity, with a significantly higher hospital LOS, ICU LOS, and mortality. Once infected, however, younger patients with penetrating trauma have the greatest risk of mortality. Chronic obstructive pulmonary disease in elderly trauma patients was found to be an independent predictor of infection.

Emergence of axons from distal dendrites of adult mammalian neurons following a permanent axotomy

The distinctive features of axons and dendrites divide most neurons into two compartments. This polarity is fundamental to the ability of most neurons to integrate synaptic signals and transmit action potentials. It is not known, however, if the polarity of neurons in the adult mammalian nervous system is fixed or plastic. Following axotomy, some distal dendrites of neck motoneurons in the adult cat give rise to unusual processes that, at a light microscopic level, resemble axons (Rose, P.K. & Odlozinski, M., J. Comp. Neurol., 1998, 390, 392). The goal of the present experiments was to characterize these unusual processes using well-established ultrastructural and molecular criteria that differentiate dendrites and axons. These processes were immunoreactive for growth-associated protein-43 (GAP-43), a protein that is normally confined to axons. In contrast, immunoreactivity for a protein that is widely used as a marker for dendrites, microtubule-associated protein (MAP)-2a/b, could not be detected in the unusual distal arborizations. At the electron microscopic level, unusual distal processes contained dense collections of neurofilaments and were frequently myelinated. These molecular and structural characteristics are typical of axons and suggest that the polarity of adult neurons in the mammalian nervous system can be disrupted by axotomy. If this transformation in neuronal polarity is common to other types of neurons, axon-like processes emerging from distal dendrites may represent a mechanism for replacing connections lost due to injury. Alternatively, the connections formed by these axons may be aberrant and therefore maladaptive.

Community-acquired infections in the geriatric trauma population

The incidence of community-acquired infections (CAs) and their relationship to the incidence of nosocomial infections (NI), to our knowledge, is unknown in elderly trauma patients. We prospectively collected data on 380 patients > or =65 years of age who were admitted >48 h to our trauma center over a 2-year period. One hundred seventy-seven patients (47%) developed an infection. A total of 147 (39%) patients were diagnosed with an NI, and 67 (18%) were diagnosed with a CA. Of the 67 patients with CA, 37 (55%) went on to develop an NI. Patients with the combination of CA and NI had the greatest mean ICU (28.6 days) and hospital length of stay (38.2 days). Mortality was increased significantly in patients with the combination of CA and NI (27%). Respiratory and genitourinary infections were the most common CA. Patients with respiratory CAs accounted for the greatest proportion of NIs. Thus, community-acquired and nosocomial infections significantly increase morbidity and mortality in elderly patients post-injury. Patients who present with a CA are at increased risk of acquiring an NI, which is associated with the most significant increase in length of stay and mortality.

Risk factors for nosocomial pneumonia in critically ill trauma patients

Nosocomial pneumonia is the most common pulmonary complication in trauma patients and the leading cause of death in nosocomial infections. A comprehensive review of pneumonia studies is provided. The Centers for Disease Control's nosocomial pneumonia pathogenesis model is reviewed and was used to guide the selection of risk factors evaluated in this study. The purposes of this research were to identify underlying dimensions (factors) of variables that increase the risk of nosocomial pneumonia and to identify predictors of nosocomial pneumonia in critically ill trauma patients.

Synthesis and construction of a novel multiple peptide conjugate system: strategy for a subunit vaccine design

We describe the design and synthesis of a novel well characterized multi-peptide conjugate (MPC) system containing antigens from human malaria parasite and the Tat protein of HIV type-1 (HIV-1-Tat). Construction of the MPC utilizes Fmoc solid-phase peptide synthesis coupled with solution chemistry. In the first phase, a core template that serves as primary anchor for the synthesis and attachment of multiple antigens is synthesized. Serine(trityl) and multiple lysine branches with epsilon groups blocked during chain assembly are incorporated forming a tetrameric core. Cysteine whose side chain thiol serves to couple haloacetyl or S-protected haloacetyl peptides is added to complete assembly of the core template. Modification to the coupling solvent, addition of key amino acid derivatives (N-[1-hydroxy-4-methoxybenzyl]) in the peptide sequence allows the synthesis of base peptides on the core template with molecular mass greater than 7500 kDa. Base peptides are then reacted with high performance liquid chromatography purified haloacetyl peptides to generate multiple peptide conjugates with molecular masses of 10 to 13 kDa. MPC constructs thus formed are further characterized by matrix assisted laser desorption-time of flight mass spectroscopy (MALDI-MS), amino acid analysis, size exclusion chromatography, and SDS-polyacrylamide gel electrophoresis (PAGE). To our knowledge, this is the first report describing a chemically well defined multiple conjugate system with potential for development of synthetic subunit vaccines.

Unusual radiological presentation and rapid fatal progression of invasive pulmonary aspergillosis in an immunocompetent young patient

Invasive aspergillosis occurs very rarely in immunocompetent hosts. We describe a 21-year-old female with no obvious immunosuppression or underlying lung disease, who presented with minimal symptoms and bilateral hilar prominence on chest X-ray. Invasive aspergillosis was diagnosed on an open lung biopsy. She deteriorated in the ensuing 2 weeks and died of a sudden massive haemoptysis. This initial radiological abnormality and the rapid clinical course of the disease in young immunocompetent patients have not been previously reported.