Attenuated cerebrospinal fluid leukocyte count and sepsis in adults with pneumococcal meningitis: a prospective cohort study

BACKGROUND: A low cerebrospinal fluid (CSF) white-blood cell count (WBC) has been identified as an independent risk factor for adverse outcome in adults with bacterial meningitis. Whereas a low CSF WBC indicates the presence of sepsis with early meningitis in patients with meningococcal infections, the relation between CSF WBC and outcome in patients with pneumococcal meningitis is not understood. METHODS: We examined the relation between CSF WBC, bacteraemia and sepsis in a prospective cohort study that included 352 episodes of pneumococcal meningitis, confirmed by CSF culture, occurring in patients aged >16 years. RESULTS: CSF WBC was recorded in 320 of 352 episodes (91%). Median CSF WBC was 2530 per mm(3 )(interquartile range 531–6983 per mm(3)) and 104 patients (33%) had a CSF WBC <1000/mm(3). Patients with a CSF WBC <1000/mm(3 )were more likely to have an unfavourable outcome (defined as a Glasgow Outcome Scale score of 1–4) than those with a higher WBC (74 of 104 [71%] vs. 87 of 216 [43%]; P < 0.001). CSF WBC was significantly associated with blood WBC (Spearman's test 0.29), CSF protein level (0.20), thrombocyte count (0.21), erythrocyte sedimentation rate (-0.15), and C-reactive protein levels (-0.18). Patients with a CSF WBC <1000/mm(3 )more often had a positive blood culture (72 of 84 [86%] vs. 138 of 196 [70%]; P = 0.01) and more often developed systemic complications (cardiorespiratory failure, sepsis) than those with a higher WBC (53 of 104 [51%] vs. 69 of 216 [32%]; P = 0.001). In a multivariate analysis, advanced age (Odds ratio per 10-year increments 1.22, 95%CI 1.02–1.45), a positive blood culture (Odds ratio 2.46, 95%CI 1.17–5.14), and a low thrombocyte count on admission (Odds ratio per 100,000/mm(3 )increments 0.67, 95% CI 0.47–0.97) were associated with a CSF WBC <1000/mm(3). CONCLUSION: A low CSF WBC in adults with pneumococcal meningitis is related to the presence of signs of sepsis and systemic complications. Invasive pneumococcal infections should possibly be regarded as a continuum from meningitis to sepsis

Effects of urinary cortisol levels and resting heart rate on the risk for fatal and nonfatal cardiovascular events

AbstractBackground and aimsHigher cortisol levels are associated with cardiovascular mortality in the elderly. It is unclear whether this association also exists in a general population of younger adults and for non-fatal cardiovascular events. Likewise, resting heart rate is associated with cardiovascular mortality, but fewer studies have also considered non-fatal events. The goal of this study was to investigate whether twenty-four-hour urinary cortisol (24-h UFC) levels and resting heart rate (RHR) predict major adverse fatal and non-fatal cardiovascular events (MACE) in the general population.MethodsWe used data from a subcohort of the PREVEND study, a prospective general population based cohort study with a follow-up of 6.4 years for 24-h UFC and 10.6 years for RHR. Participants were 3432 adults (mean age 49 years, range 28–75). 24-h UFC was collected and measured by liquid chromatography—tandem mass spectrometry. RHR was measured at baseline in a supine position for 10 min with the Dinamap XL Model 9300. Information about cardiovascular events and mortality was obtained from the Dutch national registry of hospital discharge diagnoses and the municipal register respectively.Results24-h UFC did not significantly increase the hazard of MACE (hazard ratio = 0.999, 95% confidence interval = 0.993–1.006, p = 0.814). RHR increased the risk for MACE with 17% per 10 extra heart beats per minute (hazard ratio = 1.016, 95% confidence interval = 1.001–1.031, p = 0.036) after adjustment for conventional risk factors.ConclusionsIn contrast to 24-h UFC, RHR is a risk marker for MACE in the general population

Photoionization spectroscopy of CH3C3N in the vacuum-ultraviolet range

International audienceUsing vacuum-ultraviolet (VUV) synchrotron radiation, threshold and dissociative photoionization of cyanopropyne (CH3C3N) in the gas phase have been studied from 86 000 cm−1 up to 180 000 cm−1 by recording Threshold-PhotoElectron Spectrum (TPES) and PhotoIon Yield (PIY). Ionization energies of the four lowest electronic states X̃+2E,Ã+2A1,B̃+2E and C̃+ of CH3C3N+ are derived from the TPES with a better accuracy than previously reported. The adiabatic ionization potential of CH3C3N is measured as 86872±20 cm−1. A description of the vibrational structure of these states is proposed leading to the first determination of the vibrational frequencies for most modes. The vibrational assignments of the X̃+ state are supported by density functional theory calculations. In addition, dissociative photoionization spectra have been recorded for several cationic fragments in the range 12–15.5 eV (96 790–125 000 cm−1) and they bring new information on the photophysics of CH3C3N+. Threshold energies for the cationic dissociative channels leading to CH2C3N+, CHC3N+, HC3H+, HCNH+ and CH3+ have been measured for the first time and are compared with quantum chemical calculations

Can too few and too many climato-economic resources elevate blood pressure?:A 120-nation study

Elevated blood pressure as a major indicator of higher health risks varies considerably around the globe. We examine whether the livability of the environment can account for part of this variation. Overly resource-poor and overly resource-rich countries are expected to be less livable, with elevated blood pressure as a likely result. Male and female populations from 120 countries indeed have higher blood pressures to the extent they have to cope with too few or too many rather than just enough environmental resources. In poorer countries, predominantly located in hotter climes, both genders have higher blood pressures in too difficult-and-expensive environments with more demanding summers or winters (too few resources), than in just-right environments with more temperate summers and winters (optimal resources). In richer countries, predominantly located in colder climes, both genders have higher blood pressures in too easy-and-cheap environments with more temperate winters and summers (too many resources), than in just-right environments with more demanding winters or summers (optimal resources). We conclude that the livability of climate-based demands and wealth-based resources have a heretofore hidden ecological impact on chronic health risks, which may shed novel light also on policies of climate protection and poverty reduction

Cognitive outcome in adults with moderate disability after pneumococcal meningitis

Objectives To assess cognitive outcome and quality of life in patients with moderate disability after bacterial meningitis as compared to patients with good recovery. Methods Neuropsychological evaluation was performed in 40 adults after pneumococcal meningitis; 20 patients with moderate disability at discharge on the glasgow outcome scale (GOS score 4) and 20 with good recovery (GOS score 5). Results Patients with GOS score 4 had similar test results as compared to patients with GOS score 5 for the neuropsychological domains ‘intelligence’, ‘memory’ and ‘attention and executive functioning’. Patients with GOS score 4 showed less cognitive slowness than patients with GOS score 5. In a linear regression analysis cognitive speed was related to current intelligence, years of education and time since meningitis. Overall performance on the speed composite score correlated significantly with time since meningitis (−0.62; P<0.001). Therefore, difference between both groups may have been related to a longer time between meningitis and testing for GOS four patients (29 vs. 12 months; P<0.001). Conclusions Patients with moderate disability after bacterial meningitis are not at higher risk for neuropsychological abnormalities than patients with good recovery. In addition, cognitive slowness after bacterial meningitis may be reversible in time

Dexamethasone and long-term outcome in adults with bacterial meningitis

This follow-up study of the European Dexamethasone Study was designed to examine the potential harmful effect of adjunctive dexamethasone treatment on long-term neuropsychological outcome in adults with bacterial meningitis. METHODS: Neurological, audiological, and neuropsychological examinations were performed in adults who survived pneumococcal or meningococcal meningitis. RESULTS: Eighty-seven of 99 (88%) eligible patients were included in the follow-up study; 46 (53%) were treated with dexamethasone and 41 (47%) with placebo. Median time between meningitis and testing was 99 months. Neuropsychological evaluation showed no significant differences between patients treated with dexamethasone and placebo. The proportions of patients with persisting neurological sequelae or hearing loss were similar in the dexamethasone and placebo groups. The overall rate of cognitive dysfunction did not differ significantly between patients and control subjects; however, patients after pneumococcal meningitis had a higher rate of cognitive dysfunction (21 vs 6%; p = 0.05) and experienced more impairment of everyday functioning due to physical problems (p = 0.05) than those after meningococcal meningitis. INTERPRETATION: Treatment with adjunctive dexamethasone is not associated with an increased risk for long-term cognitive impairment. Adults who survive pneumococcal meningitis are at significant risk for long-term neuropsychological abnormalities

Towards a Parasitic Ethics

The parasite is widely conceived as a negative figure that takes without giving; perceived as an agent of corruption and destruction, it is subjected to programmes of eradication and expulsion across cultural, economic, political and ethical contexts. This paper offers an alternative approach to the status of parasitic relations in light of Michel Serres’s The Parasite, elaborated through ethnographic research into the after-hours culture and hidden economy of London’s Borough Market. We highlight the mutual dependence of agents in host-parasite networks according to what we term ‘general parasitism’, while inquiring into its ethical potential. Ultimately, we argue that while taking into account the near ubiquity of parasitic relations cannot form the basis for any concrete axiomatic ethical paradigm, it should at least encourage an ethics of hesitation before judgement when faced with any apparent instance of parasitism: to presume that parasitism is undesirable and unethical is itself undesirable and unethical

Limited effect of patient and disease characteristics on compliance with hospital antimicrobial guidelines

Objective: Physicians frequently deviate from guidelines that promote prudent use of antimicrobials. We explored to what extent patient and disease characteristics were associated with compliance with guideline recommendations for three common infections. Methods: In a 1-year prospective observational study, 1,125 antimicrobial prescriptions were analysed for compliance with university hospital guidelines. Results: Compliance varied significantly between and within the groups of infections studied. Compliance was much higher for lower respiratory tract infections (LRTIs; 79%) than for sepsis (53%) and urinary tract infections (UTIs; 40%). Only predisposing illnesses and active malignancies were associated with more compliant prescribing, whereas alcohol/ intravenous drug abuse and serum creatinine levels > 130 mu mol/l were associated with less compliant prescribing. Availability of culture results had no impact on compliance with guidelines for sepsis but was associated with more compliance in UTIs and less in LRTIs. Narrowing initial broad-spectrum antimicrobial therapy to cultured pathogens was seldom practised. Most noncompliant prescribing concerned a too broad spectrum of activity when compared with guideline-recommended therapy. Conclusion: Patient characteristics had only a limited impact on compliant prescribing for a variety of reasons. Physicians seemed to practise defensive prescribing behaviour, favouring treatment success in current patients over loss of effectiveness due to resistance in future patients