Management of bacterial peritonitis and exit‐site infections in continuous ambulatory peritoneal dialysis*

SUMMARY: Peritonitis and exit‐site infections remain the most important limitations to the delivery of continuous ambulatory peritoneal dialysis (CAPD). Contamination of the peritoneum, from endogenous or exogenous sources, is responsible for most peritonitis episodes. Patients usually present with a cloudy bag, although other causes should be distinguished. Clinical suspicion of peritonitis should be followed rapidly by microbiological examination and empirical treatment. Microbiological confirmation allows for subsequent treatment based on sensitivities. Other interventions such as catheter removal may be appropriate in some patients. Exit‐site infections should also be identified and treated early. Peritonitis may be further prevented by adequate exit‐site care, hygienic methods, and techniques to minimise early contamination of the exit site. Mupirocin may also have a role in preventing infections caused by Staphylococcus aureus.     

Melioidosis. Forgotten, but not gone!

Melioidosis, infection by the soil bacterium Pseudomonas pseudomallei, has the potential for prolonged latency with recrudescence into an acute, often fulminating, and fatal infection. Although the organism is never found in North America, infection is endemic in areas of southeast Asia, and populations of service personnel exposed during the Vietnam war and southeast Asian immigrants are at risk of severe recrudescent disease. Diagnosis, however, has been missed or delayed because of lack of familiarity with this disease. We present a case of recrudescent melioidosis that illustrates the difficulties encountered in diagnosis and treatment. This case involves a 76-year-old Vietnam veteran who presented with melioidosis of the bone 18 years after exposure to the organism and 10 years after a missed diagnosis of latent pulmonary disease. This case illustrates the protean nature of latent infection and the difficulty of selecting successful antibiotic therapy.     

Psychoactive mushroom use in Koh Samui and Koh Pha-Ngan, Thailand.

This paper presents the results of recent ethnomycological exploration in southern Thailand. Field observations, interviews and collection of fungi specimens were carried out primarily on two islands, Koh Samui and Koh Pha-ngan, situated in the western region of the Gulf of Siam. Some fieldwork was also conducted in the northern Thai province of Chiang Dao and in the southern Thai province of Surat Thani. During five separate excursions (1989-90), observations were made of occurrence, harvesting, use, and marketing of psychoactive fungi by local Thai natives (males and females, adults and children), foreign tourists, and German immigrants. The first records of psychoactive Psilocybe subcubensis and Copelandia dung fungi in Thailand are presented in this paper. These fungi exhibited intense bluing reactions when handled, indicating the presence of psilocybin and/or psilocin. Seven collections of Psilocybe cubensis (Earle) Singer and/or Psilocybe subcubensis Guzman and four collections of Copelandia sp. were harvested and sun-dried for herbarium deposit. These fungi are cultivated or occur spontaneously, often appearing in the decomposed manure of domesticated water buffalo (Bubalus bubalis) and at least three different species of cattle (Bos indicus, B. guarus, and B. sundaicus). The psychoactive fungi are cultivated in clandestine plots, both indoors and outdoors, in the uplands and villages on Koh Samui by both Thai natives and some foreigners. The sale of psychoactive fungi directly to tourists and to resort restaurants for use in edible food items such as omelettes and soups is discussed in detail. The preparation and sale of mushroom omelettes adulterated with artificial hallucinogens in some restaurants is also discussed. In addition, the marketing of items such as hand painted T-shirts, post cards, and posters bearing mushroom related motifs in Thailand is described.     

Low molecular weight advanced glycation end products predict mortality in asymptomatic patients receiving chronic haemodialysis.

BACKGROUND: Advanced glycation end products (AGEs) have biological properties that may contribute to the premature cardiovascular mortality of haemodialysis patients. This study examines the hypothesis that low molecular weight forms of fluorescent AGEs (LMW fluorescence) predict mortality in haemodialysis patients. METHODS: The LMW fluorescence was measured in 85 patients treated with chronic haemodialysis and prospectively followed for 4 years. The primary outcome of all-cause mortality was assessed using Cox proportional hazards regression model. RESULTS: At the end of the follow-up period 37 (44%) patients died. The median LMW fluorescence level was 24.2 arbitrary units (range: 10.6-148.1 AU) and the receiver operator characteristic (ROC) curve cut-off for mortality was 37.0 AU. The LMW fluorescence predicted death both as a binary variable at the ROC cut-off, and as a continuous log-transformed variable when adjusted for age, albumin and C-reactive protein (CRP). Adjusted for age, albumin and CRP, the hazard ratio for mortality was 3.05 (1.41-6.60, P = 0.005) for LMW fluorescence as a binary variable and 2.71 per log unit (1.37-5.38, P = 0.004) as a continuous log-transformed variable. CONCLUSION: The low molecular weight forms of AGEs predict mortality in patients receiving chronic haemodialysis, and may be important in the mechanisms leading to atherosclerosis and inflammation in such patients.     

Synaptic modifications accompanying epileptogenesis in vitro: long-term depression of GABA-mediated inhibition

We used an in vitro model similar to kindling to examine the processes underlying epileptogenesis. A 60 Hz train was applied every 5–10 min to the Schaffer collateral pathways in guinea pig hippocampal slices until epileptiform bursting was elicited in the CA3 region. The resultant alterations in both spontaneous and evoked activities were studied using intracellular recordings from CA3 pyramidal cells. An attempt was made to elucidate the synaptic modifications responsible for the conversion to this state of enhanced excitability. Analyses revealed that the emergence of epileptiform discharge was accompanied by a long-term depression of evoked inhibitory conductances. This tetanus-induced reduction of inhibition involved both the early and late phases of the evoked hyperpolarization, suggesting modification of both the GABA_A and GABA_B receptor-mediated events. Previous studies have suggested that NMDA receptor activation plays an important role in the induction of epileptiform activity in this model. Our data, showing that depression of inhibition can be induced in the presence of CNQX, is consistent with this hypothesis. The parallel development of long-term depression of inhibition and epileptiform bursting following tetanic stimulation suggests that plasticity of the inhibitory transmission process is a potential source of vulnerability contributing to epileptogenesis.     

Scanning Density Gradient Isoelectric Focusing of Staphylococcus aureus Enterotoxins B and C1

Purified Staphylococcus aureus enterotoxins B and C(1), the causative agents of staphylococcal food poisoning, were resolved into several components by scanning isoelectric focusing in sucrose density gradients in the absence and presence of 6 M urea and 5 mM dithiothreitol. The observed heterogeneity persisted in the denaturing medium, which suggests that the primary structure of protein enterotoxins B and C(1) may be partly responsible for the isoelectric point differences of the various forms. To our knowledge, the scanning isoelectric focusing patterns of staphylococcal enterotoxins B and C(1) are reported for the first time.