Incidence, clinical spectrum, diagnostic features, treatment and predictors of paradoxical reactions during antibiotic treatment of Mycobacterium ulcerans infections

Background: Paradoxical reactions from antibiotic treatment of Mycobacterium ulcerans have recently been recognized. Data is lacking regarding their incidence, clinical and diagnostic features, treatment, outcomes and risk factors in an Australian population.

Methods: Data was collected prospectively on all confirmed cases of M. ulcerans infection managed at Barwon Health Services, Australia, from 1/1/1998-31/12/2011. Paradoxical reactions were defined on clinical and histological criteria and cases were determined by retrospectively reviewing the clinical history and histology of excised lesions. A Poisson regression model was used to examine associations with paradoxical reactions.

Results: Thirty-two of 156 (21%) patients developed paradoxical reactions a median 39 days (IQR 20-73 days) from antibiotic initiation. Forty-two paradoxical episodes occurred with 26 (81%) patients experiencing one and 6 (19%) multiple episodes. Thirty-two (76%) episodes occurred during antibiotic treatment and 10 (24%) episodes occurred a median 37 days after antibiotic treatment. The reaction site involved the original lesion (wound) in 23 (55%), was separate to but within 3 cm of the original lesion (local) in 11 (26%) and was more than 3 cm from the original lesion (distant) in 8 (19%) episodes. Mycobacterial cultures were negative in 33/33 (100%) paradoxical episodes. Post-February 2009 treatment involved more cases with no antibiotic modifications (12/15 compared with 11/27, OR 5.82, 95% CI 1.12-34.07, p = 0.02) and no further surgery (9/15 compared with 2/27, OR 18.75, 95% CI 2.62-172.73, p < 0.001). Six severe cases received prednisone with marked clinical improvement. On multivariable analysis, age ≥ 60 years (RR 2.84, 95% CI 1.12-7.17, p = 0.03), an oedematous lesion (RR 3.44, 95% CI 1.11-10.70, p=0.03) and use of amikacin in the initial antibiotic regimen (RR 6.33, 95% CI 2.09-19.18, p < 0.01) were associated with an increased incidence of paradoxical reactions.

Conclusions: Paradoxical reactions occur frequently during or after antibiotic treatment of M. ulcerans infections in an Australian population and may be increased in older adults, oedematous disease forms, and in those treated with amikacin. Recognition of paradoxical reactions led to changes in management with less surgery, fewer antibiotic modifications and use of prednisolone for severe reactions.

Urban stormwater inputs to an adapted coastal wetland : role in water treatment and impacts on wetland biota

The Lake Pertobe wetland system is a semi-natural wetland that has been modified primarily for recreational use. However, this lake system receives stormwater from much of the central business district of Warrnambool City (Victoria, Australia) and serves as a buffer zone between the stormwater system and the Merri River and Merri Marine Sanctuary. This work considers the impact of stormwater inputs on Lake Pertobe and the effectiveness of the lake in protecting the associated marine sanctuary. Sediment contaminants (including heavy metals and polycyclic aromatic hydrocarbons (PAHs)) and water quality parameters within the lake, groundwater and stormwater system were measured. Water quality parameters were highly variable between stormwater drains and rain events. Suspended solids rapidly settled along open drains and shortly after entering the lake. Groundwater inputs increased both salinity and dissolved nitrogen in some stormwater drains. Some evidence of bioaccumulation of metals in the food chain was identified and sediment concentrations of several PAHs were very high. The lake acted as a sink for PAHs and some metals and reductions in Escherichia coli, biological oxygen demand and total phosphorus were observed, affording some protection to the associated marine sanctuary. Nutrient retention was inadequate overall and it was identified that managing the lake primarily as a recreational facility impacted on the effectiveness of stormwater treatment in the system.

Estimation and extrapolation of optimal treatment and testing strategies

We review recent developments in the estimation of an optimal treatment strategy or regime from longitudinal data collected in an observational study. We also propose novel methods for using the data obtained from an observational database in one health-care system to determine the optimal treatment regime for biologically similar subjects in a second health-care system when, for cultural, logistical, or financial reasons, the two health-care systems differ (and will continue to differ) in the frequency of, and reasons for, both laboratory tests and physician visits. Finally, we propose a novel method for estimating the optimal timing of expensive and/or painful diagnostic or prognostic tests. Diagnostic or prognostic tests are only useful in so far as they help a physician to determine the optimal dosing strategy, by providing information on both the current health state and the prognosis of a patient because, in contrast to drug therapies, these tests have no direct causal effect on disease progression. Our new method explicitly incorporates this no direct effect restriction.

Grain growth and β-Mg17Al12 intermetallic phase dissolution during heat treatment and its impact on deformation behavior of AZ80 Mg-alloy

Microstructure evolution after solutionizing and ageing treatment of cast AZ80 Mg alloy were investigated using optical and scanning electron microscopy. Effect of these treatments on grain size, β-Mg17Al12 intermetallic phase, mechanical behavior, and flow asymmetry were investigated. The initial continuous network of β-phase found to be reduced after solutionizing. The dissolution of β-phase and simultaneous grain growth are found to be interrelated. Mechanical properties including yield strength, maximum strength (ultimate compressive strength), and maximum strain attainable in compressive found almost twice than the corresponding values obtained in tension. The asymmetry in compressive and tensile properties is found to decrease with grain size at certain solutionizing duration. Particular heat treatment found to offer best combination of tensile compressive flow properties in AZ80 Mg alloy. Aging under certain conditions found to minimize the strength asymmetry. © ASM International.

Gender difference in treatment and mortality of patients with ST-segment elevation myocardial infarction admitted to Victorian public hospitals: A retrospective database study.

BACKGROUND: Death from acute coronary syndrome (ACS) is avoidable with early reperfusion therapy, however, evidence suggests inequity in women's ACS treatment within a number of international healthcare systems, when compared to men's. Research indicates mortality rates are higher in some age groups of women when compared to men for the sub-group of ACS known as ST-segment elevation myocardial infarction (STEMI). OBJECTIVE: To determine whether patient sex was associated with patterns of reperfusion treatment variation or increased inhospital mortality in patients with STEMI. METHODS: We undertook retrospective analyses on a government database for patients admitted to Victorian public hospitals with STEMI. Patients were categorised into two age groups: 18-64 and 65-84 years (inclusive), to determine whether patient sex and these age groups influenced treatment from 2005 to 2008 and mortality from 2005 to 2010. RESULTS: Both younger and older women received less frequent angioplasty with stent and more often received no reperfusion treatment than men in corresponding younger and older age groups (p=0.006 and p<0.001, respectively). Overall, women in both age groups were more likely to die inhospital than men from equivalent age groups with STEMI (p<0.001, both groups). CONCLUSIONS: Proportionately, both younger and older women received less interventional reperfusion therapy for STEMI than their male cohorts, and died more often during admission than men. Further research needs to be undertaken to verify the findings and causes, and guide future research to ensure application of evidence to treatment in patients with STEMI.

Improvement of coating durability, interfacial adhesion and compressive strength of UHMWPE fiber/epoxy composites through plasma pre-treatment and polypyrrole coating

Ultra-high-molecular-weight polyethylene (UHMWPE) fibers have exceptionally higher specific strength and stiffness compared with other high-performance fibers. However, the interfacial adhesion and compressive performance of UHMWPE fiber-reinforced polymer composites (FPCs) are extremely low. The challenges are to achieve load transfer at the interface between the fiber and matrix at a molecular level. Here, we show that plasma pre-treatment of UHMWPE fibers followed by coating with polypyrrole (PPy) results in an 848% improvement in the interfacial adhesion and 54% enhancement in compressive performance. This method takes advantage of a toughening mechanism observed in spider silk and collagen, which the hydrogen bond power the load transfer. The results showed that these improvements of interfacial adhesion and compressive strength were attributed to hydrogen-bonding interactions between the plasma pre-treated UHMWPE and PPy, which improves the fiber-matrix-fiber load transfer process. In addition, the hydrogen-bonded PPy coatings also endowed durability electrical conductivity properties of the UHMWPE fiber.

Be nice to your innovators: employee treatment and corporate innovation performance

This paper investigates the effect that employee treatment schemes have on corporate innovation performance. We find that firms with better employee treatment schemes produce more and better patents through improving employee satisfaction and teamwork. Additional tests suggest that our main findings cannot be attributed to job security, unionization, reverse causality, and omitted variables. We also find that firms with better employee treatment schemes produce patents that enhance market valuation and facilitate better future operating performance. Collectively, our findings show that treating employees well benefits firms and shareholders, for well treated employees are encouraged to create intellectual property.

Hypertension, antihypertensive treatment and cancer incidence and mortality : a pooled collaborative analysis of 12 Australian and New Zealand cohorts

BACKGROUND: Observational studies examining associations between hypertension and cancer are inconsistent. We explored the association of hypertension, graded hypertension and antihypertensive treatment with cancer incidence and mortality. METHOD: Eighty-six thousand five hundred and ninety-three participants from the Australian and New Zealand Diabetes and Cancer Collaboration were linked to the National Death Index and Australian Cancer Database. Cox proportional hazards models estimated hazard ratios and 95% confidence intervals (95% CI) for the association of treated and untreated hypertension with cancer incidence and mortality. RESULTS: Over a median follow-up of 15.1 years, 12 070 incident and 4350 fatal cancers were identified. Untreated and treated hypertension, compared with normotension, were associated with an increased risk for cancer incidence [hazard ratio 1.06, 95% CI (1.00-1.11) and 1.09 (1.02-1.16) respectively], and cancer mortality (1.07, 0.98-1.18) and (1.15, 1.03-1.28), respectively. When compared with untreated hypertension, treated hypertension did not have a significantly greater risk for cancer incidence (1.03, 0.97-1.10) or mortality (1.07, 0.97-1.19). A significant dose-response relationship was observed between graded hypertension and cancer incidence and mortality; Ptrend = 0.053 and Ptrend = 0.001, respectively. When stratified by treatment status, these relationships remained significant in untreated, but not in treated, hypertension. CONCLUSION: Hypertension, both treated and untreated, is associated with a modest increased risk for cancer incidence and mortality. Similar risks in treated and untreated hypertension suggest that the increased cancer risk is not explained by the use of antihypertensive treatment.