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Biomedical subjects

D J Sexton

Publications and source records attributed to D J Sexton.

At least 73 records · Page 4Linked to original sources
PubMed1996

Predictors of prognosis and risk of acute renal failure in patients with Rocky Mountain spotted fever.

BACKGROUND: Acute renal failure has long been associated with severe Rocky Mountain spotted fever (RMSF). Despite many descriptions of the protean manifestations of this disease, relatively little is known concerning the risk factors for acute renal failure. Only a few studies have examined the outcome of patients infected with Rickettsia rickettsii who develop renal insufficiency, and these studies had methodological problems. OBJECTIVE: To study the incidence, risk factors, and outcomes of acute renal failure in a large group of hospitalized patients with definite or probable RMSF. METHODS: The clinical records of 114 patients with definite or probable RMSF were retrospectively reviewed to identify clinical and biochemical abnormalities at the time of admission that were associated with the development of acute renal failure and subsequent mortality. Renal failure was defined as a serum creatinine (Cr) above 2 mg/dL. Logistic regression was used to study the association between these variables and the outcomes during hospitalization: death and the development of acute renal failure. RESULTS: The mortality rate in this series was 14%; 19% of the patients developed acute renal failure. The development of acute renal failure increased the odds ratio (OR) of dying by a factor of 17 (P = 0.001). Factors at the time of hospitalization that were associated at a univariate level with subsequent mortality included elevated serum Cr, increased age, increased level of AST, increased level of bilirubin, decreased serum sodium and platelet count, the presence of neurological involvement, and being male. Both the presence of neurological involvement and an elevated serum Cr at presentation were independently associated with increased mortality by multivariate analysis. Three patients developed acute renal failure that required hemodialysis, and only 1 of these 3 patients survived; he was ultimately discharged with a normal serum Cr. Factors at presentation that were associated with the development of acute renal failure included increased bilirubin, increasing age, thrombocytopenia, and the presence of neurological involvement. Both age and decreased platelet count at presentation were independently associated with the development of acute renal failure by multivariate analysis. CONCLUSION: Acute renal failure was a frequent complication of RMSF in this series of patients from a tertiary referral medical center. The presence of acute renal failure was strongly associated with death. Clinical and biochemical variables are useful in predicting which patients will develop acute renal failure.

Acute Kidney Injury↗
PubMed1996

Periprosthetic infections due to Mycobacterium tuberculosis in patients with no prior history of tuberculosis.

Although uncommon, infection of prostheses with Mycobacterium tuberculosis can be managed successfully if it is diagnosed early and treated correctly. A case of M. tuberculosis infection of a prosthetic knee first diagnosed 4.5 years after initial arthroplasty is described. This case and a review of the literature led to the conclusion that there are two distinct patterns of M. tuberculosis infection following joint implant surgery in patients without a history of tuberculosis. (1) Mycobacterium tuberculosis infection may be an unexpected finding at the time of arthroplasty. These patients generally have favorable outcomes using standard antituberculous chemotherapy, without implant removal. (2) Late-onset M. tuberculosis joint infection may be identified in patients with painful, clinically infected, or malfunctioning prostheses. In these cases, medical treatment alone is usually unsuccessful; prosthesis removal is often required. With recent increases in the incidence of tuberculosis in the United States and the emergence of multidrug-resistant strains of M. tuberculosis, periprosthetic tuberculous infection is likely to become more common.

Aged↗
PubMed1996

Resistant enterococci: a prospective study of prevalence, incidence, and factors associated with colonization in a university hospital.

OBJECTIVE: To determine the prevalence of gastrointestinal tract colonization with antibiotic-resistant enterococci at ward entry and to study the incidence and risk factors for nosocomial acquisition of colonization with resistant enterococci. DESIGN: A prospective cohort study conducted between February 1 and March 15, 1993. METHODS: Rectal cultures were obtained within 24 hours of admission or transfer onto the study wards and repeated at weekly intervals and at the time of discharge. Patients harboring antibiotic-resistant enterococci at the time of admission or after admission were compared to patients who were not colonized with these organisms. Clinical and epidemiologic risk factors for colonization were abstracted prospectively by daily chart review. Following a univariate analysis of risk factors associated with colonization, a multivariate statistical analysis using three separate models was done. SETTING: A 1,125-bed, tertiary-care teaching hospital in North Carolina. PATIENTS: A total of 350 patients admitted to two general medical wards and the medical intensive care unit during the study period. RESULTS: Antibiotic-resistant enterococci were isolated from 52 patients: 19 were colonized at admission to the study, and 33 later acquired resistant strains. At the time of admission, 5.4% of the patients were colonized with ampicillin-resistant enterococci (ARE), including 1.1% that were colonized with vancomycin-resistant enterococci. Prior hospitalization was associated with colonization with ARE at admission (P = .01). Independent risk factors for nosocomial acquisition of ARE included treatment with more than three antibiotics, empiric use of antibiotics, use of third-generation cephalosporins, and the use of enteral tube feedings. Antibiotics used prophylactically were not associated with resistant enterococcal colonization. CONCLUSIONS: Our data help to elucidate the epidemiology of gastrointestinal tract colonization with resistant enterococci. We hypothesize that surveillance and control programs will be more likely to succeed if targeted at patients receiving more than three antibiotics, empiric antibiotics, and enteral tube feedings (Infect Control and Hosp Epidemiol 1996;17:36-41).

Ampicillin Resistance↗
PubMed1995

Mediastinitis after coronary artery bypass graft surgery. Risk factors and long-term survival.

BACKGROUND: Mediastinitis is a severe complication of coronary artery bypass graft surgery (CABG). The purpose of the present study was to determine preoperative and intraoperative variables that predict mediastinitis and to determine the impact of this complication on long-term survival. METHODS AND RESULTS: Data on 20 preoperative and intraoperative variables were collected prospectively on 6459 consecutive patients who underwent CABG between January 1987 and January 1994. Eighty-three patients (1.3%) developed mediastinitis postoperatively, and a total of 24 patients (29%) died. Multivariate analysis identified 4 of the 20 variables as highly significant independent predictors for the development of mediastinitis: obesity (P = .0002), New York Heart Association congestive heart failure class (P = .002), previous heart surgery (P = .008), and duration of cardiopulmonary bypass (P = .05). A comprehensive review of the literature identified 13 other studies that evaluated 48 factors as predictors of mediastinitis; these data were critically analyzed and compared with the results from this series. In this series, postoperative interval mortality during the first 90 days after surgery for the patients with mediastinitis was 11.8% compared with 5.5% for the patients without mediastinitis. Interval mortality between 1 and 2 years after surgery remained high for the mediastinitis group (8.1%) relative to the nonmediastinitis group (2.3%). These differences were not eliminated by adjusting for important variables that influenced late survival in this population. CONCLUSIONS: The present study and a review of the literature suggest that obesity and duration of surgery are the most important predictors of mediastinitis. Furthermore, although the early increase in mortality has been well described, the present study documents for the first time that mediastinitis has a significant negative influence on long-term survival independent of the patient's preoperative condition.

Cardiac Surgical Procedures↗
PubMed1995

Consultation in university-based and community-based infectious disease practices: a prospective study.

Infectious disease physicians in university and community practices completed a standard data form following each of 1,366 inpatient consultations during a 7-month period. The rate of consultation was higher in the university practice than in the community practice (3.4 vs. 1.8 per 100 discharges, respectively). Known or suspected bacterial pathogens accounted for more than half of all consultations in both practice groups. The three organ systems most commonly affected by infection were pulmonary (20% in university practice vs. 19% in community practice), skin and soft tissue (13% in university practice vs. 20% in community practice), and musculoskeletal (12% in university practice vs. 16% in community practice). Bloodstream infection, pneumonia, unexplained fever, osteomyelitis, urinary tract infection, and cellulitis were the six most common disease processes that led to consultation in both practice groups. The percentage of patients with noninfectious diseases and the percentage for whom a change in antimicrobial therapy was advised was nearly identical in both practice settings. Physicians in private practice performed more consultations on weekends (20% vs. 11% in university practices, P < .001) and between 6:00 P.M. and 7:00 A.M. (15% vs. 6% in university practices, P < .001). The scope and diversity of the work of consultants in community practices are nearly identical to those of their colleagues in university-based practices.

Communicable Diseases↗
PubMed1995

Therapeutic delay and mortality in cases of Rocky Mountain spotted fever.

We conducted a retrospective cohort study of patients with Rocky Mountain spotted fever (RMSF) at a university hospital in order to assess the relationship between delay in treatment and mortality and to identify predictors of delay in initiating therapy. Patients with RMSF who received antirickettsial therapy within 5 days of the onset of symptoms were significantly less likely to die than were those who received treatment after the 5th day of illness (6.5% vs. 22.9%, respectively; P < .03). Ninety percent of patients were seen by a physician during this 5-day period, yet less than one-half of them received treatment before day 6. Three factors were independent predictors of failure by the physician to initiate therapy the first time a patient was seen: absence of a rash, presentation between 1 August and 30 April, and presentation within the first 3 days of illness. Until reliable early diagnostic tests become available, physicians may be able to decrease the mortality associated with RMSF by instituting empirical treatment of suspected cases within the first 5 days of illness.

Adolescent↗
PubMed1995

Long-term sequelae of Rocky Mountain spotted fever.

Twenty-five patients with definite or probable Rocky Mountain spotted fever (RMSF) who were hospitalized for > or = 2 weeks were identified from our database of 105 patients. Follow-up information was collected for 20 patients, per telephone and/or medical records. The remaining five patients were lost to follow-up or died. Nine patients had > or = 1 long-term sequelae (defined as complications related to an original acute infection with Rickettsia rickettsii that persisted for > or = 1 year following hospital discharge). The ages of patients with sequelae ranged from 2 to 74 years (mean and median, 38 years); duration of follow-up ranged from 1 to 18 years (mean, 11 years). The mean lengths of hospitalization for patients with and without long-term sequelae were 47 days and 20 days, respectively (P < .05). Long-term neurological sequelae included paraparesis; hearing loss; peripheral neuropathy; bladder and bowel incontinence; cerebellar, vestibular, and motor dysfunction; and language disorders. Nonneurological sequelae consisted of disability from limb amputation and scrotal pain following cutaneous necrosis. These data suggest that significant long-term morbidity is common in patients with severe illness due to RMSF.

Adolescent↗
PubMed1995

Prolonged Bartonella bacteremia in cats associated with cat-scratch disease patients.

Recent evidence supports a causal relationship between Bartonella (Rochalimaea) henselae, cat-scratch disease (CSD), and bacillary angiomatosis. Cats appear to be the primary reservoir. Blood from 19 cats owned by 14 patients diagnosed with CSD was cultured. Blood samples from cats owned by veterinary students (n = 25) having no association with CSD or bacillary angiomatosis were cultured as controls. Eighty-nine percent (17 of 19) of cats associated with CSD patients and 28% (7 of 25) of controls were bacteremic with Bartonella species (chi-square = 16.47; P < 0.001). Twenty-three isolates were characterized as B. henselae, while one isolate from the cat of a CSD patient appeared to be a new Bartonella species. Thirteen cats remained culture positive during the ensuing 12-month period. Our results support the conclusion that B. henselae is the predominant species involved in CSD and is transmitted by cats. The incidence of Bartonella bacteremia in control cats suggests that B. henselae bacteremia is prevalent among the domestic cat population in the United States.

Adolescent↗
PubMed1994

Pott's disease caused by Mycobacterium xenopi: case report and review.

We report a case of Mycobacterium xenopi infection of the spine in a 70-year-old woman. The findings of our case and of five other published reports of bone or joint infection with M. xenopi illustrate the problems with diagnosis and management of infection with this organism. Detection of M. xenopi in clinical specimens may require prolonged incubation at 37 degrees C or incubation at higher temperatures. Furthermore, M. xenopi may be misidentified as Mycobacterium avium-Mycobacterium intracellulare complex. For these reasons, human infection due to M. xenopi may be underrecognized. The optimal therapy for human infection with M. xenopi is unknown.

Aged↗
PubMed1994

Mycoplasma hominis septic arthritis: two case reports and review.

Mycoplasma hominis is normally a commensal of humans. When the organism is pathogenic, it primarily causes disease in the genitourinary tract. Septic arthritis caused by M. hominis is a rare condition that occurs chiefly in the postpartum period, in immunosuppressed hosts, or in patients who have recently undergone urinary tract manipulation. Arthritis caused by M. hominis is clinically indistinguishable from septic arthritis caused by other bacteria. Diagnosis is often delayed because infection with this organism is not suspected or because it grows slowly, if at all, in routine culture media. Appropriate therapy often leads to a good outcome, although relapses and resistance have been reported.

Aged↗
PubMed1994

Visible light photochemical release of nitric oxide from S-nitrosoglutathione: potential photochemotherapeutic applications.

Some aspects of the physiological role of NO may be mediated by stable NO-carriers such as S-nitrosoglutathione and related S-nitrosothiols. In this report we show that irradiation of S-nitrosoglutathione at either absorption band (lambda max = 340 nm or 545 nm) results in the release of nitric oxide. Photolysis of S-nitrosoglutathione at 545 nm exhibited a quantum yield of 0.056 +/- 0.002 and was best approximated by a first-order process with kobs = 4.9 x 10(-7) +/- 0.3 x 10(-7) s-1. The photolytic release of NO from S-nitrosoglutathione resulted in an enhanced cytotoxic effect of S-nitrosoglutathione on HL-60 leukemia cells. That the cytotoxic effect of S-nitrosoglutathione was diminished by the addition of oxyhemoglobin strongly suggests that NO is the cytotoxic species. The finding that NO can be readily liberated from S-nitrosoglutathione by visible radiation indicates that the photochemical properties of this compound in the visible spectrum must be considered in order to obtain meaningful data as to its physiological role and the S-nitrosoglutathione and related compounds may find use as photochemotherapeutic agents.

Glutathione↗
PubMed1994

Necrotizing fasciitis and myositis caused by group A streptococci. Epidemiology, diagnosis, and treatment of "flesh-eating bacteria".

Despite the absence of conclusive proof, the incidence of necrotizing fasciitis and myositis due to GAS may be increasing, possibly related to shifts in the proportion of GAS isolates of M-Types 1 and 3. These M-types (or the production of exotoxins and proteases associated with them) may lead to severe GAS infections in individuals who lack immunity. Recent television and newspaper reports underscore the potential virulence of GAS even in young and previously well individuals although they do this at the expense of raising fear in the general population. It is unfortunate that these reports often fail to emphasize the rarity with which GAS causes myositis and fasciitis. The overall incidence of these dreadful diseases is very low. In fact, by extrapolating the CDC estimates, we suspect that only 14-40 cases of GAS-induced myositis or fasciitis occur annually in North Carolina. Each of these infections is a true calamity for the affected patients and their physicians, but together they represent only a tiny fraction of all GAS infections that occur in North Carolinians each year. It is relatively easy to separate uncomplicated streptococcal cellulitis from GAS-induced fasciitis and/or myositis by bedside exam and old-fashioned clinical judgment. Prompt and aggressive surgical debridement and antibiotic therapy are needed for all patients with myositis and/or fasciitis due to GAS; others can be treated with simple beta-lactam antibiotics and careful observation.

Anti-Bacterial Agents↗