Secret History: Return of the Black Death Channel 4, 7-8pm In 1348 the Black Death swept through London, killing people within days of the appearance of their first symptoms. Exactly how many died, and why, has long been a mystery. This Secret History documentary follows experts as they pick through the evidence and reveal why the plague killed on such a scale. And they ask, what might be coming next?

Medscape

Assessment and characterization of gut microbiota has become a major research area in human disease, including type 2 diabetes, the most prevalent endocrine disease worldwide. To carry out analysis on gut microbial content in patients with type 2 diabetes, we developed a protocol for a metagenome-wide association study (MGWAS) and undertook a two-stage MGWAS based on deep shotgun sequencing of the gut microbial DNA from 345 Chinese individuals. We identified and validated approximately 60,000 type-2-diabetes-associated markers and established the concept of a metagenomic linkage group, enabling taxonomic species-level analyses. MGWAS analysis showed that patients with type 2 diabetes were characterized by a moderate degree of gut microbial dysbiosis, a decrease in the abundance of some universal butyrate-producing bacteria and an increase in various opportunistic pathogens, as well as an enrichment of other microbial functions conferring sulphate reduction and oxidative stress resistance. An analysis of 23 additional individuals demonstrated that these gut microbial markers might be useful for classifying type 2 diabetes.

/pdf/a-metagenome-wide-association-study-of-gut-microbiota-in-4gng2ouuna.pdf

A metagenome-wide association study of gut microbiota in type 2 diabetes

Infectious Diseases Society of America.

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

/pdf/european-position-paper-on-rhinosinusitis-and-nasal-polyps-mj734vsl7p.pdf

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

Background
People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

Objectives
To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

Search methods
We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

Selection criteria
Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

Data collection and analysis
Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

Main results
For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 83 interventions reported in 70 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

Authors' conclusions
For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Interventions for enhancing medication adherence.

Clindamycin is a broad-spectrum antibiotic with activity against aerobic, anaerobic, and β-lactamase-producing pathogens. This antibiotic has been used for many years as prophylactic treatment during dental procedures to prevent endocarditis. However, the spectrum and susceptibility of the bacteria species involved in dental infections indicate that clindamycin would also be an effective treatment option for these conditions. In addition to its antiinfective properties, clindamycin has high oral absorption, significant tissue penetration, including penetration into bone, and stimulatory effects on the host immune system. This review discusses the microbiologic and clinical evidence supporting the efficacy and safety of clindamycin for the successful management of dental infections.

http://www.endoexperience.com/documents/Clindamycin_in_dentistry___More_than_just_effective_prophylaxis_for_endocarditis.pdf

Clindamycin in dentistry: more than just effective prophylaxis for endocarditis?

Objective: Assessment of the microbiology and management of patients who suffered from chronic maxillary sinusitis was studied retrospectively. Design: Retrospective analysis of microbiology and antimicrobial therapy of 68 patients who underwent the Caldwell-Luc procedure for chronic sinusitis had not received antimicrobials before surgery and whose cultures showed bacterial growth. Setting: This study was performed at the Naval Hospital in Bethesda, Md. Intervention: Amoxicillin-clavulanic acid was given to 18 patients, amoxicillin or ampicillin to 25, cefaclor to 17, and erythromycin to eight. Results: A total of 183 isolates (123 anaerobic and 60 aerobic) were recovered. Anaerobic organisms only were recovered from 35 (51%), specimens, and aerobic or facultative bacteria only in 12 (18%), and mixed aerobic and anaerobic flora in 21 (31%). Thirty-four aerobic and an-aerobic β-lactamase–producing bacteria were isolated from 28 patients. The 18 patients who received amoxicillin-clavulanic acid had the most rapid and complete response to therapy, none required a change in therapy, and surgical drainage was required in one case. Of 25 patients who received amoxicillin or ampicillin, eight required a change of therapy due to clinical failure (32%), including three who also had surgical drainage. Of 17 that received cefaclor, five had an antibiotic change (29%), one with surgical drainage. Of the eight who were treated with erythromycin, three needed antibiotic change (38%), two with surgical drainage. Resistant organisms were recovered from most of the patients that required therapeutic change. Conclusions: These findings indicate the major role of aerobic and anaerobic β-lactamase–producing bacteria organisms in the polymicrobial etiology of chronic maxillary sinusitis and illustrate the superiority of therapy effective against these bacteria. (Arch Otolaryngol Head Neck Surg. 1994;120:1317-1320)

Microbiology and management of chronic maxillary sinusitis

Aspirate of pus from 5 periapical abscesses of the upper jaw and their corresponding maxillary sinusitis were studied for aerobic and anaerobic bacteria. Polymicrobial flora were found in all instances, where the number of isolates varied from 2 to 5. Anaerobes were recovered from all specimens. The predominant isolates were Prevotella sp., Porphyromonas sp., Fusobacterium nucleatum, and Peptostreptococcus sp. Concordance in the microbiological findings between periapical abscess and the maxillary sinus flora was found in all instances. However, certain organisms were only present at one site and not the other. Five beta-lactamase-producing organisms were present in the five specimens. These data confirm the importance of anaerobic bacteria in periapical abscesses and demonstrate their predominance in maxillary sinusitis that is associated with them.

Microbiology of periapical abscesses and associated maxillary sinusitis

This review summarizes the microbiology, management and prevention of tetanus. Tetanus is an acute toxemic illness caused by Clostridium tetani infection at a laceration or break in the skin. It can also occur as a complication of burns, puerperal infections, umbilical stumps (tetanus neonatorum) and surgical-site infection. Tetanus is an intoxication, manifested mostly by neuromuscular dysfunction, caused by tetanal exotoxin (tetanospasmin), a potent exotoxin produced by C. tetani. It starts with tonic spasms of the skeletal muscles and is followed by paroxysmal contractions. The muscle stiffness initially involves the jaw (lockjaw) and neck and later becomes generalized. Treatment goals include interrupting the production of toxin, neutralizating the unbound toxin, controlling muscle spasms, managing dysautonomia and appropriate supportive management. Specific therapy includes intramuscular administration of tetanus immunoglobulin to neutralize circulating toxin before it binds to neuronal cell membranes. The disease can be prevented by immunization with tetanal toxoid and appropriate wound care.

Current concepts in the management of Clostridium tetani infection.

This article describes the microbiology, diagnosis, and management of human and animal bite wound infections. Various organisms can be recovered from bite wounds that generally result from aerobic and anaerobic microbial flora of the oral cavity of the biting animal, rather than the victim's own skin flora. The role of anaerobes in bite wound infections has been increasingly appreciated. Anaerobes were isolated from more than two thirds of human and animal bite wound infections, especially those associated with abscess formation. This article describes several of the organisms found in the bites of various species. In addition to local wound infection, other complications may occur, including lymphangitis, local abscess, septic arthritis, tenosynovitis, and osteomyelitis. Rare complications include endocarditis, meningitis, brain abscess, and sepsis with disseminated intravascular coagulation, especially in immunocompromised individuals. Wound management includes the administration of proper local care and the use of proper antimicrobial agents when needed.

https://www.primarycare.theclinics.com/article/S0095-4543(02)00056-8/pdf

Itzhak Brook

Papers

Clindamycin in dentistry: more than just effective prophylaxis for endocarditis?

Microbiology and management of chronic maxillary sinusitis

Microbiology of periapical abscesses and associated maxillary sinusitis

Current concepts in the management of Clostridium tetani infection.

Microbiology and management of human and animal bite wound infections