Diagnosis of ventilator-associated pneumonia.
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Adult↗
Biomedical subjects
R A Barnes
Publications and source records attributed to R A Barnes.
Fungal infections: a survey of laboratory services for diagnosis and treatment.
A questionnaire on the services provided and the methods used for the diagnosis of fungal infections and for the support of antifungal chemotherapy was sent to members of the British Society for Medical Mycology (BSMM) and the British Society for Antimicrobial Chemotherapy (BSAC). Ninety-five responses from general microbiology laboratories in the United Kingdom were analysed, and we compared services provided by laboratories that serve a transplant unit with those offered by other laboratories. We estimate that about 150 cases of cryptococcosis, 500 to 600 of candidaemia, and 300 to 400 of invasive aspergillosis are identified by laboratories in the United Kingdom (UK) each year. The clinical laboratories are aware of the importance of fungal infection, but rely heavily on reference services. In some laboratories, however, the degree of investigation of specimens and the procedures in use are inadequate for diagnosing systemic mycoses and determining the susceptibility of isolates to antifungal agents. The balance between reference and local services requires attention and external quality assurance needs to be applied effectively. In addition, effective methods for the diagnosis of systemic mycoses, and reliable and practicable methods for determining the susceptibility of isolates to antifungal agents, are needed urgently.
Antifungal Agents↗
A novel simple method for quantifying bacteria from endotracheal aspirates.
A convenient dipstrip method (Bacteruritest; Mast Diagnostics) for bacterial quantification was evaluated with 42 endotracheal aspirates. For 31 specimens, the dipstrip method yielded counts within a 10-fold range of surface plate counts. Two specimens yielded counts by the dipstrip within a 100-fold range of plate counts. Six specimens yielded confluent growth at the greatest dilution tested by the dipstrip method, and counts > 10(10) cfu/ml in the surface plate method. Three specimens yielded no detectable growth by the dipstrip and surface plate counts < 10(2) cfu/ml. Dipstrips provide a cheap, convenient method for the routine quantification of the bacterial load in endotracheal aspirates.
Adult↗
Immunotherapy and immunoprophylaxis in bone marrow transplantation.
Immunotherapy can be defined as treatment directed at augmenting host immune defence mechanisms. Non-antimicrobial therapies and immunoprophylaxis in bone marrow transplantation (BMT) can be subdivided into three broad categories: passive immunotherapy with intravenous immunoglobulin (IVIG); cytokine therapy; and anti-endotoxin-directed treatments. Most studies using IVIG in BMT are prophylactic and suffer from variability in study design, type of IVIG and dosing regimens. Various effects on viral and bacterial infections and graft-versus-host disease (GVHD) have been reported but few if any have shown benefit in terms of improved patient survival. Moreover the immunomodulatory effect of immunoglobulin G preparations is frequently overlooked. With the exception of cytomegalovirus (CMV) pneumonitis, there is little evidence of benefit in the treatment of established infections and the relative benefits of hyperimmune preparations are poorly established. The development of haemopoietic growth factors has led to the widespread use of cytokines in BMT. The benefits of these agents both in the prevention of fever and infection and as adjuvants to standard antimicrobial therapy in established infection (e.g. invasive mycoses) are rapidly becoming apparent. Both human recombinant granulocyte-macrophage colony-stimulating factor (rhGM-CSF) and granulocyte colony-stimulating factor (rhG-CSF) have been shown to accelerate granulocyte recovery following BMT and reduce fever days, antibiotic usage and hospitalization. RhGM-CSF appears superior in these respects. The roles of interleukin 1 (IL1), IL3, IL6 and interferons are also under evaluation. As with the much publicised studies using anti-endotoxin antibodies as therapy in sepsis, there is little evidence of benefit in the few studies performed in BMT patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Bone Marrow Transplantation↗
Antifungal drug susceptibility testing. Working Party of the British Society for Antimicrobial chemotherapy.
This article describes the current situation with regard to intrinsic and acquired resistance to antifungal compounds and progress with the development of standardized methods of susceptibility testing for amphotericin B, flucytosine, and the azoles. Recommendations for testing of isolates from patients destined to receive antifungal drug treatment, or in whom therapeutic failure or relapse is suspected, are presented.
Antifungal Agents↗
The role of footwear in minimizing lower limb injury.
The shoe can be thought of as a powerful tool for controlling human movement. A well-designed shoe can assist in reducing the number of lower limb injuries arising from sport and training activities. The purpose of this paper is to present a summary of the main thrusts of research in this field by means of a digest of current thinking and practice. The paper initially presents a survey of work in the biomechanical field with particular reference to the design of footwear. A review of the types of injury acquired by sportsmen in both training and playing is then followed by a discussion of aspects of footwear design and their role in both contributing to and preventing lower limb injury. Finally, the paper considers support and shock absorption techniques in the context of footwear design. It is concluded that research has been wide-ranging and thorough. However, the complexity of the biomechanical system being studied has prevented definitive recommendations for the prevention of injury being made in every case. Nonetheless, it is clear that a number of guiding principles have been established which should be the basis for future developments in footwear design to minimize the chance of lower limb injury.
Athletic Injuries↗
Effect of IgM-enriched intravenous immunoglobulin (Pentaglobin) on endotoxaemia and anti-endotoxin antibodies in bone marrow transplantation.
Endotoxin was measured in over 1000 plasma samples from bone marrow transplant patients in a randomized trial of the IgM-enriched intravenous immunoglobulin (IVIG) Pentaglobin. Peak endotoxaemia was significantly reduced (P = 0.02) in patients receiving Pentaglobin and 70% of all pyrexias of unknown origin were associated with endotoxaemia. Gut mucosal damage, assessed by lactulose/mannitol ratios, was significantly associated (P = 0.02) with endotoxaemia. Specific IgM antibody to endotoxin core-glycolipid was significantly raised (P < 0.01) in patients receiving the IVIG, and the IgM fraction of Pentaglobin was found to contain most of the anti-endotoxin antibody activity of the IVIG. These results suggest a role for IgM-enriched IVIG as a prophylactic agent for the reduction of endotoxaemia and its consequences in bone marrow transplant patients.
Adolescent↗
Antigen detection in invasive aspergillosis.
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Antigens, Fungal↗
Use of IgM enriched intravenous immunoglobulin (Pentaglobin) in bone marrow transplantation.
In a study of 63 allogeneic and autologous bone marrow transplants, patients were randomized to receive the IgM and IgA enriched intravenous immunoglobulin (IVIG) preparation (Pentaglobin). Pentaglobin has been postulated to have anti-endotoxin properties and one of the aims of the study was to measure endotoxin levels in these patients together with the clinical sequelae of infection. The anti-endotoxin effects of Pentaglobin were found to reside in the IgM fraction. Those patients who received Pentaglobin were significantly protected from dying from infection in the first 100 days after the transplant, although it was not actually possible to document bacterial infections as the cause of death in the control patients. Peak endotoxin levels were significantly reduced (p = 0.02) in those patients receiving Pentaglobin. Liver damage as assessed by liver enzyme abnormalities correlated significantly with the presence of endotoxaemia greater than 25 pg/ml and up to 70% of pyrexial episodes were associated with endotoxaemia. Our results suggest that Pentaglobin is useful in reducing hepatic toxicity and this may be related to a reduction in endotoxaemia.
Adolescent↗
Invasive pulmonary aspergillosis in non-immunocompromised patients.
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Aged↗
Value of antigen detection in predicting invasive pulmonary aspergillosis.
Two ELISAs were used to detect serum and urinary aspergillus antigen in 121 patients who were profoundly neutropenic after leukaemia therapy or bone marrow transplantation. The presence of antigen correctly predicted development of invasive pulmonary aspergillosis (IPA) in 16 patients. In 2 other cases antigen appeared after the clinical diagnosis had been made, while in only 1 case was antigen not detected. In 11 of 13 episodes of clinically suspected fungal infection antigen was detected before clinical diagnosis was made. By contrast, antigen was detected in only 1 of 90 patients who had no evidence of IPA. Both ELISAs gave positive and negative predictive values for IPA of greater than 95%, demonstrating the value of antigen detection in early diagnosis of aspergillus infection and the assay's ability to predict subsequent development of IPA. We conclude that neutropenic patients should be screened for aspergillus antigen, and propose that initial detection of fungal antigen justifies commencement of empirical antifungal therapy. Such an approach should improve the survival of patients who are at risk of developing this usually fatal infection.
Adolescent↗
Control of an outbreak of nosocomial aspergillosis by laminar air-flow isolation.
In the course of construction of a new bone marrow transplantation (BMT) unit, six of nineteen children undergoing BMT in the adjacent ward area died of invasive pulmonary aspergillosis (IPA). Ward air samples confirmed that heavy fungal spore contamination had occurred. The introduction of laminar air flow (LAF) isolation terminated the outbreak and no subsequent cases of IPA have been documented in patients nursed entirely in LAF. LAF has not reduced the rates of other complications associated with BMT.
Aspergillosis↗
Depression in self-harm patients.
DSM-III diagnoses and responses to the Beck Depression Inventory (BDI) were examined in 71 consecutive admissions to an in-patient psychiatric crisis service following deliberate self-harm. Although 80% of the admitted patients were moderately or severely depressed according to BDI scores, only 31% were diagnosed with a major depressive episode. While all of the self-harm patients may be viewed as experiencing severe subjective distress, only a minority were shown to suffer from DSM-III depressive illness. The high depression scores on the BDI may be related to the patients' extreme distress preceding a crisis admission and to the high prevalence of personality disorders in this group of patients.
Adolescent↗
Prevention of airborne fungal infection in immunocompromised patients.
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Air Microbiology↗
Response rates to a staged antibiotic regimen in febrile neutropenic patients.
In a prospective study of 50 patients with prolonged neutropenia, we observed a 75% response rate to a staged empirical antibiotic regimen used to treat 101 episodes of fever. Additions or modifications to the protocol were rarely necessary. The use of an approach such as this improves the management of febrile neutropenic patients.
Adolescent↗
An evaluation of empirical antibiotic therapy in febrile neutropenic patients.
A prospective study was undertaken to determine the effectiveness of an empirical antibiotic therapy regimen in 34 neutropenic patients undergoing bone marrow transplantation or remission-induction chemotherapy for leukaemia. Throughout the study period a total of 90 pyrexial episodes were monitored in which organisms designated to be pathogens were isolated from blood cultures on 38 occasions. The response rate to the combination of a ureidopenicillin with gentamicin fell sharply from 50% during patients' first pyrexial episodes to zero during the third and subsequent episodes. The preponderance of Gram-positive bacteria and the high overall resistance of bacterial isolates to these antibiotics have led us to reconsider our approach to empirical therapy and to include antibiotics with greater activity against Staphylococcus epidermidis. The emergence of fungi as a major cause of morbidity in patients with prolonged neutropenia underlines the necessity to introduce early empirical antifungal therapy in this group of patients.
Adolescent↗
Symptomatic depression in elderly medical outpatients. I. Prevalence, demography, and health service utilization.
The authors assessed the prevalence and demography of depressive symptoms, their association with specific chronic diseases, and their influence on health service use in a large sample of elderly men seen in a primary care setting. Twenty-four percent of respondents reported clinically significant depressive symptoms; the prevalence of major depressive disorders was estimated at 10%, but only 1% reported receiving mental health treatment by a specialist. Self-reported marital separation or divorce and physical disability affecting employment were strongly associated with high depression scores, whereas the normative stresses of aging (widowhood, retirement, social isolation) were not. Only chronic lung disease was differentially associated with high depression scores, and this effect was weak. The authors discuss the implications of these findings for the design of comprehensive health services for the elderly with chronic disease.
Aged↗
The recurrent self-harm patient.
A semistructured interview was used to collect information on a consecutive series of 163 self-harm patients (suicide attempters); 65.8% of the patients had a history of previous self-harm (repeaters). Male repeaters were more likely than men with no self-harm history (first cases) to have left school before ninth grade, to have alcohol abuse problems, and to have family stress. Female repeaters were younger than first cases and reported more difficulties with sexual adjustment and loneliness. Repeaters were more likely to have contacted distress centers and to have had previous mental health contact, including psychiatric hospitalization. A 6-month follow-up indicated four suicides in the repeaters' group and none in the first cases' group. Repeaters appear to be much more dependent than first cases on professional care and to present a high short-term risk for suicide.
Adult↗