Biomedical subjects
Publications and source records attributed to M Sands.
Lymphangitis and lymphedema are rarely reported complications of herpetic hand or genital infection. The natural history of these complications is gradual resolution over 14 to 21 days. Recognition of this presentation of herpes infection avoids unnecessary surgery and antibacterial therapy. Antiviral therapy may have a role in shortening the duration of symptoms and aborting recurrent lymphangitic episodes.
We investigated prospectively clinical bleeding in 1,328 consecutive patients admitted to a medical/surgical ICU over 1 yr. One hundred thirty-eight (10.4%) patients bled after ICU admission, and an additional 388 (29.2%) bled coincident with admission. The upper GI tract was the site of bleeding in 34.8% of patients whose bleeds commenced in the ICU, and accounted for 22% of total sites. Patients with clinical bleeding after ICU admission had a significantly (p less than .001) higher likelihood of death than those who did not bleed, and those with multiple bleeding sites had a higher mortality (54.9%) than those with single sites (31%) (p less than .006). Multiple logistic regression analyses revealed that risk ratios (RR) for bleeding after ICU admission were mechanical ventilation (RR = 1.82), nutritional failure (RR = 3.45), acute renal failure (RR = 3.36), antiulcer medication (RR = 3.36), and anticoagulants (RR = 4.19). No antibiotics could be specifically incriminated. This study defines the scope, characteristics, and importance of bleeding in ICU patients and establishes risk factors.
In order to examine the effects that race and personality type have on self-reported drinking practices, samples of 49 White and 49 Black male alcoholics were matched on age and education, and classified into two personality types according to MMPI scores. The results of multivariate and univariate analyses of variance yielded significant main effects. White alcoholics reported a greater: (a) use of alcohol for symptomatic relief of psychological distress, (b) loss of motor control and tendency to engage in destructive acts, and (c) daily consumption of beverage alcohol than Black alcoholics. Alcoholics with psychiatric-appearing MMPI profiles reported greater: (a) social benefits of alcohol use, (b) alcohol use for symptomatic relief of psychological distress, and (c) perceptual distortions associated with alcohol withdrawal than alcoholics with characterlogical-appearing MMPIs. Results were discussed in terms of need to control confounding effects of biosocial variables in cross-cultural research and implications that these effects may have on the generalizability of alcoholic personality typologies.
All infections occurring in a busy pediatric intensive care unit (PICU) from 1982 to 1984 were characterized by site, bacteriology, acquisition status, and outcome. Standard Centers for Disease Control criteria were employed. Nine hundred sixty-five patients were admitted to the PICU. Mortality was 3.4%. Two hundred twenty-one infections occurred in 180 patients. Infection rates were 23% and 6% for total and PICU-acquired infections, respectively. Infections of the central nervous system (n = 56), lower respiratory tract (n = 53), and genitourinary tract (n = 46) made up 70% of all infections. Haemophilus influenzae (n = 39) was the most commonly isolated pathogen. Staphylococcus aureus (20%) and Klebsiella-Enterobacter-Serratia (18.3%) were most commonly noted in PICU-acquired infections. Twenty infected patients (11.1%) died in the PICU. Lower respiratory tract infections (20.5%) were associated with the highest mortality. Both PICU-acquired and community-acquired infections were associated with similar mortalities. Infected patients in a PICU have a mortality approximately 300% higher than that seen in the overall PICU population. The data presented document the importance of infection and provide information against which similar units can gauge their infection status for quality-assurance purposes.
Shorter lengths of hospitalization may result in more surgical wound infections being documented after hospital discharge. The current investigation analyzed 1644 surgical procedures performed over a 3-month period, and documented surgical wound infections both before and for 1 month after hospital discharge. Physician and patient questionnaires were used. One hundred eight infections were noted, of which 50 (46%) were seen after hospital discharge by either the patient or the surgeon. Rates of infection were 5.2%, 7.5%, and 7.5% for clean, clean-contaminated, and contaminated-dirty categories, respectively. Had postdischarge surveillance not been used, rates would have appeared to be 2.5%, 6.5%, and 6.8% for the same surgical classes. Infections following clean and clean-contaminated procedures were more likely to be noticed after hospital discharge. Excluding those that were patient-documented, wound infection rates would have been 4.2% (clean), 6.3% (clean-contaminated) and 6.8% (contaminated-dirty). Postdischarge surveillance is imperative to meaningfully document true rates of surgical wound infection, inasmuch as increasing numbers are likely to occur only after patients leave the hospital.
Both Streptococcus pneumoniae and Legionella pneumophila are well defined causes of community-acquired pneumonia, and may be associated with substantial mortality. Optimal therapy consists of penicillin for the former organism and erythromycin for the latter. We have presented a case of pneumonia caused by simultaneous infection with both of these agents. Organisms were recovered either from blood or lung tissue. This case carries important implications for treatment of community-acquired pneumonia, and conceivably could explain some of the mortality that continues to be seen with pneumococcal pneumonia.
We have reported a case of Streptococcus pneumoniae endocarditis involving the aortic valve of a 61-year-old alcoholic man. Antibiotic therapy with vancomycin sterilized the blood and valve, but aortic valve replacement was required for progressive congestive heart failure resulting from a ruptured valve leaflet.
Prosthetic joint infection caused by Streptococcus pneumoniae is a rare condition. An 86-year-old woman with a S. pneumoniae-infected total knee arthroplasty was successfully treated by a combined medical-surgical approach.
Hemostatic gelatin sponges were placed in hemispheric defects created in four dogs which were then periodically scanned by computed tomography to determine the postoperative appearance of the sponges. The hemostatic sponges appeared as low attenuation regions for 7-10 days. The attenuation value of these Gelfoam cavities was intermediate between fat and air. Subsequently, clinical cases were selected in which the location of gelatin sponges were known to demonstrate the appearance of the material in patients. In addition to enhancing the accuracy of computed tomographic interpretation, we have found that the gelatin sponge can be useful as a transient computed tomography marker for localization of surgical activity.
A recent case of posttraumatic splenic abscess in a young man following nonoperative management of his splenic rupture is reported. With the recent trend toward nonoperative management of hemodynamically stable splenic rupture, the potential complications of splenic abscess may become more common. In view of the high mortality associated with unrecognized splenic abscess, it is important for the clinician to be aware of this entity.
Mixed bacterial pneumonia caused by organisms other than anaerobes has been infrequently reported. We describe six cases and review the literature. Two patients had co-infection with S pneumoniae and L pneumophila. Two were infected with S pneumoniae and K pneumoniae and the others simultaneously harbored M tuberculosis and N asteroides. The first two sets of patients had bacteria isolated from usually sterile sites (blood and lung), while the latter harbored repeatedly isolated organisms not usually felt to be part of the normal respiratory flora. Mixed infection may help explain the substantial mortality still seen from pneumonia. This is especially true if Legionella, mycobacteria, or Nocardia species are encountered where routine smears and cultures may not aid in the diagnosis. Poor clinical response to specific antibacterial therapy in pneumonia should trigger further investigation for other potential pathogens.
Optimal empiric therapy for the infected patient in the intensive care unit (ICU) is based on many considerations, including acquisition of illness, severity, and host factors, such as organ dysfunction. In addition, the type of ICU may also play a role in helping decide appropriate empiric therapy. Complete clinical examination and the results of initial Gram's stain provide the most important therapeutic guidelines. Descriptions of the types of infections seen in various ICUs, including medical/surgical, pediatric, coronary care, and neonatal, are presented. Recommendations based on clinical experiences regarding effective therapeutic agents and combinations are provided.
Most cases of beta-lactam-associated coagulopathy occur in patients with other risk factors. This study analyzed temporally related clinical bleeding events in 1493 patients who received one antibiotic for at least three days. Univariate and multivariate analyses controlled for condition variables (nutritional status, renal, hepatic, or hematologic dysfunction, intensive care unit stay) and treatment variables (use of antiplatelet agents, anticoagulants, vitamin K, antitumor chemotherapy or antiulcer therapy, steroids) that could have been associated with bleeding independently. Rates of bleeding ranged from 0% (chloramphenicol sodium succinate, vancomycin hydrochloride, erythromycin lactobionate) to 8.2% (cefoxitin) to 22.2% (moxalactam disodium). Multiple logistic regression analyses revealed that only moxalactam (odds ratio, 9.9) and cefoxitin (odds ratio, 2.1) exhibited significantly higher likelihoods of bleeding than other agents. This study statistically confirms increased risk of bleeding with moxalactam, heretofore reported only anecdotally. Cefoxitin may carry risks greater than previously believed.
All infections in patients in an active coronary care unit (CCU) over a 3-year period were analyzed to ascertain rates, outcomes, pathogens and sites of infections. Standard surveillance methods and definitions of the Center for Disease Control were used. A total of 236 infections were documented in 200 infected patients. Infection rates were 5 and 2% for total and CCU-acquired infections, respectively. CCU infections accounted for 11% of nosocomial infections that occurred within all critical care areas surveyed. Of all documented infections, 131 (56%) were community-acquired and 90 (38%) were acquired within the CCU. Lower respiratory and urinary tract infections were most frequently noted, with E. coli, S. aureus, and klebsiella-enterobacter-serratia most usually implicated. Mortality among patients with infections was 31%, compared with 8 to 12% in those who were not infected. Those with lower respiratory infections or primary bacteremias had a higher mortality rate than those with infections at other sites (p less than 0.001). Infections are seen in close to 5% of CCU patients and may adversely affect the survival rate. The mortality rate in infected patients may be 3 times higher than that in the general CCU population. This study also provides data against which other similar institutions can gauge their CCU infection rates.
Infections identified between 1981 and 1983 in a hospital's medical/surgical, pediatric, neonatal, coronary care, and cardiac surgery ICUs were compared. Among 14,360 admissions, 1840 infections occurred in 1360 patients. Total infection rates ranged from 1.0% (cardiac surgery ICU) to 23.5% (medical/surgical ICU). Rates of ICU-acquired infection ranged from 0.8% (cardiac surgery ICU) to 11.2% (medical/surgical ICU), indicating that only about half of infections in the latter unit were acquired from within. Primary bacteremias comprised 14.5% of neonatal ICU infections, a rate 500% higher than in other ICUs. Meningitis and genitourinary infections were more common in pediatric and coronary care ICUs. Candida and Pseudomonas species and Klebsiella-Enterobacter-Serratia were most common in the medical/surgical ICU. Survival rate of infected patients was over 87% in pediatric and neonatal ICUs, compared with only 55.4% in the medical/surgical ICU. These differences in types and rates of infection have an important bearing on infection-control activities in the ICU, and also provide a yardstick against which similar institutions can gauge their ICU infection status.
Using a hemagglutination assay we surveyed antibody distribution to human sperm antigen in a sexually transmitted disease (STD) clinic population and in an AIDS study group. We found no significant difference for the mean antisperm antibody titres between sexually active heterosexual men, women or homosexual men, homosexual men with or without AIDS, and no correlation between T4/T8 lymphocyte ratios and antibody titres in homosexual men. We conclude that levels of antibody to sperm antigens are not significantly greater in homosexual men and antisperm antibody levels do not correlate with the diagnosis of AIDS.
Two non-ionic contrast media, iohexol and metrizamide, were compared in a double-blind clinical trial which included 50 patients who underwent lumbar myelography for disc herniation or spinal stenosis. The frequency of adverse reactions was lower for iohexol which is recommended for extended trials and for examination of other compartments of the subarachnoid space.
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