Pneumocystis-jiroveci-Pneumonie (PcP) bei Patienten mit rheumatologischen Erkrankungen: Fallbeschreibung und Review

Zusammenfassung: Eine 74-jährige, polymorbide Patientin mit einer rheumatoiden Arthritis erlitt unter Therapie mit Methotrexat und Prednison eine Pneumocystis-jiroveci-Pneumonie (PcP). Eine Therapie mit Bactrim wurde eingeleitet. Trotz nicht mehr nachweisbaren Pneumozysten in einer Bronchiallavage verstarb die Patientin. Die genaue Todesursache blieb unklar. Wie dieses Beispiel zeigt, muss bei immunkompromittierten rheumatologischen Patienten an die Differenzialdiagnose einer PcP gedacht werden. Der typische Verlauf, Diagnose, Prophylaxe und Therapie der PcP bei dieser Patientengruppe werden diskutier

Clostridium difficile assoziierter Durchfall: "An emerging infection"

Zusammenfassung: Die Clostridium difficile assoziierte Diarrhö (CDAD) wird häufig als lästige und relativ banale Nebenwirkung einer Antibiotikatherapie angesehen. Während schon in den 1980er und 90er Jahren Morbidität, Mortalität und entsprechend auch die Kosten von CDAD beträchtlich waren, sind diese aufgrund des Aufkommens eines hochvirulenten Stamms von Clostridium difficile (C.difficile) Anfang2000 deutlich angestiegen. Die pathogenetischen Schlüsselereignisse sind Veränderungen der Darmflora nach Antibiotikagabe, Kolonisation mit einem toxinbildenden C.difficile und dessen intraluminale Vermehrung. Die Therapie besteht bei milden Formen im Absetzen der angeschuldigten Medikamente, bei mäßig bis schwer ausgeprägten Erkrankungen erfolgt die Gabe von Metronidazol oder Vancomycin per os. Als ultima ratio bei toxischem Megakolon muss die subtotale Hemikolektomie erwogen werden. Der verantwortungsvolle Einsatz von Antibiotika ("antibiotic stewardship") in Kombination mit spitalhygienischen Maßnahmen sind essenziell, um Ausbrüchen vorzubeugen und sie einzudämme

Wie Personen mit Autismus und geistiger Behinderung das eigene Problemverhalten sehen - eine qualitative Untersuchung unter Einbeziehung von Fokusgruppen

In dieser Untersuchung wurde den Fragen nachgegangen, a) wie Personen mit einer geistigen Behinderung und/oder autistischen Störungen das eigene Problemverhalten hinsichtlich seiner Auslösung und Überwindung interpretieren und b) welche hilfreichen Vorschläge die Betroffenen entwickeln, die eigene Lebensqualität zu verbessern, um dadurch auch das eigene Problemverhalten zu reduzieren bzw. zum Verschwinden zu bringen. Methodisch wurde mit qualitativen Forschungsansätzen gearbeitet. Die Informationen wurden an sog. Fokusgruppen und anlässlich von Interviews erhoben. Die aus der qualitativen Forschung geläufigen Techniken der Informationssammlung und Datenreduktion, der Generierung von thematischen Kategorien und Kodes und der Interpretationen von wiederkehrenden Themen führten zu bemerkenswerten Ergebnissen. So zeigte sich, dass Variablen der Lebensqualität sich auf Variablen des Problemverhaltens auswirken und dass die Betroffenen motiviert und auch in der Lage dazu sind, mit den ihnen zur Verfügung stehenden Mitteln lösungsorientierte Informationen zu entwickeln

Improving a Family’s Overall Quality of Life Through Parent Training in Pivotal Response Treatment

As the diagnoses of autism in young children continually increase, the need for families to have access to research-based treatment models that are effective and efficient has become clear. Current research demonstrates the demand for parent-delivered behavioral interventions. The aim of this single-case study, conducted as part of an integrated Masters in Education/Special Education Credential Program, was to examine the relationship between one parent trained in pivotal response treatment (PRT), her implementation of PRT techniques, and the correlated gains of behavioral compliance in her 6-year-old boy with high-functioning autism (HFA). Visual analysis of collected data as well as calculation of nonoverlapping data points suggest that a parent, when effectively trained, can utilize PRT to increase the rate of behavioral compliance of his or her own children

Extended-spectrum β-lactamase-producing Gram-negative pathogens in community-acquired urinary tract infections: an increasing challenge for antimicrobial therapy

Background: Extended-spectrum β-lactamases (ESBLs) are an increasing challenge in the treatment of urinary tract infections (UTIs), and also in the community. We aimed to investigate the characteristics of patients with UTIs due to ESBL-producing Escherichia coli and to assess the risk factors for ESBLs in community-acquired isolates. Methods: We performed a retrospective study from January 1, 2007 to December 31, 2009 at a tertiary care teaching hospital in Switzerland, comparing patients with community-acquired versus healthcare-associated UTIs due to ESBL-producing E. coli. Additionally, we investigated the antimicrobial susceptibility of these isolates. Results: A total of 123 patients were studied, of whom 79 (64%) had community-acquired and 44 (36%) had healthcare-associated UTIs. Community-acquired isolates were associated with acute uncomplicated UTIs (odds ratio [OR] 6.62, 95% confidence interval [CI] 1.83-36.5, P<0.001). Risk factors were recurrent UTI (OR 3.04, 95% CI 1.14-9.14, P=0.022) and female sex (OR 2.46, 95% CI 1.01-6.08). Community-acquired ESBL-producing E. coli urinary isolates showed high resistance rates to most of the currently used oral antimicrobial agents, including β-lactam antibiotics (amoxicillin-clavulanic acid, 69.6% resistance), quinolones (ciprofloxacin, 84.8% resistance; norfloxacin, 83.9% resistance), and trimethoprim-sulfamethoxazole (75.9% resistance), except for nitrofurantoin (15% resistance) and fosfomycin (0% resistance). Conclusion: UTI due to ESBL-producing E. coli are emerging, and also in a country with low antibiotic use. Because of increasing antibiotic resistance rates of E. coli to current standard therapy and because of the resistance patterns of ESBL-producing E. coli, guidelines for the management of UTIs must be revised. Fosfomycin or nitrofurantoin are recommended for the first-line empirical oral treatment of community-acquired uncomplicated UTI

Rapidly Destructive Staphylococcus epidermidis Endocarditis

Abstract : A 29-year-old man with rapidly destructive Staphylococcus epidermidis endocarditis after mitral valve reconstruction is presented. Resistance to rifampin and teicoplanin occurred during antibiotic treatment resulting in clinical failure and valve destruction. Subsequently, the patient was successfully treated, by combining valve replacement with antibiotic therapy including quinupristin/dalfopristin, levofloxacin, and vancomycin. In conclusion, S. epidermidis can cause rapid valve destruction with large vegetations, and combination of surgery and antibiotic therapy may be necessar

T179. DO INDIVIDUALS IN A CLINICAL HIGH-RISK STATE FOR PSYCHOSIS DIFFER FROM HEALTHY CONTROLS IN THEIR CORTICAL FOLDING PATTERNS?

Background Volumetric brain differences between persons meeting criteria for a clinical high-risk state for psychosis (CHR) and healthy controls (HC) have been previously reported, yet little is known about potential abnormalities in surface-based morphological measures. Gyrification (i.e., the amount of cortical convolution) remains relatively stable across the lifespan and is minimally influenced by ubiquitous confounding factors (e.g., drug use, medication, or stress). Recently, a multi-site analysis conducted in 104 CHR persons found global increases in cortical gyrification compared to HC (Sasabayashi et al. 2017). If replicated, gyrification abnormalities in CHR could potentially serve as early neuromarkers of elevated risk, and thus could eventually be used to identify objectively and efficiently the CHR state. Methods A total of 124 CHR and 264 HC subjects were recruited as part of the PRONIA consortium (www.pronia.eu), a large-scale international longitudinal study currently consisting of 10 European sites. Cortical surfaces were reconstructed from structural MRI images using a volume-based, newly introduced technique called the Projection-Based-Thickness (PBT) as available in the SPM-based-toolbox CAT12. Local gyrification was quantified automatically across the whole brain as absolute mean curvature for each vertex of the brain surface mesh consisting of thousands of individual measurement points. Vertex-wise differences of curvature values were calculated applying a General Linear Model, corrected for age, gender and site effects. Results were investigated at corrected and uncorrected levels. Results We found no significant differences in vertex-wise gyrification between CHR and HC at either corrected or uncorrected levels (p&gt;0.05). Further investigations of potential confounding site effects also did not reveal differences. Discussion Our preliminary findings suggest that CHR subjects do not show whole-brain gyrification abnormalities when compared with healthy subjects. These negative results agree with literature suggesting that cortical convolution might be more affected by neurodevelopmental or genetic factors, and thus deviations from normal patterns might not be detectable in heterogeneous samples of at-risk subjects wherein the etiology and ultimate prognosis is unknown. In order to better investigate differences in cortical folding and address the role of gyrification as neuroanatomical biomarker for psychosis, future investigations should focus on subgroups within CHR populations (e.g. patients groups defined by basic symptoms, ultra-high risk, or familial risk) in addition to specific analyses of individuals with higher neurodevelopmental (e.g., obstetric complications) or genetic (e.g., polygenic risk) loadings

Family Perspectives on Problem Behavior

Abstract: Data from interviews with 17 families who have a member with mental retardation and problem behavior were reported. The interview was focused on the families &apos; definition of problem behavior, current challenges they face, and successful approaches for helping individuals with problem behavior and their families as well as suggestions from families about what kinds of information they believe would help them in addressing challenges. Key recommendations focus on the implications of this information for research, demonstration, and training activities. The mental retardation literature concerning problem behavior is primarily limited to documentation of families &apos; or service providers &apos; priorities an

Initial management of and outcome in patients with pneumococcal bacteremia: a retrospective study at a Swiss university hospital, 2003-2009

Purpose: The aim of this quality control study was to assess the time to initial diagnostic procedures and the time to the first dose of antibiotics in patients with pneumococcal bacteremia, and to investigate whether the timeliness of these interventions influenced outcome. Methods: We retrospectively studied patient characteristics, chronological sequence of diagnostic and therapeutic steps, and the course of disease of all patients with pneumococcal bacteremia at a Swiss university hospital between 2003 and 2009, and we analyzed associations between these factors and the length of hospital stay (LOS) and mortality. Results: A total of 102 episodes of pneumococcal bacteremia in 98 patients were analyzed, of whom 15.7% died during hospitalization. The median time (interquartile range [IQR]) to the first antibiotic dose was 4.0 (2.0-5.9)h, and the median times (IQR]) to blood cultures, chest radiograph, lumbar puncture, and brain computed tomography (CT) scan or magnetic resonance imaging (MRI) were 1.4 (0.5-3.3), 2.5 (1.2-4.2), 4.2 (2.7-7.2), and 2.3 (0.6-6.2)h, respectively. The time to diagnostic procedures and therapy were not associated with LOS or death. Risk factors for death in the univariable analysis were: Charlson comorbidity index [odds ratio [OR] (95% confidence interval) per unit increase, 1.3 (1.1-1.6)], neutropenia [OR 10.1 (2.0-51.0)], human immunodeficiency virus (HIV) infection [OR 3.9 (1.1-13.8)], chronic respiratory disease [OR 4.4 (1.2-16.0)], chronic liver disease [OR 3.2 (1.0-9.7)], smoking [OR 3.8 (1.1-13.5)], injection drug use [OR 9.7 (1.5-63.7)], and antibiotic therapy within 6months before admission [OR 4.0 (1.3-12.5)]. The multivariable analysis revealed age >60years (P=0.048) and alcoholism (P=0.009) as risks for prolonged LOS. Conclusions: The outcome of pneumococcal bacteremia may be more influenced by patient characteristics than by minor differences in the timeliness of initial diagnostic and therapeutic measures within the first several hours after hospital admissio

Risks Factors for Infections with Extended-Spectrum Beta-Lactamase-Producing Escherichia coli and Klebsiella pneumoniae at a Tertiary Care University Hospital in Switzerland

Abstract : Background: : There are considerable geographical differencesin the occurrence of extended-spectrum beta-lactamase(ESBL)-producing bacteria, both in the community and in thehospital setting. Our aim was to assess risk factors forbloodstream, urinary tract, and vascular catheter-associatedinfections with ESBL-producing Escherichia coli and Klebsiellapneumoniae at a tertiary care hospital in a low-prevalencecountry. Methods: : We performed a case-control study comparing 58patients with infections due to ESBL-producing E. coli orK. pneumoniae vs 116 controls with infections due to non-ESBL producing organisms at the University Hospital Zurich,Switzerland, between 1 July 2005 and 30 June 2007. Results: : Cases included 15 outpatients and 43 inpatients.Multivariable analyses found three risk factors for ESBL-producingisolates: begin of symptoms or recent antibioticpre-treatment in a foreign country (odds ratio [OR] 27.01,95% confidence interval [CI] 2.38-1,733.28], p = 0.042),antibiotic therapy within the year preceding the isolation ofthe ESBL-producing strain (OR 2.88, 95% CI 1.13-8.49,p = 0.025), and mechanical ventilation (OR 10.56, 95% CI1.06-579.10, p = 0.042). Conclusions: : The major risk factors for infections due toESBL-producing bacteria were travel in high-prevalencecountries, prior antibiotic use, and mechanical ventilationduring a stay in the intensive care unit. Community-acquiredinfections were documented in 17% of the patients.An early identification of risk factors is crucial to providingthe patients an optimal empiric antibiotic therapy and tokeep the use of carbapenems to a minimu