Torsades de pointe probably related to sparfloxacin.
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Anti-Infective Agents↗
Biomedical subjects
M Wolff
Publications and source records attributed to M Wolff.
Intra-alveolar hemorrhage following bipedal lymphography.
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Hemorrhage↗
The prevalence and aetiology of persistent diarrhoea in adults in urban Zambia.
As the AIDS pandemic has spread, diarrhoea in adults has become a major burden on health care institutions in central Africa and on the families of sufferers. In order to assess the magnitude of the problem, we carried out a survey of households in a high population density township of Lusaka to determine the prevalence of persistent diarrhoea in adults. We also carried out a study of the causes of persistent diarrhoea in patients attending the University Teaching Hospital, Lusaka. The community survey assessed 460 households, representing a sample of 1440 adults. 94 adults were reported as having had diarrhoea in the 2 weeks prior to the survey, implying an attack rate of 1.74 per adult per year. Of these 94 cases, six had diarrhoea of between 2 and 4 weeks duration, and ten had diarrhoea of over 4 weeks duration. In the hospital study, 75 (97%) out of 77 patients with diarrhoea of over 1 months' duration were HIV seropositive; potentially pathogenic parasites were found in 61/75 (81%) of seropositives. This information indicates that persistent diarrhoea in adults, mostly related to HIV infection, is likely to be an important and growing reservoir of enteric pathogens and represents a significant burden on hospitals and relatives. This emerging problem in sub-Saharan Africa may foreshadow developments in other continents.
Adult↗
Outbreak of multiply resistant enterobacteriaceae in an intensive care unit: epidemiology and risk factors for acquisition.
A prospective study was initiated in an intensive care unit (ICU) where extended-spectrum beta-lactamase-producing enterobacteriaceae (ESBLPE) were endemic. From July 1990 to July 1991, patients hospitalized for > or = 5 days were screened for ESBLPE acquisition by means of weekly rectal sampling and clinical cultures. Baseline characteristics and various ICU procedures in 62 cases of ESBLPE were compared with those for 205 patients without ESBLPE, with use of Cox's model. Risk for acquiring ESBLPE (Klebsiella pneumoniae in most cases) increased during the ICU stay, from 4.2% in the first week to 24% in the fourth week. Baseline characteristics were not different between the two groups. Urinary catheterization (P = .04) and arterial catheterization (P = .03) were independent risk factors for acquiring ESBLPE and probably reflected frequency of health care manipulations. The first site of ESBLPE acquisition was the digestive tract in 58 of the 62 patients; 28 infections developed in 22 patients, and these followed or occurred simultaneously with rectal colonization in 18 of those 22. DNA macrorestriction analysis suggested that the same strain was responsible for most cases. In conclusion, ESBLPE acquisition depends on length of stay in the ICU and the use of invasive procedures. Colonization is a prerequisite for infection.
Adult↗
Tuberculous meningitis in adults: review of 48 cases.
The cases of 48 adult patients with tuberculous meningitis who were admitted to intensive care unit (ICU) between 1982 and 1993 were reviewed. An underlying disease was present in 24 patients (50%), including 10 with human immunodeficiency virus infection. Forty-seven patients were referred to the ICU because of neurological deterioration; 22 were comatose at admission. Forty-six patients received antituberculous treatment; 36 required mechanical ventilatory support, and 16 underwent neurosurgery. Thirty-one patients died within 4 months after admission, and the remaining 17 were alive at a 1-year follow-up. Univariate prognostic analysis selected three variables, all assessed at admission, associated with outcome: time to onset of treatment of > or = 3 days (P = .003), coma (P = .006), and simplified acute physiology score of > 11 (P = .03). Thus, the outcome of tuberculous meningitis is mainly determined by the clinical stage at admission and the delay in starting treatment. These findings underscore the need to initiate early therapy as soon as the diagnosis of tuberculous meningitis is suspected.
Adolescent↗
Cryptococcus neoformans infection in France: epidemiologic features of and early prognostic parameters for 76 patients who were infected with human immunodeficiency virus.
We retrospectively carried out a descriptive and prognostic study of 76 human immunodeficiency virus-infected patients with cryptococcosis diagnosed by a positive culture of cerebrospinal fluid (CSF), blood, urine, or other body fluid or tissue. We focused on the 65 patients with cryptococcal meningitis. At diagnosis, the mean CD4 lymphocyte count was 46/mm3; 86% of patients had fever; 67%, headache; 37%, stiff neck; 29%, altered mentation or confusion; 20% cranial nerve deficiency; and 48%, other focal deficiencies. Analysis of CSF specimens revealed the following results: normal (25% of the specimens), leukocyte count of < 20/mm3 (62%), positive India ink smear (87%), and positive cryptococcal antigen (92%). Twenty patients died within the first 3 months (3-month survival rate, 70%). A Cox regression model selected the following as prognostic parameters: age older than 30 years (relative risk [RR] = 2.1), CSF glucose level of < 2 mmol/L (RR = 3.7), previous admission to an intensive care unit (RR = 4.7), and mechanical ventilation (RR = 4.6). The outcome of cryptococcal meningitis in patients with AIDS remains difficult to predict at admission, and every case should be considered as potentially severe.
AIDS-Related Opportunistic Infections↗
How valid are clinical signs of dehydration in infants?
Our objective was to determine the ability of several clinical signs of dehydration to distinguish among degrees of dehydration in infants with acute diarrhea. The design was a prospective cohort study in a pediatric referral hospital in Cairo, Egypt. Infant boys, 3-18 months old, with a history of acute diarrhea (5 or more watery stools per day for no more than 7 days) were eligible, except those with frank protein-energy malnutrition, serious nongastrointestinal illness, or being exclusively breast-fed. Several clinical signs of dehydration were assessed upon study entry. Subjects were then rehydrated with an oral rehydration solution and fed a standardized diet until diarrhea ceased (no watery or loose stools for 16 h). The main outcome measure was percent body weight gain at rehydration and at resolution of illness. Data from 135 subjects were available for analysis. Average (SD) rehydration phase duration was 5.2 (2.1) h, and average (SD) duration of illness was 54.5 (38) h. Multiple regression analysis selected prolonged skinfold, altered neurologic status, sunken eyes, and dry oral mucosa as the clinical signs that correlated best with percent dehydration (R2 for model 0.244, p < 0.001). Mean weight gain for the two assessment systems was 3.6-3.9% for mild, 4.9-5.3% for moderate, and 9.5-9.8% for severe dehydration. The most valid clinical signs of dehydration include prolonged skinfold, altered neurologic status, sunken eyes, and dry oral mucosa. Children with clinical signs of mild or moderate dehydration have fluid deficits on the order of 3 or 5% body weight, respectively.
Acute Disease↗
Nosocomial cerebral aspergillosis: a report of 3 cases.
Cerebral aspergillosis carries a mortality rate close to 100%, especially in immunocompromised patients. We describe 3 patients who contracted cerebral aspergillosis after neurosurgery, 2 of whom survived after exhaustive surgical treatment and medical treatment with high doses of amphotericin B (once liposomal), 5-fluorocytosine and itraconazole. We review the few non-fatal cases of cerebral aspergillosis reported. We consider that surgical excision must be complete and repeated if necessary, always in combination with medical treatment.
Adolescent↗
[Prognostic factors of prosthetic valve endocarditis. Apropos of 122 cases].
The prognostic factors of 122 patients suffering from prosthetic valve endocarditis between 1978 and 1992 were studied by univariate and multivariate analysis. The principal causative organisms were Staphylococcus aureus (33%), streptococci (20%), coagular-negative staphylococci (12%), enterococci (10%) and gram-negative bacilli (9%). The 4 month survival rate was 66% (42 deaths). The main predictive factor for death was infection with S. aureus (75% vs 15% with other organisms). In S. aureus infection, multivariate analysis identified the following predictive factors for death: a prothrombin ratio less than 30% (RR = 8.3), mediastinitis (RR = 4.9), cardiac failure (RR = 4.4) and septic shock (RR = 2.6). In cases of infection with other organisms, the following factors were predictive of death: a prothrombin ratio of less than 30% (RR = 32.26), renal failure (RR = 7.31) and cardiac failure (RR = 6.07). In patients with S. aureus infection, survival was better after than without surgery: 9/20 (45%) versus 0/20 (p < 0.001). In infection with other organisms, there was no difference in a survival after surgical (89%) or medical therapy (81%). Chronic endocarditis relapses over 1 to 5 years was observed in 9 cases. All patients were reoperated a total number of 18 times with 5 deaths. Very prolonged antibiotic therapy is recommended in these patients. The authors conclude that endocarditis not due to S. aureus and without complications may be treated medically. Rapid reoperation is necessary in all other cases.
Adult↗
Primary care physicians as gatekeepers in managed care. Primary care physicians' and dermatologists' skills at secondary prevention of skin cancer.
BACKGROUND AND DESIGN: This study determines (1) the readiness of primary care physicians (PCPs) to triage optimally lesions suspicious for skin cancer, (2) the difference in their abilities from those of dermatologists, and (3) whether accurate diagnosis after viewing slide images transfers to accurate diagnosis after viewing lesions on patients. Seventy-one primary care residents and 15 dermatologists and resident dermatologists diagnosed and selected a treatment/diagnostic plan for skin lesions suspicious for cancer. The lesions were shown on slides, computer images, and patients. Participants' performance was compared with biopsy results of all lesions. RESULTS: Dermatologists' scores were almost double those of primary care residents, and primary care residents' performance was positively associated with previous experience in dermatology. Primary care residents failed 50% of the time to diagnose correctly nonmelanoma skin cancer and malignant melanomas, and 33% of the time they failed to recommend biopsies for cancerous lesions. Primary care residents failed to diagnose malignant melanomas 40% of the time; dermatologists failed to do so 26% of the time. Both groups performed better using slide images compared with patients. CONCLUSIONS: Primary care residents may not be ready to assume a gatekeeper role for lesions suspicious for skin cancer. Because of the seriousness of missed diagnoses, especially of malignant melanomas, we need to improve the triage skills of PCPs. Future studies should evaluate whether primary care training allows sufficient time for PCPs to learn the necessary skills. Until we can show that PCPs are prepared to triage optimally, managed care plans should reduce the threshold for referrals to dermatologists of potential skin cancers.
Adult↗
[Use of recombinant erythropoietin in surgery--are the costs justified?].
The combination of autologous blood donation and rHuEPO therapy is rarely justified for medical and economic reasons. Adequate alternative indications for the use of rHuEPO perioperatively have yet to be studied. Therefore, in addition to the increasing costs of safe homologous blood products and the decreasing costs of recombinant proteins, a reevaluation of the cost-effectivity relationship will be mandatory for rHuEPO in surgery.
Blood Transfusion, Autologous↗
[HIV infection: recommendations for the management of asymptomatic adults and of various clinical syndromes].
This paper presents recommendations on the care of HIV infected adults based upon the authors' personal experience with close to 700 patients in a multiprofessional pilot center. This medical care has 5 main objectives: 1) Promotion of good health (through standard recommendation of hygiene, health habits and regular checkups); 2) prevention of infectious complications (through detection of latent pathogens, chemoprophylaxis, vaccination and avoidance of risky exposures); 3) Treatment of complications (mainly infectious, through early diagnosis and proper treatment); 4) Delay of HIV disease progression (through timely and properly chosen antiretroviral therapy); 5) Reduction of HIV infection spread from index case to others (through promotion of responsible behavior and avoidance of pregnancy and HIV exposure to others). Studies for evaluating global health and immunologic status and carriage of potential pathogens are discussed as well as the criteria and timing for chemoprophylaxis for tuberculosis and P carinii pneumonia (PCP). Algorithms for the management of major clinical syndromes are presented: Diarrhea (afebrile, mostly parasitic, versus febrile, frequently bacterial); Pneumonia (lobar mostly bacterial versus interstitial, frequently PCP especially if lymphopenic and not receiving PCP prophylaxis); Brain mass lesion (most commonly toxoplasmosis). Finally, the evaluation and diagnostic possibilities of febrile patients is presented, based upon the immunologic status and associated symptoms.
AIDS-Related Opportunistic Infections↗
Comparative biomass spectra and species composition of the zooplankton communities in Golfo Dulce and Golfo de Nicoya, Pacific coast of Costa Rica.
This study is based on a subset of plankton samples obtained during an expedition of the German RV Victor Hensen to the Pacific coast of Costa Rica in 1993/94. It aims at the identification of the main plankton taxa for a general description and comparison of the plankton communities of the gulf systems Golfo de Nicoya (GN) and Golfo Dulce (GD) and the analysis of biomass spectra at inshore and offshore stations at the end of the rainy season and during the dry season. Inshore plankton biomass was significantly higher in GN than GD and exceeded offshore biomass several times, while in the GD area the reverse was found. In the rainy season, inshore biomass spectra of GN and GD were discontinuous with biomass concentrations at small sizes (around 0.06 mg) suggesting little developed communities, with highest production and energy use occurring in the small organisms. From the rainy to the dry season inshore species richness increased in both gulf systems and a shift was observed towards the larger size groups resulting in more continuous biomass spectra. In GN, bivalve larvae, foraminifers, ostracods, mysids and nauplii increase heavily in abundance and some gelatinous specimens occur. In GD, gelatinous zooplankton appears in enormous abundance and dominate the community biomass, followed by large chaetognaths and ostracods. In GD, inshore plankton has neritic and oceanic elements and differs less from the offshore plankton, whereas in GN, inshore plankton in largely neritic. The high abundance of fish eggs and invertebrate larvae suggest that this area is an important spawning ground. While in the rainy season inshore biomass was about 15 times higher in GN compared to GD, this difference was reduced to 3-4 times in the dry season due to the appearance of the large predators mentioned above. The changes from the rainy to the dry season at the offshore stations of both gulf systems are less pronounced in terms of total biomass, shape of the biomass spectra and taxonomic composition of the community. The differences-relatively continuous biomass spectra with an increasing slope and a high total biomass in GD versus flat and shorter spectra due to the absence of large chaetognaths and medusa in the GN-suggest that conditions in the former area allow for a better development of a trophodinamically tightly structured plankton community.
Animals↗
Demersal fish assemblages along the Pacific coast of Costa Rica: a quantitative and multivariate assessment based on the Victor Hensen Costa Rica expedition (1993/1994).
During two cruise legs with the RV Victor Hensen (December 1993, February 1994), the demersal fish assemblages of the Golfo de Nicoya (GN), Bahía Coronado-Sierpe Terraba (ST) and Golfo Dulce (GD) areas were assessed from nearshore (approximately 20 m) to shelf edge (approximately 200 m) waters. 44 Beam- and 29 otter trawl collections were made on an area of 2,119,405 m2, yielding a total of 242 species of fish. Despite the lower number of samples taken, more species were collected by the otter trawl (189 compared to 160), due to a wider area swept. As revealed by the species-area curve and a longnormal-curve constructed from the pooled (log) abundance data, the fish assemblage appeared as well sampled and a theoretical species richness (SR) of-306 was estimated for the whole area. Mean species number per collection and mean biomass per area were much lower in the GD-area (9.3 species, 0.36 g/m2) compared to the ST (15.4, 0.81 g/m2) and GN (17.3, 0.74 g/m2) areas, indicating a depauperate fish assemblage in the former. Lowest species numbers and biomass were found in the central deep part of GD with increasing values towards the sill area at the opening of the gulf and towards the shallow stations above the thermocline. Average biomass was an order of magnitude higher in the interior part of GN compared to the other areas with values up to 18.1 g/m2. Based on results of a multivariate analysis of the collections, the GN area can be divided into (1) an interior shallow area above the thermocline (< 50 m) characterized by scianids, sea carfishes, stingrays, flatfishes, sea robins, (2) an outer part (> 100 m) characterized by cods, scorpionfishes, gobies, cutlassfishes, serranids, anglerfishes and flatfishes and (3) a transition zone of the central and lateral parts with a mixed species assemblage with carangids, pufferfish, snappers, several flatfish species and the lizardfish as common elements. Characteristic for the deep basin of GD were small species of the genera Cynoscion and Porichthys. These occurred in low densities, suggesting a reduced carrying capacity of this deep basin for fish biomass in terms of food and oxygen. Species occurring at the shallow stations of GD are also found at a similar depth in the other areas, but many species are missing, namely ariids and many scianids found in the GN area. The species assemblage of the ST area resembles that of GN. Ariids, however, are missing here too. Biotic station parameters like species richness, biomass, abundance and production were not significantly correlated with abiotic parameters (temperature, oxygen, nutrients) suggesting that other habitat factors not evaluated in this study like habitat heterogeneity, distance to the open ocean, current regime and food availability probably are important factors for the structure of the fish assemblage.
Animals↗
[Epidemiology of antibiotic resistance: implications for empirical treatment in intensive care].
The adequacy of initial antibiotic therapy is an important prognostic factor in severe infections. Concerning nosocomial infections, the selection of appropriate empirical therapy should take into account the incidence of offending pathogens within a specific unit. The changing trends in the hospital's microbial resistance patterns should be known to the physicians. The bacteria involved and the susceptibility testing vary widely among institutions and among countries. Many risk factors for acquisition of resistant pathogens have been identified. The duration of stay in hospital, previous colonization, and antibiotic treatment are the most frequently cited risk factors. When P. aeruginosa is suspected, an ureido-penicillin/aminoglycoside combination is usually effective. However, in some units with high levels of resistance, the beta-lactam should be ceftazidime or imipenem. When enterobacteria are suspected, a third generation cephalosporin, alone or in combination with an amino-glycoside or a broad spectrum penicillin associated with a beta-lactamase inhibitor is appropriate. Early nosocomial staphylococcal infections are treated with nafcillin or oxacillin, alone or in combination with an aminoglycoside. In units with a high rate of MRSA, the initial antibiotic therapy should include a glycopeptide.
Bacteria↗
Why monitor peak vancomycin concentrations?
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Bacteremia↗
[Amebic liver abscess complicated by a voluminous intraperitoneal collection].
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Adult↗
Early predictors of outcome for HIV patients with neurological failure.
OBJECTIVE: To carry out a descriptive study of human immunodeficiency virus (HIV)-infected patients admitted to an intensive care unit (ICU) with neurological failure and to identify parameters that are predictive of death within 3 months. DESIGN: Case series study. POPULATION AND SETTING: A total of 84 consecutive HIV-infected patients admitted to an infectious disease ICU in a university hospital for neurological failure. A thorough clinical, laboratory, and brain computed tomography (CT) scan workup was done within 48 hours of admission. MAIN RESULTS: The mean (+/- SD) CD4+ lymphocyte count was 0.067 (+/- 0.086) x 10(9)/L. Mechanical ventilation was necessary within 48 hours of admission in 67 cases (80%). The brain CT scan revealed abscesses in 51 patients (61%). The abscesses were attributed to probable toxoplasmosis in 47 patients. A total of 57 patients died, yielding a 3-month survival rate of 32%. By the log-rank test, the following factors were predictive of death within 3 months of admission to the ICU: Glasgow Coma Scale score less than 7 (P = .01), signs of brain stem involvement (P = .001), and need for mechanical ventilation in the 48 hours after admission (P = .02). In a Cox model, only Glasgow Coma Scale score less than 7 (P = .006) and clinical signs of brain stem involvement (P = .02) were predictive of death within 3 months of admission to the ICU. CONCLUSIONS: Despite a thorough examination, no initial HIV-specific parameters were identified as predictive of death. The prognostic factors found simply reflected the severity of neurological involvement in the various etiologies.
AIDS Dementia Complex↗