Biomedical subjects
Publications and source records attributed to R Gleckman.
A prospective double-blind study in a homogeneous population and according to a uniform protocol documents the value of sulfonamide susceptibility testing, as performed by the disk-agar diffusion method, for the management of chronic urinary tract infections.
The decision to perform exploratory laparatomy in search of the cause of prolonged fever should not be made hastily. The operation is not benign, and before the patient is subjected to it, a meticulous medical evaluation should be made. A number of recently developed diagnostic techniques are invaluable aids to the physician challenged by this diagnostic dilemma.
An investigation was conducted with 65 selected febrile patients, 33 of whom fulfilled in all respects the classic criteria of "fever of unknown origin." Clinical evaluation included extensive radiological and immunological testing. Multiple blood cultures were examined by conventional methods in control studies. In addition, venous blood was cultured in a variety of hyperosmolar media using the special techniques used to detect L-forms and other cell wall-defective bacterial forms. By the extensive methods used, no bacterial forms were isolated. The use of media containing osmotic stabilizers did not detect L-forms or other aberrant bacterial forms, nor did it contribute to the determination of the etiology of fever of unknown origin in these patients.
Many concepts pertaining to urinary tract infections and considered to be established or dogma are, in fact, incorrect or subject to modification. The physician should not be too rigid in his thinking regarding this disorder, as new knowledge constantly becomes available, disproving previously cherished beliefs. The case described appears to underscore this better than any hypothetical situation.
Data derived from longitudinal studies demonstrate that asymptomatic bacteriuria in non-pregnant women without stones or obstructive uropathy is a benign pathological condition. Evidence has accumulated that untreated asymptomatic bacteriuria in otherwise healthy women does not result in hypertension and/or a decline in renal function, and that this condition required neither detection nor antimicrobial therapy.
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The clinical features of a patient with macroglobulinemia and pneumococcal erysipelas are presented. The cellular and humoral factors generated by the host to contain acute pneumococcal tissue invasion are described, and their activities in patients with plasma cell dyscrasias are discussed.
Excretory urography is not an infallible diagnostic procedure and should not be relied upon exclusively. A normal study must never result in the rejection of additional data derived from history, physical examination and laboratory tests. Two case histories are presented to underscore this caveat. Excretory urography must be supplemented additional radiographic evaluations when the conventional study fails to completely explain the clinical situation.
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Earlier studies on the antibody response to inactivated influenza vaccines injected by different routes have given contradictory results, some suggesting that 0.1 ml intradermally is superior to 1.0 ml subcutaneously, others suggesting the opposite. With the advent of the 1968-69 Hong Kong influenza epidemic it seemed worth while to re-evaluate whether a smaller intradermal dose would elicit antibody responses comparable to those following a larger subcutaneous dose.A study was performed evaluating 3 doses: 0.1 ml (65 CCA), 0.25 ml (160 CCA), and 0.5 ml (320 CCA) of zonal-purified vaccine. The 0.1-ml dose was administered by both routes, and the other doses subcutaneously only. The effect of "booster" inoculation by the same route 2 and 4 weeks later was also studied. Sera were examined for haemagglutination-inhibiting antibody, and antibody response was determined by the percentage showing 4-fold or greater titre rises and by increase in geometric mean titre.The antibody response to the first inoculation was highest in the 0.1-ml intradermal groups and the lowest in the 0.1-ml subcutaneous groups. All groups receiving a second inoculation 2 weeks after the first experienced an increase in antibody response; responses to the second inoculation given 4 weeks after the first were variable. Considering the over-all effect of all combinations of doses and routes, the intradermal groups appeared to achieve the best antibody response and the 0.1-ml subcutaneous groups the least.There appeared to be an inverse relationship between antibody response and pre-immunization antibody titre.The data show that, with vaccine of similar CCA content, 0.1 ml intradermally would be a reasonable alternative to, and perhaps better than, the usual 0.5-ml subcutaneous dose. The limitations of this approach are discussed.
Biogenesis of tetrahydrofolate cofactors essential for bacterial growth and survival is blocked by sulfamethoxazole-trimethoprim. An intravenous form of the antimicrobial combination has recently been approved for the treatment of acute, symptomatic, bacterial pyelonephritis, recurrent urinary tract infections, shigellosis, and Pneumocystis carinii pneumonia. Intravenous sulfamethoxazole-trimethoprim has emerged as an invaluable agent for the management of selected infections, including bacterial meningitis and Salmonella bacteremia, where limited therapeutic alternatives exist. In addition, co-administration of intravenous sulfamethoxazole-trimethoprim with a carboxypenicillin provides an empiric treatment for the infected granulocytopenic patient that compares favorably with standard combinations. Adverse events unique to the intravenous form of the drug consist of phlebitis and fluid imbalances. Fluid overload results from the relatively large volumes of 5% dextrose solution required as diluent.
Trimethoprim has recently been marketed as a single-entity product for the treatment of initial episodes of uncomplicated symptomatic urinary tract infections; it was previously available only in combination with sulfamethoxazole. Trimethoprim exerts antimicrobial activity by blocking the reduction of dihydrofolate to tetrahydrofolate, the active form of folic acid, by susceptible organisms. It has inhibitory activity for most gram-positive aerobic cocci and some gram-negative aerobic bacilli. Resistance to trimethoprim may be either intrinsic or acquired. Acquired resistance most commonly stems from a chromosomal mutation that results in the production of a dihydrofolate reductase enzyme which is less vulnerable to trimethoprim inhibition. Gastrointestinal intolerance and skin eruptions are the most common untoward reactions resulting from the administration of trimethoprim. Trimethoprim constitutes very effective therapy for women with acute symptomatic urinary tract infections caused by E. coli, and the compound compares favorably with alternative standard agents, such as ampicillin and cephalexin. The safety of trimethoprim in the pregnant woman has not been established. Since indiscriminate use of trimethoprim could foster the emergence of trimethoprim resistance, thereby negating the value of both trimethoprim and trimethoprim-sulfamethoxazole, trimethoprim should only be prescribed for well defined indications. Trimethoprim is currently being investigated as definitive therapy for a wide range of infections, including bacterial exacerbations of chronic bronchitis, bacterial pneumonia, and typhoid fever. Initial reports are encouraging.
Antibiotics are often misused, resulting in a high frequency of adverse effects, emergence of drug-resistant organisms, and excessive costs. The high cost of antibiotics is currently receiving the greatest attention. Considerable cost savings can be achieved by appropriate prescribing of antibiotics for patients receiving these drugs prophylactically as well as for those with established infections. This article cites specific examples of how cost-effective antibiotic prescribing practices can realize substantial cost savings without any diminished quality in patient care.
A prospective study was performed in a community hospital to determine the specific diseases responsible for "fever of unknown origin." Thirty-four adults with persistent unexplained fever were subjected to extensive diagnostic evaluations. Alcoholic hepatitis and recurrent pulmonary emboli were found to be frequent causes of "fever of unknown origin" in this patient population. Approximately a third of the patients had no disease identified which would have explained the persistent fever. This group of patients, for whom no diagnosis was established, shared an important characteristic: failure to lose more than two pounds/week during the hospitalization.
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The laboratory test of paramount importance in patients with suspected infective endocarditis is blood culture. This article considers the generations-old problem of the timing and frequency of these cultures, describes techniques to increase their yield, and outlines measures to take whenever special cultures fail to identify the etiologic agent.