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PubMedDate not supplied

Extended broad spectrum beta-lactamase in Klebsiella pneumoniae including resistance to cephamycins.

A plasmid-encoded beta-lactamase conferring extended broad spectrum resistance including cephamycins was identified in a Klebsiella pneumoniae strain isolated from a patient's wound. Strains harbouring the plasmid pMVP-1 were resistant to penicillins, cephalosporins of all generations (parenteral and new oral compounds) cephamycins, aztreonam, tetracycline, chloramphenicol, sulfonamides and to all aminoglycosides modified by AAC-(6)-I-transferase. beta-lactams still active against these strains were temocillin, ceftazidime, cefpirome, carumonam and the carbapenems imipenem and meropenem. The new cephamycinase (CMY-1) was more strongly inhibited by sulbactam in the majority of combinations than by clavulanic acid or tazobactam. MICs of ceftazidime and carumonam were not reduced by inhibitors in the wild type and the transconjugant. A transferable plasmid (pMVP-1) of about 9.6 x 10(7) dalton was demonstrated by gel-electrophoresis. In the wild type and the transconjugant a beta-lactamase with an isoelectric point of 8.0 was identified. This enzyme CMY-1 is different from the other extended broad spectrum beta-lactamases (TEM-3 to TEM-10, SHV-2 to SHV-5). The incidence of this enzyme may be underestimated, since resistance to cephamycins in Klebsiella and Escherichia coli has so far been regarded as almost exclusively chromosomally encoded and sensitivity of CMY-1 to clavulanic acid is low. Therefore, screening for CMY-1 beta-lactamases by the usual double disk test including clavulanic acid is not sensitive enough to detect CMY-1 producers. Sulbactam (e.g. in combination with ampicillin) disks and a cephamycin should therefore be used as well when screening for super extended broad spectrum (SEBS-) beta-lactamases.

Cephamycins↗

PubMed1998

Repeated epidemics caused by extended-spectrum beta-lactamase-producing Serratia marcescens strains.

An outbreak of Serratia marcescens involving 42 patients admitted to the general intensive care unit of the Hospital of Varese, Italy, occurred from March 1994 to August 1995. The causative strains were resistant to oxyimino-cephalosporins and monobactams due to their production of an extended-spectrum beta-lactamase. Another outbreak caused by Serratia marcescens strains had occurred in the same unit a few months earlier, from February to October 1993, with the strains involved producing a novel TEM-derived extended-spectrum beta-lactamase. In order to verify whether there were any relationships between isolates from the two epidemics, the strains and their enzymes were characterized. Biochemical data and gene amplification experiments showed that the isolates of the second outbreak harbored a non-conjugative plasmid of approximately 48 kb, codifying for the production of an SHV-derived extended-spectrum beta-lactamase with pI 8.2. Restriction fragment length polymorphism analysis of total genomic DNA by pulsed-field gel electrophoresis of Serratia marcescens isolates unambiguously identified two different bacterial clones responsible for the two epidemics. Epidemiological and microbiological investigations demonstrated the long persistence of Serratia marcescens strains and their circulation in other hospital wards, thus suggesting their possible role as a long-term reservoir for further epidemic spread.

Cross Infection↗

PubMed1993

A decrease in the estimated frequency of the extended HLA haplotype B18 CF130 DR3 DQw2 is common to non-insulin-dependent diabetes, juvenile rheumatoid arthritis, and Berger's disease.

Extended HLA haplotypes frequencies were estimated from the HLA, C2, Bf and C4 phenotypes of 74 patients with non-insulin-dependent diabetes (NIDD), 92 with juvenile rheumatoid arthritis (JRA), 44 with Berger's disease (BD), 83 with insulin-dependent diabetes (IDD), and 140 healthy controls. The extended HLA haplotype B18 CF130 DR3 DQw2, which is common (around 10% phenotype frequency) in healthy Spaniards and in other populations of paleo-North African origin, was found to be significantly less frequent in NIDD, JRA and BD, whereas its frequency was normal in IDD (although DR3 DQw2 haplotypes were increased in the latter disease). These data support the existence of a common HLA-linked pathogeneic mechanism in NIDD, JRA and BD, and point to a genetic difference between IDD and NIDD at the HLA level. This effect is readily detectable in our population because the uncommon BfF1 allele marks that haplotype instead of the more common BfS, which marks B8 CS01 DR3 DQw2 in other Caucasians. Our results support the hypothesis of strong selective pressures operating at the HLA level to preserve extended HLA haplotypes with advantageous gene sets from dilution by crossing-over. Imbalanced incomplete haplotypes may give rise to inappropriate T-cell repertoire selection in the thymus and/or antigen handling in the periphery, and be partly responsible for the pathogenesis of certain HLA-linked diseases (i.e. NIDD, JRA, and BD).

Alleles↗

PubMed1994

Clinical significance of extended-spectrum beta-lactamases.

Extended-spectrum beta-lactamases (ESBLs) have now been described in many hospitals worldwide. While they have been detected in many pathogenic gram-negative bacteria, they are particularly prevalent in Klebsiella isolates. Known risk factors for colonization and/or infection with organisms harboring these enzymes include admission to an intensive care unit, recent surgery, instrumentation, prolonged hospital stay and antibiotic exposure, especially exposure to extended-spectrum beta-lactam agents. In this report three recent epidemics from the USA will be described in which the role of selective antibiotic pressure seems clear. Data from two hospital epidemics, one from New York and another from Stanford, California, will be reviewed briefly. In addition, recent studies describing the spread of extended-spectrum beta-lactamases among nursing home patients in Chicago, Illinois, will be outlined. The limited data available on treatment options for patients infected with ESBL-containing strains will be reviewed, focusing on the activity of piperacillin/tazobactam and imipenem against these otherwise broadly resistant strains. Lastly, attempts to control these organisms, including infection control measures and selective bowel decontamination, will be reviewed.

Child↗

PubMed1994

Extended central bisegmentectomy--an en bloc resection of hepatic segments 4, 5, 8 and 7: report of a case.

We herein present an example of an extended central bisegmentectomy in a patient with a large hepatocellular carcinoma. According to a magnetic resonance imaging study, the right hepatic vein was displaced and narrowed at its origin and a large inferior right hepatic vein was revealed. In this case, owing to the only slightly functional remaining hepatic reserve, an extended central bisegmentectomy was selected as the optimum treatment. The postoperative course was uneventful except for some bile leakage. Twelve months after operation, the patient is still alive and no sign of recurrence has been detected. The extended central bisegmentectomy is an en bloc resection of hepatic segments 4, 5, 7, and 8. When the large inferior right hepatic vein is present, segment 6 can be preserved even when the right hepatic vein is sacrificed at its origin.

Carcinoma, Hepatocellular↗

PubMed1996

Physician extenders for cost-effective management of hypercholesterolemia.

OBJECTIVE: Treatment of elevated cholesterol levels reduces morbidity and mortality from coronary heart disease in high-risk patients, but can be costly. The purpose of this study was to determine whether physician extenders emphasizing diet modification and, when necessary, effective and inexpensive drug algorithms can provide more cost-effective therapy than conventional care. DESIGN: Randomized controlled trial. SETTING: A Department of Veterans Affairs Medical Center. PATIENTS: Two hundred forty-seven veterans with type IIa hypercholesterolemia. INTERVENTIONS: Patients assigned to either a cholesterol treatment program (CTP) or usual health care provided by general internists (UHC). CTP included intensive dietary therapy administered by a registered dietitian utilizing individual and group counseling and drug therapy initiated by physician extenders for those failing to achieve goal low-density lipoprotein (LDL) levels with diet alone. A drug selection algorithm for CTP subjects utilized niacin as initial therapy followed by bile acid sequestrants and lovastatin. Subjects were followed prospectively for 2 years. MEASUREMENTS: Primary outcome measurements were effectiveness of therapy defined as reductions in LDL cholesterol (LDL-C), and whether goal LDL-C levels were achieved; costs of therapy; and cost-effectiveness defined as the cost per unit reduction in the LDL-C. MAIN RESULTS: Total program costs were higher for CTP patients than for UHC patients ($659 +/- $43 vs $477 +/- $42 per patient, p < .001). However, at 24 months the patients in CTP were more likely to achieve LDL goal levels (65% vs 44%, p < .005), and also achieved greater reductions in LDL-C 27% +/- 2% vs 14% +/- 2% at 24 months, p < .001). Program costs per unit (mmol/L) reduction in the LDL-C, a measure of cost-effectiveness, was significantly lower for CTP ($758 +/- $58 vs $1,058 +/- $70, p = .002). CONCLUSIONS: Although more expensive than usual care, the greater effectiveness of physician extenders implementing cholesterol treatment algorithms resulted in more cost-effective therapy.

Anticholesteremic Agents↗

PubMedDate not supplied

Comparative effect of different types of food on the bioavailability of cefaclor extended release tablet.

This randomized, six-treatment, six-period, six sequence, single dose, crossover pharmacokinetic study assessed the effect of different types of food on the bioavailability of 500-mg cefaclor extended release tablet in 23 healthy male volunteers. A single dose of cefaclor extended release 500-mg tablet was administered at six occasions: after overnight fasting, after two vegetarian (high-fat and low-fat), two non-vegetarian (high-fat and low-fat) and rice diets. Serial blood samples were collected up to 12 h after dose. Serum cefaclor concentrations were determined by a validated HPLC method. An almost equivalent increase in both Cmax and AUC was observed with both high-fat non-vegetarian and low-fat vegetarian breakfasts. However, when MIC90 values, a pharmacodynamic end-point were compared, the low-fat vegetarian diet fared better than the high-fat non-vegetarian diet. The results obtained favor low-fat vegetarian diet (breakfast) to be taken with cefaclor extended release tablet to achieve maximum benefit in terms of clinical efficacy.

Adult↗

PubMed1998

Analysis of lobectomy for small peripheral lung cancer supports extended segmentectomy.

We reviewed the records of 53 patients who underwent lobectomy for peripheral non-small cell lung cancer under 2 cm in diameter and established a rationale for segmentectomy with intraoperative lymph nodes dissection (extended segmentectomy). Five patients (9.4%) had intrapulmonary metastases. Nodal status was N0 in 34 patients (64.2%), N1 in 7 (13.2%), and N2 in 12 (22.6%). Based on examination of intraoperative frozen sections, 31 patients lacking lymph node metastases and visceral pleural involvement could have been candidates for extended segmentectomy. Twenty-seven had stage I disease on postoperative examination of paraffin-embedded sections. Of the remaining 4 patients, 1 had involvement of intrapulmonary lymph nodes in the segment where the primary lesion originated. Another patient had involvement only at the first mediastinal lymph node level, representing a "skipping metastasis". The remaining 2 patients had no lymph node involvement, but had intrapulmonary metastases in the same segments as the primary lesion. We conclude that an extended segmentectomy may be as effective as lobectomy for treatment of peripheral non-small cell lung cancer under 2 cm in diameter without evident lymph node involvement.

Adult↗

PubMed2000

A clinical study of surgical treatment of patients with carcinoma of the cervical esophagus extending to the thoracic esophagus.

OBJECTIVE: We studied optimum surgery for carcinoma of the cervical esophagus extending to the thoracic esophagus (Ce-Ut carcinoma). METHODS: Subjects were 13 patients diagnosed with Ce-Ut carcinoma treated at our institute from January 1989 to December 1998. Clinicopathologic information such as surgical procedures, pathologic findings, and postoperative complications were analyzed. RESULTS: In 10, laryngoesophagectomy was conducted due to tracheal invasion by the tumor. In 7, mediastinal tracheostomy was done because of the extended resection of the proximal trachea. In 3, the larynx was preserved and, in 2, cricopharyngeal myotomy was added. Lymph node metastasis was found only in the neck and the upper mediastinum at surgery and recurrences were all lung metastasis. The incidence of postoperative complications was very high (76.9%), and 1 patient died due to widespread tracheal necrosis. The cumulative 5-year survival rate for the group was 33.3% and that for the 9 curative cases was 50%, but most of the cases who underwent noncurative resection and/or who received preoperative therapy for widespread invasion to surrounding organs died within a year. CONCLUSION: The prognosis of patients who undergoing curative extended resection of the proximal trachea and suitable lymph node dissection in the neck and upper mediastinum may improve, and larynx-preserving surgery is recommended for patients without tracheal invasion. Despite preoperative chemoradiotherapy, the prognosis of patients with widespread invasion to surrounding organs was very poor, and clinical studies on new therapeutic strategies for these advanced cases are needed to improve the prognosis of Ce-Ut carcinoma patients.

Adult↗

PubMed1993

A low-level strength training exercise program for frail elderly adults living in an extended attention facility.

Little is known about low-level, mildly progressive, strength training programs for frail elderly adults who live in extended attention housing. To study the effects of a low-level strength training program, a group of 12 frail elderly adults, aged 70 to 93 years, residing in an extended attention facility, participated in a strength training exercise program using ankle and wrist weights. Baseline measurements of elbow and knee flexor and extensor muscle strength were taken with a handheld dynamometer prior to initiation of the strength training program, and every three weeks during the 12-week period of exercise with weights. Muscle strength of elbow and knee flexors improved significantly by the end of the 12-week period (p < 0.05). Elbow and knee extensors did not show significant increases in muscle strength, but were maintained. It is concluded that muscle strength can be maintained or improved in adults over 70 who live in an extended attention facility using a low-level, mildly progressive, resistive exercise program. The program is safe, inexpensive, practical and can be used in clinical as well as community settings.

Aged↗

PubMedDate not supplied

Clinical characteristics and genetic screening of an extended family with MEN2A.

MEN-2A is characterized by medullary thyroid carcinoma (MTC) with pheochromocytoma and sometimes parathyroid adenoma. In affected members of the family, the risk of MTC is about 100%. Biochemical screening allows tumors to be detected early but even at this stage treatment is not always curative. Missense mutations in exon 10 and 11 of the RET proto-oncogene are associated with MEN-2A. Early detection of this mutation by DNA analysis allows the identification of the carriers of the gene. We performed genetic screening in 88 members of an extended family with MEN-2A and found 18 members positive for RET mutation (Cys634Gly). Only three of these 18 RET positive cases had a previous diagnosis of medullary cancer and/or pheochromocytoma. Up to now, 12 of the RET positive cases have undergone thyroidectomy. There was extended disease with cervical lymph node metastasis in 6 of them, bilateral medullary microcancer in 3 and c-cell hyperplasia in the remaining 3. Three of the 18 RET positive patients had also pheochromocytoma. Primary hyperparathyroidism was present in only one patient. The mean age of diagnosis of medullary cancer was between 25-50 yr and mean age of death was between 35-95 yr in affected members of the family. The family had many other affected members in other cities in Turkey and in other countries throughout the world from Australia to the Netherlands. So this family is perhaps one of the most extended families with MEN-2A.

Adrenal Gland Neoplasms↗

PubMed2005

Feasibility and early results of interstitial intensity-modulated HDR/PDR brachytherapy (IMBT) with/without complementary external-beam radiotherapy and extended surgery in recurrent pelvic colorectal cancer.

BACKGROUND: A new multimodality treatment concept consisting of extended resection and postoperative fractionated intensity-modulated interstitial brachytherapy (IMBT) was introduced for pelvic recurrence of colorectal carcinoma. PATIENTS AND METHODS: 46 patients received extended resection and single plastic tubes were sutured directly onto the tumor bed. IMBT was started within 2 weeks postoperatively with a median dose of 24.5 Gy (5-35 Gy). Patients were treated either with high-dose-rate brachytherapy (HDR; n = 23) or with pulsed-dose-rate brachytherapy (PDR; n = 23). 25 patients received complementary 45-Gy external-beam irradiation (EBRT) to the pelvic region after explanting the plastic tubes. RESULTS: Median follow-up was 20.6 months (7-107 months) and mean patient survival 25.7 +/- 25.8 months (median 17, range 1-107 months). After 5 years overall survival, disease-free survival and local control rate were 23%, 20% and 33%, significantly influenced by the resectional state. There was a trend in favor of PDR compared to HDR, which reached statistical significance in patients who had not received additional EBRT. CONCLUSION: The combination of extended surgery and postoperative interstitial IMBT is feasible and offers effective interdisciplinary treatment of recurrent colorectal cancer. In this small and inhomogeneous cohort of patients PDR seems to be more effective than HDR, particularly when application of complementary EBRT is not possible. None of the patients who required resection of distant metastasis survived > 2 years in this study.

Brachytherapy↗

PubMed2003

[Right portal vein ligation prior to extended right hemihepatectomy for synchronous colorectal liver metastases].

INTRODUCTION: A two-step procedure is suggested to reduce the overall operative risk in patients with colorectal cancer and large synchronous liver metastases, which demand an extended right hemihepatectomy for R0 resection. METHODS: The clinical course and volumetric evaluation of the liver is described in three patients in whom preliminary ligation of the right branch of the portal vein was performed at the time of colon resection. RESULTS: The size of the left lateral lobes increased by 9.9%, 13.7%, and 4.9% of total liver volume, respectively. At the same time, the noninfiltrated part of the right lobes shrunk by 36.7%, 36%, and 6% ukereas metastatic growth was 26.8%, 22.3%, and 12%. After 7 weeks, extended right hemihepatectomy could be performed in all three patients without signs of hepatic insufficiency, yielding R0 resection. CONCLUSION: Can reduce the risk for extended right hemihepatectomy in selected patients with synchronous colorectal liver metastases.

Adenocarcinoma↗

PubMed2001

Predictable individual differences in the initiation of cocaine self-administration by rats under extended-access conditions are dose-dependent.

RATIONALE: The characterization of self-administration (SA) under extended access conditions is necessary for the development of addiction models. OBJECTIVE: The purposes of this experiment were to investigate: (1) dose effects on the initiation of cocaine SA under extended access conditions; (2) predictable individual differences in SA under these conditions and their relationships to neuroendocrine function and cocaine dose. METHODS: After they were tested for their locomotor responses to novelty and to cocaine and trained to lever-press under a food-reinforced schedule, male Sprague-Dawley rats were allowed to SA cocaine (0.25, 0.5, 1.0, or 2.0 mg/kg per infusion, IV) by lever-pressing under a FR1 schedule during five consecutive daily 10-h sessions. Plasma corticosterone (CORT) and prolactin (PRL) were measured throughout the experiment. RESULTS: Rats tested at higher cocaine doses more readily acquired and showed increased drug intake and more regular patterns of SA. High responders (HR) to novelty self-administered greater amounts of cocaine, acquired more rapidly and displayed more regular SA compared to LR rats, but only at the lowest cocaine dose tested (i.e., 0.25 mg/kg per infusion). HR rats also exhibited a greater high-dose escalation of SA compared to LR rats. Novelty-induced (but not cocaine-induced) locomotor activity, pre-SA plasma CORT, and pre-SA food-reinforced lever-pressing predicted SA, but only at the lowest cocaine dose tested. No differences in plasma CORT or PRL were observed between LR and HR rats. CONCLUSIONS: The present findings indicate that predictable individual differences in cocaine SA under extended access conditions are relevant only at low doses and are surmountable by increasing the available dose of cocaine.

Animals↗

PubMed2002

Comparative and evolutionary analysis of the rhesus macaque extended MHC class II region.

The sequence-based map of a part of the rhesus macaque major histocompatibility complex (MHC) extended class II region is presented. The sequenced region encompasses 67,401 bp and contains the SACM2L, RING1, FABGL and KE4 genes, as well as the HTATSF1-like and ZNF-like pseudogenes. Similar to human, but different from rat and mouse, no class I genes are found in the SACM2L- RING1 interval. The rhesus macaque extended MHC class II region shows a high degree of conservation of exonic as well as intronic and intergenic sequences compared with the respective human region. It is concluded that this particular genomic organization of the extended class II region-i.e., the absence of class I genes and the presence of the HTATSF1-like and ZNF-like pseudogenes-can be traced back to a common ancestor of humans and rhesus macaques about 23 million years ago.

Animals↗

PubMedDate not supplied

Correction of the crooked nose using custom-made high-density porous polyethylene extended spreader grafts.

Correction of the crooked or deviated nose, a complex cosmetic and functional problem, is a big challenge for the rhinoplasty surgeon. Although corrections using a wide range of surgical techniques to straighten the nose and maximize nasal function have been proposed, recurrence is very common because of cartilage memory and scar contracture. Therefore, to prevent recurrence and to maintain the correction of the septum, a permanent support that is stable and strong, with the ability to maintain its given shape after placement on one or both sides of the septum, is needed. For this purpose, the authors planned to use a pair of custom-made high-density porous polyethylene (HDPP) extended spreader grafts. In this study, the concept and technique of HDPP, composed of a nonresorbable alloplastic material for correction of the crooked nose, and the authors' experience using it, are presented. Currently, HDPP is readily available on the market as a thin plain sheet (0.85 x 38 x 50 mm) that can be cut to an appropriate size for spreader grafts. Ingrowths of fibrous tissue inside and around HDPP stabilize the upper lateral cartilages and septum in their new corrected position and maintain the corrected/straightened position. This material was used in 20 patients with crooked noses (9 with C-type and 11 with S-type noses). During a mean follow-up period of 18 months (range, 8-30 months), there were no complications, recurrences, or extrusions. Functional evaluation was performed using a visual analog scale before surgery and 6 months after surgery. Patients were asked to score their nasal breathing on a scale ranging from 0 to 100. The mean preoperative value was 32.50% +/- 11.18%, and the postoperative value was 88.75% +/- 8.71%. In conclusion, the use of custom-made HDPP extended spreader grafts is a safe, effective, reliable, and permanent method for correction of the crooked nose. In the long term, the authors believe that custom-made HDPP extended spreader grafts provide functional recovery and increased strength against further trauma or forces of scar contracture, and have the ability to prevent recurrence attributable to cartilage memory.

Adult↗

PubMed1998

Lack of survival benefit of extended lymph node dissection for ductal adenocarcinoma of the head of the pancreas: retrospective multi-institutional analysis in Japan.

It has not been established that extended lymph node resection is necessary for ductal adenocarcinoma of the head of the pancreas. According to the general rules for the study of pancreatic cancer, a multiinstitutional, retrospective clinical study was undertaken to investigate the efficiency of extended lymph node dissection for this malignancy. Altogether 501 patients underwent resection of the pancreas between 1991 and 1994 at 77 medical facilities; the surgical procedures, staging, lymph node dissection, curability, and survival rate were analyzed retrospectively. Eighteen of the patients died within 30 postoperative days, leaving 483 patients to be studied. The resection was curative microscopically in 94 patients, resulting in a 3-year survival of 29%. Macroscopically curative resection resulted in a 3-year survival of 14%; noncurative resection produced a 3-year survival of 6%. Although extended lymph node dissection was performed on 38 patients in stage I, 42 patients in stage II, 206 patients in stage III, and 1 patient in stage IV, there was no improvement in survival when the results were compared to those seen after standard or palliative lymph node dissection. The extent of lymph node dissection has not affected the prognosis for ductal adenocarcinoma of the head of the pancreas at any stage of the course of the disease. Excessive lymph node dissection in advanced cases does not necessarily lead to a favorable prognosis. The patients who undergo a radical operation with an adequate lymph node dissection have longer survivals.

Adult↗

PubMedDate not supplied

CT-guided epidural/perineural injections in painful disorders of the lumbar spine: short- and extended-term results.

PURPOSE: Evaluation of short- and extended-term results of repeated epidural/perineural injections (EDT/PRT) of corticoids in painful afflictions of the lumbar spine. METHODS: Thirty-two patients who had persistent radicular or low back pain for more than 6 weeks were treated with CT-guided injection therapy. By EDT/PRT, 40 mg of triamcinolonacetonid was injected either periradicularly or by a direct intraspinal epidural method at intervals of 3 weeks. Altogether, 140 EDT/PRT were performed in 32 patients (mean 4.4, range 2-8). In nine patients partial facet joint denervation with 1-2 ml of 50% alcohol solution was combined with EDT/PRT to reduce low back pain. Before and after treatment and at follow-up (mean 9.6 months), treatment success was evaluated on a visual analog scale and by physical examination (good = >50% improvement, moderate = 20%-50%, no improvement = <20%). RESULTS: Short-term (end of therapy) good or moderate improvement was achieved in 91% of patients, extended-term (mean 9.6 months) in 56%. Regarding certain subgroups, those with disc herniations of the lumbar spine showed a better outcome with good or moderate improvement in 95% short-term and 69% extended-term than those with spinal stenosis who had 72% short-term and 28% long-term. CONCLUSION: Results indicate that CT-guided EDT/PRT in combination with partial facet joint denervation is a safe and effective outpatient treatment.

Anti-Inflammatory Agents↗