Where Are All the Mycobacterium avium Subspecies paratuberculosis in Patients with Crohn's Disease?

Mycobacterium avium subspecies paratuberculosis (MAP) causes a chronic granulomatous inflammation of the intestines, Johne's disease, in dairy cows and every other species of mammal in which it has been identified. MAP has been identified in the mucosal layer and deeper bowel wall in patients with Crohn's disease by methods other than light microscopy, and by direct visualization in small numbers by light microscopy. MAP has not been accepted as the cause of Crohn's disease in part because it has not been seen under the microscope in large numbers in the intestines of patients with Crohn's disease. An analysis of the literature on the pathology of Crohn's disease and on possible MAP infection in Crohn's patients suggests that MAP might directly infect endothelial cells and adipocytes and cause them to proliferate, causing focal obstruction within already existing vessels (including granuloma formation), the development of new vessels (neoangiogenesis and lymphangiogenesis), and the “creeping fat” of the mesentery that is unique in human pathology to Crohn's disease but also occurs in bovine Johne's disease. Large numbers of MAP might therefore be found in the mesentery attached to segments of intestine affected by Crohn's disease rather than in the bowel wall, the blood and lymphatic vessels running through the mesentery, or the mesenteric fat itself. The walls of fistulas might result from the neoangiogenesis or lymphangiogenesis that occurs in the bowel wall in Crohn's disease and therefore are also possible sites of large numbers of MAP. The direct visualization of large numbers of MAP organisms in the tissues of patients with Crohn's disease will help establish that MAP causes Crohn's disease

Failure to implement hospital antimicrobial prescribing guidelines: A comparison of two UK academic centres

Background: Rational antimicrobial therapy should provide maximum benefit to patients while minimizing the development of resistant microorganisms. Objectives: The aim of this study was to investigate (i) which antimicrobial drugs were chosen by hospital doctors faced with two common infections [community-acquired pneumonia (CAP) and urinary tract infection (UTI)], (ii) whether these choices were compliant with local guidance and (iii) the factors that influenced antimicrobial choice. Methods: A questionnaire based on two hypothetical clinical scenarios was distributed to 316 hospital doctors across four UK NHS hospitals in two cities (Newcastle and Edinburgh). Results: Doctors in Newcastle were significantly more aggressive in their management: more patients were admitted (CAP: 78.9% versus 48.4%, P \u3c 0.05) and given antimicrobials intravenously (CAP: 53.4% versus 21.2%, P \u3c 0.05). Adherence to the local hospital guideline for CAP was significantly higher in Newcastle (83.3% versus 38.0%; P \u3c 0.05). Fewer than half of the doctors surveyed used the local hospital guideline when choosing an antimicrobial, and the British National Formulary was the most frequently used resource (\u3e90%). Junior doctors also identified medical school teaching and opinions of senior doctors as important influences. Conclusions: This study highlights inadequacies in the implementation and promotion of local guidelines, and demonstrates the potential for widely varying antimicrobial practices in two comparable UK cities. © 2006 Oxford University Press