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Post-cannulation radial artery aneurysm--a rare complication.
The following case report describes an expanding aneurysmal dilatation of the radial artery which developed 17 days following cannulation.
Possible causes of this complication are: abnormal state of the vessel wall, multiple attempts at cannulation, and haematoma or infection at cannulation site.
Other major and minor sequelae following arterial cannulation are reviewed.
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301
| 2,173
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The hyperimmunoglobulinaemia E and recurrent infections syndrome in an adult [published erratum appears in Thorax 1990 Dec;45(12):984]
A 27 year old white woman with a history of chronic eczema and episodes of serious infection of the chest, skin, and bone presented with acute respiratory failure.
She was found to have a spontaneous right pneumothorax and a pneumatocele in the left upper lobe.
Despite a left upper lobectomy she was left with chronic respiratory failure, bullous lung disease, and bilateral bronchiectasis.
The hyperimmunoglobulinaemia E and recurrent infections syndrome was diagnosed only in adult life.
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302
| 9,126
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A resurgence of acute rheumatic fever in a mid-South children's hospital.
A resurgence of acute rheumatic fever (ARF) has been reported in many areas of the United States in recent years.
We retrospectively reviewed the medical records of inpatients with a new diagnosis of ARF from 1982 through 1988 at a children's hospital that serves a six-state referral area in the mid-South.
Thirty patients were identified, 21 of whom were seen in 1987 (13) and 1988 (8).
The rate of new cases of ARF per 1000 hospital discharges (0.7) was significantly greater for 1987 and 1988 than it was (0.15) from 1982 through 1986.
Patients with recently diagnosed ARF were predominantly from nonurban areas, and polyarthritis was the most common recent major manifestation.
Reasons for the resurgence of ARF in the US, including the mid-South, are unclear, but our experience serves to support recently published guidelines for the diagnosis and management of streptococcal pharyngitis in light of this resurgence of ARF.
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303
| 4,849
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Subarachnoid hemorrhage caused by a fungal aneurysm of the vertebral artery as a complication of intracranial aneurysm clipping. Case report.
Intracranial aneurysms are an uncommon manifestation of fungal infection.
A case is described in which the formation of an aneurysm followed an intracranial intraoperative Aspergillus infection attributable to a long period of preoperative antibiotic medication and immunosuppressive therapy with steroids.
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304
| 2,981
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Emergence of ciprofloxacin resistance in nosocomial methicillin-resistant Staphylococcus aureus isolates. Resistance during ciprofloxacin plus rifampin therapy for methicillin-resistant S aureus colonization.
We initiated a randomized, single-blinded trial of ciprofloxacin plus rifampin vs sulfamethoxazole and trimethoprim plus rifampin in the therapy for patients who underwent colonization with methicillin-resistant Staphylococcus aureus (MRSA).
Patients who were colonized with MRSA received 2 weeks of either regimen.
The study was terminated after the enrollment of 21 subjects due to the recognition of ciprofloxacin resistance in 10 of 21 new MRSA isolates during the last 2 months of the study.
Five of the 10 patients with ciprofloxacin-resistant MRSA isolates had never received ciprofloxacin.
Long-term (6-month) eradication had been achieved in only three of 11 ciprofloxacin plus rifampin and four of 10 sulfamethoxazole and trimethoprim plus rifampin recipients.
The use of this new fluoroquinolone for the eradication of MRSA colonization is usually not effective and may risk the development of ciprofloxacin resistance in MRSA within the hospital environment.
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305
| 9,883
|
Parents' vs physicians' utilities (values) for clinical outcomes in potentially bacteremic children.
Our previous analyses of decision strategies in children 3-24 months with acute-onset fever greater than or equal to 39 degrees C and no evident bacterial focus of infection indicated that the risks of routine blood cultures (the unnecessary hospitalization and treatment of children who clear their bacteremia spontaneously) outweigh its benefits (the prevention of a few cases with major infectious sequelae).
Because those analyses were based on parents' values for beneficial and adverse clinical outcomes, we wished to examine whether those values differed in physicians and, if so, whether the differences were sufficient to change the results of the decision analysis.
Using a pre-tested linear analog utility (value) scale, we evaluated eight potential clinical outcomes in potentially bacteremic children by surveying 121 parents of healthy 3-24-month-old children attending a private pediatric group practice and 57 attending physicians of a tertiary-care children's hospital emergency room.
Utilities were based on a 0-1 normalization, where 0 is the utility of the worst outcome (meningitis or other major bacterial infection, plus venipuncture), and 1 the utility of the best outcome (complete recovery without venipuncture or hospitalization), and were analyzed using a recently developed statistical model of utility.
The majority of parents and physicians combined the imputed components of the outcomes (disease, pain of venipuncture, and stress of hospitalization) in a nonlinear fashion.
Parents assigned substantially lower utility (i.e.
greater disutility) to venipuncture, minor infection, and hospitalization than did physicians, and these utilities were even lower in parents with other children at home.
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306
| 6,908
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Job's syndrome: a rare cause of recurrent lung abscess in childhood.
A clinical syndrome characterized by recurrent staphylococcal infection of the skin and respiratory tract from birth was described in 1966 and referred to as Job's syndrome.
Marked hyperimmunoglobulinemia E was later found to be associated with this syndrome.
This article describes a case of Job's syndrome as a cause of recurrent lung abscess during childhood necessitating lung resection.
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307
| 5,342
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Extrapulmonary pneumocystosis: clinical features in human immunodeficiency virus infection.
Pneumocystis carinii infection is reported with increasing frequency as a cause of disease outside of the respiratory tract in patients with human immunodeficiency virus (HIV) infection.
Extrapulmonary pneumocystosis is not limited to patients in any discrete risk group for HIV infection.
Patients with HIV infection who develop extrapulmonary pneumocystosis frequently do not have concurrent P.
carinii pneumonia.
Signs and symptoms of extrapulmonary pneumocystosis are nonspecific but when present are frequently referable to the tissues or organs involved.
Extrapulmonary pneumocystosis can be diagnosed by examination of tissue biopsies from affected sites using standard histologic techniques.
Therapy with antimicrobial agents used to treat P.
carinii pneumonia has been effective in some patients.
An association between use of aerosolized pentamidine for prevention of P.
carinii pneumonia and development of extrapulmonary pneumocystosis has been suggested but remains unconfirmed.
Other factors such as the use of zidovudine and duration of immunodeficiency may also be important to the pathogenesis of extrapulmonary pneumocystosis.
Further studies are needed to better identify risk factors that may predispose patients to the development of extrapulmonary pneumocystosis.
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308
| 995
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A case of unexpected pasteurella multocida bacteremia.
A case of Pasteurella multocida bacteremia in a previously healthy hospital employee is presented.
The patient had sustained a scratch from his dog four days prior to being seen in the emergency department with adequate healing and no evidence of localized infection.
He presented with an acute febrile illness, and was discharged from the emergency department with a diagnosis of viral syndrome.
He was asked to return to the hospital the next day when a bacteriology report of gram negative rods in both aerobic and anaerobic blood culture bottles was received in the emergency department.
Pasteurella multocida bacteremia/septicemia is seen most frequently in immunocompromised patients but the diagnosis should be considered in any patient with a febrile illness and exposure to cats or dogs.
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309
| 2,881
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SCH-39304 in prevention and treatment of disseminated candidiasis in persistently granulocytopenic rabbits.
To investigate the potential use of SCH-39304 for the prevention and treatment of disseminated candidiasis in granulocytopenic patients, we studied its in vivo antifungal activity as preventive, early, and late treatments in three models (acute, subacute, and chronic) of disseminated candidiasis in persistently granulocytopenic rabbits.
SCH-39304 was an effective as amphotericin B alone and fluconazole alone for the prevention of disseminated candidiasis.
SCH-39304 alone and fluconazole alone were as effective as amphotericin B plus flucytosine for early treatment of subacute disseminated candidiasis.
When treatment was delayed for 5 days to establish chronic disseminated candidiasis, SCH-39304 was less effective than amphotericin B plus flucytosine.
In comparison with different treatment regimens, SCH-39304 was more effective in early and preventive treatment.
Thus, SCH-39304 was comparable to treatment control regimens in prevention and early treatment of subacute disseminated candidiasis.
SCH-39304 also was most effective in granulocytopenic rabbits with disseminated candidiasis when used for prevention or early treatment.
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310
| 7,522
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Antifungal therapy and its use in surgical treatment.
Modern surgery continues to make significant therapeutic advances, and a major component in the adjunctive care allowing these improved procedures is the successful use of broad-spectrum antibacterials.
However, the widespread administration of potent antibacterials and the frequent use of a variety of catheters, along with an increase in the number of immune compromised patients requiring invasive procedures, have allowed deep-seated mycoses to become more common.
Nosocomial fungal infections are frequent, particularly in the urinary tract and in the blood.
This rise in identified fungal infections, along with frequent empiric treatment of suspected infection, has significantly increased amphotericin B therapy in surgical services in the last five years.
While amphotericin B remains the standard for treatment of nosocomial mycoses, other antifungal agents are available (flucytosine, miconazole, ketoconazole and fluconazole).
Despite experience with the older agents and the development of new agents, many questions remain concerning the use of currently available antifungal treatments in postsurgical patients.
The following discussion attempts to summarize the magnitude of the problem, the difficulties with diagnosis and laboratory evaluations, the characteristics of the antifungal agents and particular problems with antifungal treatment in surgery.
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311
| 7,537
|
Brain abscess associated with congenital pulmonary arteriovenous fistula.
A case of brain abscess associated with congenital pulmonary arteriovenous fistula was presented and 52 reported cases were reviewed.
The brain abscess was successfully treated with repeated aspiration and drainage, and the pulmonary arteriovenous fistula, located in the right lower lobe, was resected.
The arteriovenous fistula occurs as a common pulmonary manifestation of hereditary hemorrhagic telangiectasia; however, no symptoms suggesting these two were noted in this case.
Brain abscesses can be an initial clinical manifestation in asymptomatic pulmonary arteriovenous fistula.
This possible association should be borne in mind in cases of brain abscesses of unexplained etiology.
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312
| 879
|
Itraconazole in the management of chronic dermatophytosis.
Fifty-five patients with griseofulvin-unresponsive dermatophytosis caused by Trichophyton rubrum were treated with itraconazole.
They had either tinea corporis or "dry type" infections of the palms, soles, or nails.
The following sites were affected: trunk (12 infections), soles (47), toe webs (52), palms (26), fingernails (29), and toenails (42).
Patients were treated with oral itraconazole until clinical and mycologic remission were achieved.
Response rates and mean times to recovery were as follows: trunk, 100%, 1.5 months; soles, 83%, 6.7 months; toe webs, 90%, 7.2 months; palms, 96%, 4.6 months; fingernails, 90%, 5.4 months; and toenails, 76%, 10.3 months).
In a 6-month follow-up period 7 of 30 patients with toenail infections who had responded to treatment had a clinical and mycologic relapse, usually of one nail.
Side effects were minimal but included abdominal discomfort (three patients), headache (one), and weight gain (two).
No persistent abnormalities in blood biochemistry were seen, even in patients who received itraconazole for more than 9 months.
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313
| 9,421
|
Cumulative AIDS incidence and altered mortality from bacterial infections.
To determine whether populations with high cumulative incidence of acquired immunodeficiency syndrome (AIDS) experienced increased deaths from sepsis, central nervous system abscess, or endocarditis, New Jersey AIDS patients were grouped according to their age, sex, race, and residence-specific cumulative incidence of AIDS since the onset of the AIDS epidemic.
Between 1980 and 1986, among 25-44 year olds in the highest cumulative incidence group for AIDS, sepsis mortality increased from 3.3 to 15.2 deaths/100,000/year, an increase of 11.9 deaths/100,000/year (95% confidence interval (6.9, 17.0) deaths/100,000/year); mortality from central nervous system abscesses increased from zero to 1.7 (0.1, 3.2) deaths/100,000/year; and mortality from endocarditis increased from 0.8 deaths/100,000/year to 2.4 deaths/100,000/year, an increase of 1.6 (-0.5, 3.7) deaths/100,000/year.
Age-matched New Jersey patient populations with low cumulative incidence of AIDS did not sustain a similar increase.
The HIV disease-associated increase in sepsis mortality among young populations represents a new component of the substantial increase in U.S.
sepsis mortality that occurred over the last two decades, but was previously limited to older populations.
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314
| 4,922
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Adult immunizations: are they worth the trouble?
There are good data to recommend routine use of vaccines against measles, rubella, tetanus, influenza, and pneumococcal infections in adults.
An adolescent or an adult born after 1956 is considered to be susceptible to measles unless he or she has received two doses of live measles vaccine or has suffered a physician-diagnosed case of measles.
Tetanus is largely a disease of the elderly, and there is a universal need for immunizations with tetanus toxoid.
Influenza continues to be a major public health problem, and influenza vaccine should be given annually to the elderly and to those at high risk.
The efficacy of pneumococcal vaccine in American adults is still being debated.
Results from case-control studies show that the vaccine is about 60% effective in reducing the incidence of disease due to vaccine-related strains.
Its use in the elderly and in those at higher risk for pneumococcal infection is recommended.
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315
| 2,240
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Renal abscess in children.
Three cases of renal abscesses in children are described to illustrate the variable presenting features.
An additional 23 pediatric cases, reported over the past ten years, were reviewed for clinical features and therapy.
Fever, loin pain, and leukocytosis were common presenting features, but less than half of all abscesses were associated with either an abnormal urinalysis or a positive urine culture.
The presenting features were sometimes confused with appendicitis, peritonitis, or a Wilms tumor.
An organism was identified in 17 cases--Escherichia coli in 9 children and Staphylococcus aureus in 8 children.
The majority of E.
coli infections occurred in girls and the majority of S.
aureus infections occurred in boys.
Reflux was documented in 5 patients, and 2 children had a possible extrarenal source of infection.
Antibiotics alone produced a cure in 10 children (38%), but 16 children (62%) required a surgical procedure.
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316
| 5,136
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Disseminated histoplasmosis with embolic endovascular complications: a case report.
A 57-year-old man had subacute embolic ischemia of his right foot and subsequent acute embolic ischemia of his left foot after angiography.
Thrombus removed at the time of the left femoral thromboembolectomy grew Histoplasma capsulatum confirming the diagnosis of disseminated histoplasmosis.
Surgical revascularization of the right leg and parenteral amphotericin B was followed by chronic ketoconazole therapy for 16 months.
The patient has remained asymptomatic at 30 months after operation.
Effective treatment of endovascular infection with ischemic complications of Histoplasmosis requires surgical revascularization and intensive chemotherapeutic intervention.
Histoplasmosis is a ubiquitous infection in endemic areas that often has an asymptomatic subclinical course.
Involvement of the cardiovascular system is rarely reported.
Previous case reports have described infected cardiac valves and aortic aneurysms.
This report describes the uncommon presentation of disseminated Histoplasma capsulatum infection as a peripheral embolic event and the successful management with revascularization combined with systemic amphotericin B followed by ketoconazole therapy.
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317
| 887
|
Itraconazole therapy in aspergillosis: study in 49 patients.
Itraconazole, 200 to 400 mg once daily, was administered to 49 patients with different types of aspergillosis: pulmonary aspergilloma (14 patients), chronic necrotizing pulmonary aspergillosis (14), and invasive aspergillosis (21).
Itraconazole was prescribed alone or in combination or after treatment with amphotericin B and flucytosine.
Of 14 aspergilloma patients, 2 were cured and 8 had symptomatic improvement.
In chronic necrotizing pulmonary aspergillosis, 7 of 14 patients were cured and 6 improved significantly.
In invasive aspergillosis treatment failed in 6 patients and 15 were cured.
Itraconazole can be an alternative to amphotericin B in the treatment of invasive aspergillosis and chronic necrotizing pulmonary aspergillosis.
In aspergilloma itraconazole may be useful in inoperable cases.
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318
| 4,682
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Treatment evaluation of experimental staphylococcal infections: comparison of beta-lactam, lipopeptide, and glycopeptide antimicrobial therapy.
LY 146032, teicoplanin, vancomycin, oxacillin, cephalothin, cefamandole, ampicillin plus sulbactam, and cefoperazone plus sulbactam were studied against six isolates of staphylococci (including both Staphylococcus aureus and coagulase negative staphylococci) using in vivo and in vitro methods.
In vitro susceptibility measurements demonstrated that all six isolates were sensitive to LY 146032 and vancomycin and that five of six isolates were sensitive to tiecoplanin, cefamandole, ampicillin plus sulbactam, and cefoperazone plus sulbactam.
Comparison of antimicrobial therapy in an in vivo rabbit model demonstrated that cefoperazone plus sulbactam was active against the greatest number of isolates (five of six) based on a reduction of greater than or equal to 5.0 log10 colony forming units per milliliter (CFU/ml) from growth control at the end of the animal treatment study.
Vancomycin and oxacillin were equal in achieving reductions of greater than or equal to 5.0 log10 CFU/ml in four of the six isolates.
Comparing each isolate's in vivo outcome to in vitro data shows that in vitro susceptibility tests overpredict the sensitivity of these six isolates to LY 146032 and vancomycin, are variable for teicoplanin, cefamandole, ampicillin plus sulbactam, and cefoperazone plus sulbactam, and underpredict for oxacillin.
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319
| 9,791
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Widespread dermatophyte infections that mimic collagen vascular disease.
This article reports the cases of two patients in whom a widespread dermatophyte infection mimicked the cutaneous lesions of their underlying collagen vascular disease.
Griseofulvin may be associated with an increased incidence of adverse cutaneous reactions in patients with systemic lupus erythematosus.
One patient with systemic lupus erythematosus developed erythema multiforme after taking griseofulvin.
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320
| 7,180
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Immunogenicity in animals of a polysaccharide-protein conjugate vaccine against type III group B Streptococcus.
The native capsular polysaccharide of type III group B Streptococcus elicits a specific antibody response in only 60% of nonimmune human subjects.
To enhance the immunogenicity of this polysaccharide, we coupled the type III polysaccharide to tetanus toxoid.
Prior to coupling, aldehyde groups were introduced on the polysaccharide by controlled periodate oxidation, resulting in the conversion of 25% of the sialic acid residues of the polysaccharide to residues of the 8-carbon analogue of sialic acid, 5-acetamido-3,5-dideoxy-D-galactosyloctulosonic acid.
Tetanus toxoid was conjugated to the polysaccharide by reductive amination, via the free aldehyde groups present on the partially oxidized sialic acid residues.
Rabbits vaccinated with the conjugate vaccine produced IgG antibodies that reacted with the native type III group B streptococcal polysaccharide (3/3 rabbits), while rabbits immunized with the unconjugated type III polysaccharide failed to respond (0/3 rabbits).
Sera from animals receiving conjugate vaccine opsonized type III group B streptococci for phagocytic killing by human peripheral blood leukocytes, and protected mice against lethal challenge with live type III group B streptococci.
The results suggest that this method of conjugation to a carrier protein may be a useful strategy to improve the immunogenicity of the type III group B Streptococcus polysaccharide in human subjects.
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321
| 777
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Selection of antibiotic coverage in vascular patients undergoing cystoscopy.
Bacteremic seeding of prosthetic vascular grafts represents a cause for graft infection; transurethral procedures account for one source of bacteremia.
Therefore, a prospective study of 200 patients undergoing cystoscopy was conducted to identify the incidence of bacteruria and factors associated with it, organisms involved and their antibiotic sensitivities.
Positive cultures were found in 21%.
The incidence was 64% in in-patients and 8% in out-patients.
Positive cultures were found in 12% of patients who received antibiotics and 29% who did not.
Four percent showed signs of bacteremia.
The cultures identified both Gram positive and negative organisms; multiple organisms grew in 22%.
Gram negative organisms were more common in in-patients.
Candida grew in 8%.
The Gram positive organisms were sensitive to ampicillin (92%), sulfatrimethoprim (75%) and cefazolin (60%); Gram negative to aminoglycosides (100%) and cefazolin (92%).
In view of the unpredictable and multiple organisms, it is recommended that pre-cystoscopy cultures be performed and specific antibiotic coverage be based on the sensitivities.
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322
| 3,774
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Septic pulmonary emboli. A rare cause of bilateral pneumothorax in drug abusers.
An intravenous drug abuser presented with bilateral pneumothorax.
This is a previously unreported (to our knowledge) complication of septic pulmonary emboli secondary to right-sided endocarditis.
This possibility must be considered in the differential diagnosis of pneumothorax in drug addicts.
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323
| 8,306
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Chlamydial infections.
Chlamydia trachomatis is a unique intracellular parasite that causes a number of common sexually transmitted disease syndromes, including nongonococcal urethritis in both men and women, epididymitis in men, and pelvic inflammatory disease in women.
Infants exposed at delivery are at risk for the development of conjunctivitis and pneumonia.
There is strong evidence that Chlamydia is a cause of obstructive infertility and ectopic pregnancy in women.
It appears that these complications result from the chronic inflammatory response and secondary scarring that are elicited by long-term asymptomatic or nearly asymptomatic fallopian tube infections.
Because treatment with tetracycline, doxycycline, or erythromycin is simple, effective, and inexpensive, major efforts should be put into identifying asymptomatic young women through screening of the subpopulations at highest risk.
These include sexually active adolescent women and older women who are not monogamous.
Blacks are at higher risk than other ethnic groups for infection.
The cost of diagnosing chlamydial infection has decreased with the introduction of new nonculture diagnostic tests.
This should increase the availability of testing for screening purposes.
It is critical to remember that male sex partners of infected women must be treated; otherwise all efforts to prevent long-term complications by identifying and treating asymptomatic women are doomed to failure.
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324
| 4,340
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A clinical trial of topical terbinafine (a new allylamine antifungal) in the treatment of tinea pedis.
Twenty-three patients were enrolled in a randomized, double-blind trial of terbinafine 1% cream compared with placebo vehicle in the treatment of tinea pedis.
Of the 20 patients who were evaluated for efficacy, 10 received terbinafine and 10 received placebo.
Except for the terbinafine-treated patients being an average of 11 years older than the patients receiving placebo and the median duration of disease being 6 weeks longer in the placebo group, the two groups were demographically and clinically similar.
Results of mycologic tests and clinical findings showed terbinafine to be significantly more effective than placebo in the treatment of tinea pedis.
Significantly more terbinafine-treated patients than placebo-treated patients showed conversion to negative culture and microscopy at end of therapy and a significant reduction in scored signs and symptoms.
Overall efficacy at follow-up (combined mycologic and clinical findings) was also significantly greater in the terbinafine group (78%) than in the placebo group (zero) (p less than 0.001).
Unexplained elevation of liver function test results was noted in three placebo-treated patients and in one terbinafine-treated patient, but these changes were not considered clinically relevant or drug related.
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325
| 2,592
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Lyme borreliosis in the severe combined immunodeficiency (scid) mouse manifests predominantly in the joints, heart, and liver.
The authors describe the histopathologic evolution of Lyme disease in severe combined immunodeficiency (scid) and normal C.B-17 and C57BL/6 mice inoculated with Borrelia burgdorferi.
Starting on day 7 after inoculation, all scid mice infected subcutaneously in the tail with a low-passage European tick isolate of B.
burgdorferi had clinical evidence of arthritis characterized by reddening and swelling of tibiotarsal joints.
Later on, other joints, ie, metatarsal and ulnacarpal joints were also affected.
The infection of scid mice resulted in a persistent spirochetemia and the development of a multisystem disease with chronic progressive inflammation of joints, heart, and liver.
Major histopathologic alterations included 1) severe joint lesions, characterized by the presence of hyperplastic inflamed synovial lining cells associated with the erosion and destruction of cartilage and/or bone; 2) pancarditis with infiltrations of mononuclear cells in the endocardium, myocardium, and pericardium; and 3) hepatitis with mononuclear cell infiltrations confined to the portal field and central vein, granulomatous reactions, and eventually the development of liver fibrosis.
In addition, smaller more confined lesions were found in kidneys, lung, brain, and striated muscle.
The inflammatory infiltrates in the various organs were associated mostly with Mac-1+ cells, largely monocytes and macrophages, as well as some polymorphonuclear leukocytes, but not B and T lymphocytes.
Infective spirochetes could be readily isolated from blood and joints and were found at the site of inoculum and the myocardium.
In contrast, subcutaneous inoculation of normal C.B-17 or C57BL/6 mice with spirochetes in general did not result in clinical signs of arthritis.
Only 10% to 20% of the C57BL/6 mice, but none of the C.B-17 mice, showed clinical evidence of oligoarthritis, which appeared not before day 36 after inoculation.
In general, the infection of normal mice resulted in minimal lesions in various organs, and no spirochetes could be visualized or reisolated from their tissues.
The data demonstrate that Lyme borreliosis may develop in mice in the absence of detectable specific B and T cells and thus suggest an immunologic control of the disease in this species.
The scid mouse model therefore can be used to define the components of the immune system responsible for the suppression and/or the progression of the disease.
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326
| 2,555
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Intraamniotic infection in the very early phase of the second trimester.
A total of 157 consecutive patients were studied in an effort to examine prospectively the incidence of asymptomatic intraamniotic infection in the early phase of the second trimester.
All patients were referred for amniotic fluid karyotyping.
In addition, the amniotic fluids were examined for Gram stain and were directly cultured on blood agar and MacConkey agar as well as in thioglycollate broth.
We found positive amniotic fluid cultures in eight cases (5.09%); however, results of Gram stain examinations were negative in all amniotic fluid samples.
The data indicate that there is no correlation between white blood cells in the amniotic fluid and positive amniotic fluid culture results.
Only one pregnancy with positive amniotic fluid culture resulted in a septic abortion.
Therefore we can suggest that intraamniotic infection can exist early in pregnancy, even with intact membranes, and in most cases without any clinical symptoms.
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327
| 5,925
|
Endocarditis due to ampicillin-resistant nontyphoid Salmonella: cure with a third-generation cephalosporin.
A case of ampicillin-resistant salmonella bacteremia complicated by endocarditis in a 78-year-old man is presented.
Previous rheumatic valvular heart disease and the lack of response to initial treatment with chloramphenicol prompted us to consider this diagnosis.
There was a good clinical response after treatment with ceftriaxone alone and corresponding improvement on the echocardiogram.
This case demonstrates the possible endovascular complications of salmonella bacteremia in elderly people and that endocarditis should be included among the invasive infections due to ampicillin-resistant Salmonella that could potentially be treated with the newer cephalosporins.
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328
| 3,412
|
Effect of granulocyte colony-stimulating factor on neutropenia due to chemotherapy for non-Hodgkin's lymphoma.
The authors administered recombinant human granulocyte colony-stimulating factor (rhG-CSF) to 16 patients with advanced non-Hodgkin's lymphoma treated with combination chemotherapy.
Groups of three to five patients were treated with 50, 100, 200, and 400 micrograms/m2 per day of rhG-CSF by intravenous infusion for 14 days, beginning 3 days after chemotherapy.
There was a strong linear relationship between the dose and the area under the curve over this dose range.
The rhG-CSF was rapidly cleared from serum, with a mean half-life of 5.97 hours for the second phase (t1/2).
In patients treated with a dose of more than 100 micrograms/m2 per day, the duration of neutropenia (P less than 0.01) and the duration of fever (P less than 0.05) were significantly decreased.
The rhG-CSF was well tolerated and the only clinical observation that appeared relating to rhG-CSF administration was slight bone pain.
This study strongly suggests that an optimum dose of rhG-CSF in patients after chemotherapy is 100 to 200 micrograms/m2.
Our study shows that rhG-CSF is a clinically useful drug for patients treated with myelosuppressive chemotherapy.
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C01
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329
| 5,637
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Case-control study of Cryptosporidium parvum infection in Peruvian children hospitalized for diarrhea: possible association with malnutrition and nosocomial infection.
A retrospective, hospital-based case-control study was used to investigate whether there were any clinical characteristics that could distinguish Cryptosporidium parvum-infected children with diarrhea from other non-C.
parvum-infected children with diarrhea.
Ten percent (24 of 248) of children admitted to a rehydration ward at Cayetano Heredia University Hospital, Lima, Peru, were infected with C.
parvum.
The 24 patients infected with C.
parvum (cases) were matched to an equal number of noninfected patients (controls).
C.
parvum-infected patients were more likely to be malnourished than were children without this infection (P less than 0.05).
Also nosocomial infection caused by C.
parvum occurred in three severely malnourished patients, two of whom died.
No other clinical or laboratory characteristics were found that would distinguish children with diarrhea caused by C.
parvum from other children with diarrhea.
In children hospitalized for diarrhea C.
parvum infection occurs most frequently in malnourished children.
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C01
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330
| 3,790
|
Yersinia enterocolitica abscess of the transverse colon. Report of a case.
Yersinia enterocolitica abscess of the bowel is a rare entity.
Only five cases have previously been reported--none in the surgical literature.
A unique presentation for Yersinia infection, abscess of the transverse colon, is described, and the literature of Y.
enterocolitica intestinal perforation and abscess is reviewed.
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331
| 6,855
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Air contamination in open heart surgery with disposable coveralls, gowns, and drapes.
The effect of a polypropylene coverall, replacing shirt and trousers, combined with sterile laminated gowns and drapes compared with an all-cotton system was studied in regard to the dispersion of bacteria and particles in a conventionally ventilated operating theater.
The operations carried out were open heart procedures in 30 adult patients.
Blood agar sedimentation plates were placed in the operative, anesthesia, and perfusion areas.
The mean sedimentation values during 1 hour after the start of operation were as follows in the laminate group: 63 colony-forming units (cfu)/m2 in the operative area; 77 cfu/m2 in the anesthesia area; and 143 cfu/m2 in the perfusion area.
The corresponding figures in the cotton group were 350 cfu/m2, 364 cfu/m2, and 437 cfu/m2, respectively (p less than 0.0002).
At the beginning of the operation, the mean values noted for colony-forming units in the air at the operative site were 8.0 cfu/m3 in the laminate group and 31 cfu/m3 in the cotton group.
One hour later, the values were 10 cfu/m3 and 22 cfu/m3, respectively (p less than 0.0002).
At the end of the operation, the number of particles 5 microns or larger in the air at the operative site was 278/m3 in the laminate group and 592/m3 in the cotton group.
It is concluded that the use of a polypropylene coverall and laminated gowns and drapes significantly reduces the particle and bacterial contamination of the air and the bacterial sedimentation during cardiac operations.
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C01
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332
| 8,520
|
Perirenal candidial abscess.
Perirenal candidial abscesses are rare, with few well-documented cases in the literature.
We describe a case of a perinephric abscess treated with amphotericin B and nephrectomy.
|
C01
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333
| 2,382
|
Clostridium difficile invasion and toxin circulation in fatal pediatric pseudomembranous colitis.
The direct involvement of Clostridium difficile in the lesional tissue of pseudomembranous colitis has not been demonstrated; the organism's effects have been assumed to be strictly toxin mediated.
Because C.
difficile cytotoxin may be found incidentally in the intestinal lumina of asymptomatic infants, the role of the organism in a variety of pediatric intestinal diseases is uncertain.
The authors studied seven cases of fatal pediatric pseudomembranous colitis in which the presence of C.
difficile was uniformly demonstrable in lesional tissues with the use of both an intestinal spore stain and a specific immunostain.
The patients had either underlying Hirschsprung's disease or hematologic malignancy; the striking pathologic features peculiar to these patients were altered mucosal mucin and immunologic barriers in the former group and neutropenia in the latter.
Two patients had demonstrable circulating cytotoxin in serum or ascitic fluid, and C.
difficile was identified invading colonic mucosa or submucosa.
Such phenomena did not occur in control pediatric patients with multiple other intestinal lesions.
Altered host factors may be responsible for the intestinal invasion of C.
difficile and its systemic toxin circulation in cases of fatal pediatric pseudomembranous colitis.
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C01
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334
| 3,622
|
Total knee arthroplasty in diabetes mellitus.
A retrospective study was done of 59 total knee arthroplasties (TKAs) in 40 patients diagnosed with diabetes mellitus.
The overall infection rate was 7%, with an overall revision rate of 10% and an average follow-up period of 4.3 years.
Wound complications were present in 12% of the TKAs.
The rate of deep joint infections in diabetic patients was statistically higher than the reported incidence of sepsis in nondiabetic patients.
Therefore, maximum precautions should be taken for diabetic patients having TKA to minimize both wound complications and joint sepsis.
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C01
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335
| 838
|
Effect of sample volume on yield of positive blood cultures from adult patients with haematological malignancy.
Six hundred and sixteen blood samples from patients with haematological malignancy were each distributed equally among three identical cells in a Malthus Microbiological Growth Analyser.
The mean (SD) volumes inoculated into sets in which one, two, or three of the three bottles were positive were 37.7 (10.1) ml, 37.4 (12.9) ml, and 37.7 (10.5) ml, respectively.
Overall, clinically important organisms were isolated from one bottle only with 18 cultures, from two bottles only with 19 cultures, and from all three bottles in a set with 104 cultures.
If the yield from a single bottle inoculated with a mean volume of 12.6 ml blood is taken as 100%, the yield from 25.2 ml in two bottles was 110.7% and the yield from 37.7 ml in three bottles was 115.6%.
The increased yield from increased volume was considerably lower than that reported from unselected groups of patients, which suggests that the magnitude of bacteriaemia is greater in patients with neutropenia.
The isolation of infecting organisms from the blood of patients with neutropenia is, however, particularly important in directing chemotherapy and consequently 45 ml blood samples from these patients continue to be requested.
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C01
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336
| 9,890
|
Tampon absorbency, composition and oxygen content and risk of toxic shock syndrome.
Tampon use has been identified as a major risk factor for toxic shock syndrome, although the etiologic role of tampons is not clearly understood.
Two epidemiologic studies conducted to date have reported an association between tampon absorbency and risk of toxic shock syndrome.
This finding is not corroborated by laboratory studies, however, which have suggested that absorbency may be a marker for other characteristics that create an environment conductive to the elaboration of toxic shock syndrome toxin 1.
We used data from the previously reported Tri-state study to estimate simultaneously the effects of tampon oxygen content, absorbency and chemical composition.
Although the data are sparse, oxygen content was more strongly associated with risk of toxic shock syndrome than either absorbency or chemical composition.
The results suggest that it may be possible to develop a highly absorbent tampon that is not associated with a high risk of toxic shock syndrome.
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C01
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337
| 9,240
|
Increased septic complications with three-drug sequential immunosuppression for cadaver renal transplants.
In 152 renal transplant recipients, the results of immunosuppression with three-drug sequential (Minnesota antilymphocyte globulin, prednisone, azathioprine, and cyclosporine) immunosuppression (n = 107) were compared with those of a two-drug sequential protocol (Minnesota antilymphocyte globulin, prednisone, and cyclosporine) that excluded azathioprine (n = 45).
The study groups were comparable by age, sex, etiology of renal failure, incidence of diabetes, and degree of HLA matching.
Patient survival at 1 year was not significantly different in the two groups (two drug, 93% versus three drug, 86%; p = 0.19).
One-year graft survival was superior in the two-drug group (two drug, 93% versus three drug, 75%; p = 0.02).
Analysis of primary transplants only (n = 116) yielded the same results.
During the first year, the serum creatinine level remained stable in both groups.
As expected, the three-drug therapy group had significantly more bacterial and viral infections.
For low-risk primary cadaveric renal transplants, two-drug sequential immunosuppression is superior.
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C01
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338
| 3,043
|
Reoperative surgery for the morbidly obese. A university experience.
Patients who undergo surgery for morbid obesity are often subjected to reoperation for a wide array of indications.
To evaluate outcome following revisional procedures, we reviewed the records of 32 such patients treated at UCLA between April 1986 and May 1989.
Twenty-five women (78%) and 7 men (22%) with a mean age of 44 years underwent 76 reoperations (2.4 per patient) for complications of prior obesity surgery.
Indications for initial surgical revision consisted primarily of metabolic derangements (12 patients) and weight-related problems (11 patients).
In contrast, indications for the patients' final surgical procedure were commonly for bowel obstruction (41%), intra-abdominal sepsis (12%), and gastrointestinal bleeding (6%).
Following initial revision, 23 patients (71.8%) required further surgery for major complications and four patients died (12.5%).
While initial revisions are frequently indicated for metabolic problems, final reoperations are more frequently undertaken for urgent, life-threatening complications.
Revisional procedures for morbid obesity should be carefully considered, and the potential for major complications and/or death should be weighted heavily against proposed benefits.
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C01
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339
| 2,813
|
Toxic shock syndrome after inguinal hernia repair. Report of a case with patient survival.
A 40-year-old man developed fulminant multisystem failure several days after elective repair of an inguinal hernia.
Toxic shock syndrome (TSS) was diagnosed.
There was, however, no evidence of wound infection at the time of multisystem failure.
Only later in his hospital course did the wound drain.
Staphylococcus aureus was cultured from the wound and was the presumed etiologic agent in the patient's life-threatening illness.
The patient recovered fully with supportive care, antibiotics, and surgical debridement of the inguinal hernia site.
This case is discussed in the context of existing literature on the toxic shock syndrome.
The site of infection is typically nonsuppurative, but the systemic manifestations are typically life threatening.
The responsible organism is commonly believed to be a strain of S.
aureus that expresses a toxin (TSS toxin-1) that effects multisystem failure, but which also diminishes the local inflammatory response and explains the benign appearance of the wound.
Although this is a rare clinical entity, elective surgical procedures complicated by fatal TSS have been reported.
Surgeons should understand this disease and the management necessary to avert mortality.
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C01
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340
| 7,871
|
Cardiac involvement in AIDS.
Cardiac involvement in AIDS may occur at any stage of HIV disease and may manifest as congestive cardiomyopathy, potentially lethal arrhythmia, or pericardial effusion and tamponade.
The heart may be affected by nearly all of the opportunistic infections and many of the malignancies associated with the syndrome.
Although often clinically unobtrusive, cardiac lesions may be important in the pathogenesis of significant clinical symptoms and play an often unrecognized role in the prognosis and natural history of AIDS.
|
C01
|
341
| 5,910
|
Bacterial tracheitis: report of eight new cases and review.
Bacterial tracheitis, previously referred to as nondiphtheritic laryngitis with marked exudate, was commonly discussed in pediatric textbooks before 1940.
It seemed to disappear as a clinical entity after that time, but it has been recorded with increasing frequency in the pediatric literature since 1979.
We describe eight new cases and review 110 previously described cases.
The clinical course consists of a prodromal upper respiratory illness with stridor, fever, and a variable degree of respiratory distress.
Unlike patients with croup, patients with bacterial tracheitis do not respond to aerosolized racemic epinephrine.
Most patients require endotracheal intubation; some require tracheostomy.
Reported complications include pneumonia, pneumothorax, formation of pseudomembranes, toxic shock syndrome, and cardiopulmonary arrest.
Bacterial tracheitis is a secondary bacterial infection following a primary viral respiratory infection.
The most common preceding viral infection is parainfluenza.
Staphylococcus aureus and Haemophilus influenzae are the predominant causes of bacterial tracheitis.
Secondary bacterial infection may occur as a result of tracheal mucosal injury or impairment of normal phagocytic function due to viral infection.
|
C01
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342
| 8,239
|
A comparison of rapid enzyme immunoassay tests for the detection of Chlamydia trachomatis cervical infections.
Two rapid enzyme immunoassay test kits were compared with culture for the detection of Chlamydia trachomatis endocervical infections.
Endocervical samples for C trachomatis culture and the two enzyme immunoassay tests were evaluated from 502 county health department and Planned Parenthood patients.
The prevalence of infection in this population was 12%.
Sensitivity and specificity of the Abbott TestPack Chlamydia were 51.7% and 99.5%, respectively, and of the Kodak Surecell Chlamydia were 76.7% and 98.6%, respectively.
The positive and negative predictive values for TestPack were 93.9% and 93.8%, and for Surecell were 88.5% and 96.9%, respectively.
Additionally, an in vitro investigation was used to evaluate whether typical office staff (physicians, nurses, medical technicians, receptionists, and radiology technicians) were able to perform competently the tests in each kit.
Office personnel tested 12 dilutions of a C trachomatis stock sample or negative control sample as unknowns for each kit in the in vitro investigation.
There were no differences among office staff in performance when compared for each test kit.
Selective use of these enzyme immunoassay tests for high-risk patients in a family practice population that has a high prevalence of patients with C trachomatis infection may be helpful when rapid test results are required and cultures are not feasible.
After appropriate training, most physician office personnel were equally able to perform the enzyme immunoassay tests evaluated.
|
C01
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343
| 5,632
|
The use of prophylactic furazolidone to control a nosocomial epidemic of multiply resistant Salmonella typhimurium in pediatric wards.
The nosocomial spread of enteric pathogens is often difficult to control in overcrowded pediatric wards.
During 1983 and 1984, despite cohorting of patients and enforced hand washing, more than 200 cases of nosocomial multiply resistant Salmonella typhimurium phage type R-9 were observed on two adjacent pediatric wards.
Most cases occurred during the summer months.
After 19 new cases were detected early in the summer of 1985, oral administration of furazolidone throughout their entire hospital stay (2.5 mg/kg twice daily) was recommended for all subsequently hospitalized infants.
Among the 114 (65%) infants who were appropriately treated, only one additional case (1%) was detected.
In contrast 11 (19%) cases occurred among the 59 infants who were inappropriately treated: 5 of 35 (14%) of those who were not treated and 6 of 24 (25%) in whom treatment with furazolidone was delayed greater than 24 hours (P less than 0.001 between the appropriately and inappropriately treated groups).
In pediatric wards where infection control measures cannot be optimally applied, prophylactic furazolidone administration may be helpful in preventing the spread of enteric pathogens.
|
C01
|
344
| 5,917
|
Spectrum of Cryptococcus neoformans infection in 68 patients infected with human immunodeficiency virus.
Sixty-eight patients infected with human immunodeficiency virus (HIV) and Cryptococcus neoformans who presented to three major medical centers in New Orleans, Louisiana, were studied retrospectively.
In patients with meningitis the most common presenting symptoms were fever and headache.
Those without central nervous system involvement generally had an isolated pulmonary infection due to C.
neoformans and presented with cough and dyspnea.
CSF parameters were abnormal in 41% of patients, and the India ink preparation was positive in 88% of patients with cultures of CSF positive for C.
neoformans.
The overall median survival time for the 47 patients who died was 5 months, with a range of 0-22 months.
Of the 27 patients who received maintenance therapy with amphotericin B, two (7%) relapsed.
The only factors found to be associated with a poor prognosis were abnormal computed tomography of the head and altered mental status on presentation.
C.
neoformans infections in HIV-infected patients remain difficult to treat and have a poor prognosis.
|
C01
|
345
| 5,256
|
Buruli ulcer in Benin
In a study of 28 patients with Mycobacterium ulcerans infection (Buruli ulcer) in Oinhi, Benin, it became clear that the disease can regress as well as progress, and that patients can have lesions of different stages simultaneously.
A system of disease staging was introduced (I = subcutaneous nodule; II = cellulitis; III = ulceration; IV = scar formation).
Research to find an effective treatment for this crippling disease is urgently needed.
|
C01
|
346
| 3,257
|
Intraocular pressure changes and postural changes of intraocular pressure in experimentally induced Hansen's disease of rhesus, mangabey, and African green monkeys.
In our long term evaluation of patients with Hansen's disease we have frequently found reduction of their intraocular pressure.
Furthermore, we noted changes in their intraocular pressure on change of posture.
To determine if these changes have any significance we measured the intraocular pressures of 24 experimentally infected and 39 control monkeys in both sitting and reclining positions.
We found significant reduction of intraocular pressure in 66.7% compared with controls in the sitting position, and a significant increase in intraocular pressure in 79% when checked first in the sitting then in the reclining position.
We offer a possible pathophysiological explanation as to why the changes occur.
|
C01
|
347
| 5,670
|
Health assessment of the early adolescent. Challenges and clinical issues.
Although early adolescence spans only 4 years, it is a critical time in the life of a young person in forming opinions and selecting options.
Specific attention to the growing and changing needs of this population is imperative if their health status is to improve.
|
C01
|
348
| 6,739
|
The inactivation of antithrombin III by serum elastase in patients with surgical infections.
The relationship between serum elastase and antithrombin III was determined in septic surgical patients as a possible mechanism for intravascular thrombosis and hypercoagulability during sepsis.
Eighteen patients with surgical infections and elevated white blood cell counts had their blood assayed daily for white blood cell count, serum elastase, and antithrombin III, until the patient's white blood cell count returned to normal.
Antithrombin III was significantly lower (0.87%) when elastase was above the normal range (greater than 14.2 micrograms/ml).
Elastase was significantly higher (30.6 micrograms/ml), when antithrombin III was less than normal.
These data indicate that elevated serum elastase is associated with a significant reduction in circulating antithrombin III.
Stimuli that increase serum elastase, i.e.
surgery, trauma, or sepsis may promote intravascular thrombosis by the inhibition of antithrombin III at the blood-endothelial cell interface.
|
C01
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349
| 5,878
|
Antibiotic therapy for common infections.
Several important points regarding the treatment of urinary tract infections should be made.
Single-dose and short-course antibiotic therapy is appropriate only for women with acute bacterial cystitis due to E.
coli.
Studies comparing single-dose to full-course therapy have not been sufficiently designed to draw valid statistical conclusions, and only TMP/SMX is recommended at this time.
Recurrent UTI in women is almost always due to reinfection, which is best managed by prophylactic antibiotics.
Acute bronchitis and acute exacerbations of chronic bronchitis are often due to viral infections, and therefore antibiotic therapy is not always needed.
In acute exacerbations of chronic bronchitis, the clearest success rates for antibiotic therapy have been in patients, who have all three of the following symptoms: increased dyspnea, increased sputum production, and sputum purulence.
Mupirocin is an important addition to the agents used to treat bacterial skin infections due to streptococcal and staphylococcal strains.
In impetigo, mupirocin has been demonstrated to be as effective or superior to oral erythromycin.
In prostatitis, data on the fluoroquinolones appears impressive, but further comparative trials are needed.
They may become first-line, empiric therapy.
The newer oral antibiotics are not recommended as initial, empiric therapy in the outpatient management of common infections, with the possible exception of the treatment of prostatitis.
These newer agents may be more important in the treatment of recurrent or resistant infections.
|
C01
|
350
| 3,735
|
Subpleural mononuclear cell infiltration. Significance in the differential diagnosis of pleuritis showing nonspecific histologic findings.
To determine if patients who had lymphocyte-rich pleural effusion and a pleural biopsy without any specific findings could be histopathologically differentiated between those with tuberculous and nontuberculous pleuritis, we histologically re-evaluated the pleural biopsies of all patients whose pleural effusion was predominant with lymphocytes and contained no malignant cells.
A total of 40 patients with a nonspecific histologic findings of pleural biopsy specimen were categorized based on their ultimate diagnosis as having tuberculous (n = 15), carcinomatous (n = 10) or nontuberculous, benign pleuritis (n = 15).
The pleural biopsy specimen of patients with nontuberculous, benign pleuritis frequently showed a band-like infiltration of mononuclear cells in the subpleural adipose tissue with minimal pleural inflammatory infiltrate (10 out of 15 patients), while the same finding was infrequent in those with tuberculous pleuritis (0 out of 15, p = 0.0001) and pleuritis associated with carcinoma (three out of 10, p = 0.082).
Based on these results, the presence of band-like infiltration of mononuclear cells in the subpleural adipose tissue with minimal pleural inflammatory infiltrate in pleural biopsy specimens of patients with lymphocyte-rich pleural effusion suggests that the pleuritis is nontuberculous in its nature.
|
C01
|
351
| 5,376
|
A randomized, prospective field trial of a conjugate vaccine in the protection of infants and young children against invasive Haemophilus influenzae type b disease
BACKGROUND.
Haemophilus influenzae type b is the leading cause of invasive bacterial disease in young children.
The capsular polysaccharide vaccine does not protect children at greatest risk (those under the age of 18 months), but a polysaccharide-protein conjugate vaccine has proved to be more immunogenic in this age group.
METHODS.
We enrolled 114,000 infants in Finland in an open, prospective, randomized trial of a H.
influenzae type b capsular polysaccharide-diphtheria toxoid conjugate vaccine (polyribosylribitol phosphate-diphtheria toxoid [PRP-D]).
Children born on odd-numbered days were vaccinated at the ages of 3, 4, 6, and 14 to 18 months; those born on even-numbered days formed the control group and received the same vaccine at the age of 24 months.
RESULTS.
After three doses of the vaccine there were 4 cases of verified bacteremic H.
influenzae type b disease in the group receiving early vaccination, as compared with 64 cases in the control group, between the ages of approximately 7 and 24 months.
The protective efficacy of the vaccine was thus 94 percent (95 percent confidence interval, 83 to 98).
No serious adverse effects were reported.
The immune response to the conjugate vaccine was characteristic of a T-cell-dependent response when studied in a cohort of 120 infants.
The primary immunization series resulted in a geometric mean concentration of anticapsular antibody of 0.53 micrograms per milliliter at the age of seven months, and the fourth dose evoked an anamnestic response, with a mean antibody concentration of 45.22 micrograms per milliliter.
CONCLUSIONS.
A new conjugate vaccine consisting of the capsular polysaccharide of H.
influenzae type b covalently linked to a protein carrier (PRP-D), administered to infants beginning at the age of 3 months, is highly effective in protecting young Finnish children (7 to 24 months old) against invasive H.
influenzae type b infections.
|
C01
|
352
| 8,145
|
Lack of association between medication use and the presence or absence of bacteriuria in elderly women.
This study was undertaken to determine if there is an association between medication use and the presence or absence of bacteriuria in elderly ambulatory women.
Of 198 women who participated in three urine culture surveys (every 6 months) during the 18-month study period, 66 (34.4%) had bacteriuria on at least one survey.
Both univariate and multivariate analyses for the demographics, age, place of residence, and medication use (by drug class) revealed that only place of residence had a significant association with the presence or absence of bacteriuria.
In this regard, bacteriuric subjects more commonly resided in the nursing home and less commonly lived in the apartment-house complex compared with nonbacteriuric subjects (P less than .05).
Therefore, this study demonstrates that in elderly ambulatory women, medication use does not appear to be associated with the presence or absence of bacteriuria.
|
C01
|
353
| 6,829
|
Outcome after acute osteomyelitis in preterm infants.
Eight cases of skeletal infection in preterm infants were studied.
All the infants were systemically unwell, with polymorpholeucocytosis.
Diagnosis was by blood culture, and any radiographic changes were apparent at the time of presentation.
Infection was often multifocal, with sites around the knee being most commonly affected.
Staphylococcus aureus was the pathogen isolated in six of the eight cases; in these treatment with fusidic acid was effective and well tolerated, even at doses that were less than the recommended therapeutic minimum.
Even with prompt diagnosis and aggressive treatment orthopaedic sequelae are common.
|
C01
|
354
| 335
|
Superficial cultures in neonatal sepsis evaluations. Impact on antibiotic decision making.
The authors performed a retrospective analysis of neonatal superficial cultures and their effect on antimicrobial decision making during a nine-month period at Nashville General Hospital.
They obtained and reviewed charts of infants (n = 66) having paired superficial (skin and/or gastric aspirate) and deep (blood and cerebrospinal fluid) cultures for the evaluation of early-onset sepsis.
Superficial cultures were positive for pathogens (any streptococcus or enteric gram-negative) in 15% (10/66) of cases.
Antimicrobial decision making was affected in only one of these cases, and in a seemingly inappropriate manner.
In summary, there was no evidence or review that superficial cultures used in sepsis evaluation influenced physician antimicrobial decision making; in one case they may have led to unnecessary antibiotic exposure.
|
C01
|
355
| 2,569
|
Oral contraceptives and myocardial infarction.
The risk of myocardial infarction in contraceptive users is limited to women over 35 years of age who smoke.
The cause of myocardial infarction in oral contraceptive users is thrombotic and not atherosclerotic.
Minor lipid changes have no clinical relevance to myocardial infarction in contraceptive pill users and do not appear to increase coronary plaques.
|
C01
|
356
| 7,418
|
Treating systemic fungal infections in AIDS patients. Prolonging life against the odds.
Fungal infections have become one of the major causes of death among immunocompromised patients, particularly patients with AIDS.
Accurate and quick diagnosis is difficult; therefore, empirical therapy is often necessary.
This scenario is complicated by the fact that most antifungal agents are toxic at the doses used or relatively ineffective against deep-seated mycoses.
Because the population of AIDS patients is increasing, physicians will be faced more often with the management of systemic fungal infections.
Despite the current bleak prognosis for these patients, several new antigen detection tests are being developed and triazole agents are proving to be effective and less toxic than their predecessors.
Many cases of systemic mycoses do result in mortality, but appropriate treatment can both prolong life and improve its quality.
|
C01
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357
| 692
|
Review of hepatic imaging and a problem-oriented approach to liver masses.
We believe that imaging of the liver is complicated.
The sporadic appearance of incidental benign lesions and variability in scanning techniques, equipment and artifacts add difficulties to the evaluation of liver masses.
Therefore we emphasize the need to define the problem for which the patient is being imaged.
This information helps in choosing the procedure of choice and the technique needed to give the most expedient, accurate answer.
This will also help apply the lowest risk and most cost-efficient care.
Imaging algorithms vary depending on the suspected pathological conditions.
Dynamic bolus-enhanced CT is the modality of choice in most situations.
Tc99m sulfur-colloid liver-spleen scans are helpful in patients with suspected FNH, and Tc99m-tagged-RBC-SPECT scans are recommended to confirm cavernous hemangiomas.
Cysts are easily confirmed by US.
Although MRI is competitive with CT, it has not become a primary modality because of cost, availability, patient selection and variability of scanner capabilities among the many manufacturers and models.
It is hard to predict what future development of imaging techniques will bring.
Many feel that significant advances have plateaued.
Time and money will more likely be concentrated on improving image resolution, speed of scanning and ability to transfer this information to sites outside of the radiology department.
In addition to faster scanning, we expect to soon have available safe intravenous and enteric contrast agents for MRI.
Certainly this will lead to a new round of investigations to compare MRI with CT scanning.
|
C01
|
358
| 4,634
|
Restriction endonuclease analysis of total cellular DNA of Aspergillus fumigatus isolates of geographically and epidemiologically diverse origin.
No typing system exists for Aspergillus fumigatus, though isolates are distinguishable by phenotypic characteristics.
DNA was prepared by lysis of protoplasts, followed by deproteination, phenolchloroform extraction, and dialysis.
DNA prepared was of uniform size and exceeded 60 kb.
After digestion with SalI and XhoI endonucleases, DNA was electrophoresed, stained, and photographed.
Differences in the mobilities of 10- to 50-kb bands distinguished isolates.
Reproducibility was shown by repeated preparations and animal passage.
By use of a proposed notation system for describing restriction fragment length polymorphism patterns, 31 epidemiologically characterized isolates from three continents revealed 24 patterns (DNA types).
Three DNA types were represented by 3 isolates each and 1 DNA type by 2 isolates; 20 types were unique.
Two groups of 3 isolates of the same DNA type were from Stanford University Hospital.
One patient isolate from Stanford was the same DNA type as a sewage isolate from New Jersey.
Another Stanford isolate was the same as a German isolate.
These observations indicate widespread dispersal of some clones and restricted locales for others.
Paired isolates from airway fluids of three patients had two DNA types in each.
Restriction endonuclease typing shows promise for investigating the epidemiology and ecology of A.
fumigatus.
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C01
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359
| 685
|
Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: results of a double-blind, placebo-controlled trial.
Eighty cirrhotic patients who had recovered from an episode of spontaneous bacterial peritonitis were included in a multicenter, double-blind trial aimed at comparing long-term norfloxacin administration (400 mg/day; 40 patients) vs.
placebo (40 patients) in the prevention of spontaneous bacterial peritonitis recurrence.
At entry, both groups were similar with respect to clinical and laboratory data, ascitic fluid protein and polymorphonuclear concentrations, number of previous episodes of spontaneous bacterial peritonitis and causative organisms of the index spontaneous bacterial peritonitis.
Norfloxacin administration produced a selective intestinal decontamination (elimination of aerobic gram-negative bacilli from the fecal flora without significant changes in other microorganisms) throughout the study in six patients in whom the effect of norfloxacin on the fecal flora was periodically assessed.
Fourteen patients from the placebo group (35%) and five from the norfloxacin group (12%) developed spontaneous bacterial peritonitis recurrence during follow-up (chi 2 = 5.97; p = 0.014) (mean follow-up period = 6.4 +/- 0.6 mo; range = 1 to 19 mo).
Ten of the 14 spontaneous bacterial peritonitis recurrences in the placebo group and only one of the five spontaneous bacterial peritonitis recurrences in the norfloxacin group were caused by aerobic gram-negative bacilli (chi 2 = 8.87; p = 0.0029).
The overall probability of spontaneous bacterial peritonitis recurrence at 1 yr of follow-up was 20% in the norfloxacin group and 68% in the placebo group (p = 0.0063) and the probability of spontaneous bacterial peritonitis recurrence caused by aerobic gram-negative bacilli at 1 yr of follow-up was 3% and 60%, respectively (p = 0.0013).
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C01
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360
| 356
|
Catheter-related sepsis: prospective, randomized study of three methods of long-term catheter maintenance.
We studied the infectious risk of different methods of managing vascular catheters during long-term use.
Consecutive surgical ICU patients requiring triple lumen catheters, pulmonary artery catheters, or arterial catheters for greater than 7 days were prospectively randomized to one of three management groups: a) percutaneous (PERC) puncture with every 7-day catheter change at a new site, b) no weekly change (NWC) with a new site when changed, or c) guidewire exchange (GWX) with every 7-day catheter change at the same site.
In all groups, a catheter change was mandatory for a positive blood culture, skin site infection, or sepsis without a likely source.
Cultures were obtained when clinically indicated and at the time of every catheter change.
Catheter-related sepsis (CRS) was defined as a positive blood culture and catheter culture with the same organism.
A total of 112 patients met evaluation criteria.
There were no intergroup differences in age, primary diagnosis, severity of injury or illness, number of study days, number of protocol violations, route of catheterization, number of catheters present/patient day, catheter sepsis rate, or bacteremia rate.
The NWC group demonstrated an increased number of days/catheter, fewer catheter/subcutaneous tract segment cultures/patient, and a reduced incidence of catheter tip colonization.
These results occurred in a setting where the number of CRS episodes/patient was 0.17 for GWX, 0.22 for PERC, and 0.16 for NWC.
We conclude that there is no difference in infectious risk between these three methods of long-term catheter management.
The method with the least complications and expense should be used.
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C01
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361
| 4,718
|
Another hazard of ear syringing: malignant external otitis.
A case of malignant external otitis is presented.
This occurred in a healthy 72-year-old non-diabetic, non-immuno-compromised man after ear syringing.
The infection was treated with oral ciprofloxacin for eight weeks with complete resolution.
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C01
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362
| 6,024
|
Left ventricular pseudoaneurysm complicating mitral valve replacement in a 4-year-old child with acute bacterial endocarditis.
A 4-year-old child with acute bacterial endocarditis required mitral valve replacement.
A left ventricular pseudoaneurysm developed following surgery.
The etiology and diagnosis of this complication are discussed.
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C01
|
363
| 3,718
|
Ringer's acetate and dextran-70 with or without hypertonic saline in endotoxin-induced shock in pigs.
The effects of Ringer's acetate, 6% dextran-70, 7.5% NaCl, and the combination of 7.5% NaCl and dextran-70 were tested in resuscitation from endotoxin shock induced by continuous iv infusion of Escherichia coli endotoxin in pigs.
After about 3 h, a reproducible shock state was achieved and treatment was started, governed by the left atrial pressure.
The hypertonic solutions (7.5% NaCl and 7.5% NaCl in dextran-70) did not show any overall advantages over the isotonic solutions (Ringer's acetate and dextran-70).
Only transient beneficial hemodynamic effects lasting less than 30 min after infusion were seen.
When dextran-70 was administered, cardiovascular function was markedly improved and oxygen delivery (DO2) and survival were significantly higher compared with the crystalloid groups (Ringer's acetate and 7.5% NaCl).
Administration of large amounts of Ringer's acetate resulted in an immediate deterioration of pulmonary function.
It was difficult to elevate left atrial pressure or even to keep it at baseline level, and cardiac index was only transiently increased.
The overall result was a deterioration of DO2 and poor survival compared with the dextran-70 treated pigs.
We conclude that dextran-70 is superior to Ringer's acetate in resuscitation from endotoxin-induced shock in pigs.
Furthermore, we found no role for the use of hypertonic saline, alone or in combination with dextran, in the treatment of this type of prolonged endotoxin shock.
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C01
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364
| 306
|
The value of indium 111 leukocyte scanning in the evaluation of painful or infected total knee arthroplasties.
Evaluation of painful total knee arthroplasties (TKAs) for infection can be difficult.
Indium 111 (111In) leukocyte bone scanning provides a minimally invasive technique for evaluation of possible infection.
Thirty-eight patients with a painful TKA who had surgical exploration after 111In leukocyte scanning were reviewed.
The scan had an accuracy of 84%, a sensitivity of 83%, and a specificity of 85%.
The 111In leukocyte scans must be interpreted in conjunction with the clinical evaluation of the patient because they are less accurate for study of TKAs than of total hip arthroplasties.
|
C01
|
365
| 4,350
|
Leprotic involvement of peripheral nerves in the absence of skin lesions. Case report and literature review.
In the absence of clinically apparent cutaneous lesions, primarily neural leprosy is uncommon.
Primarily neural leprosy presents clinically as a peripheral neuropathy that most frequently affects motor nerves and that occasionally involves sensory nerves as well.
The long incubation period for leprosy and its occurrence outside endemic areas often lead to delayed diagnosis.
We present a case of glove and stocking hypoesthesia, weakness of the flexor muscle of the right great toe, palpable thickening of the right popliteal nerve, and hypoesthetic but normal-appearing areas on the back, which developed in a Trinidadian immigrant who lived in Canada for 16 years.
A skin biopsy specimen obtained from a visibly normal but hypoesthetic area on the back demonstrated a few acid-fast bacteria in small dermal nerves, in arrector pili smooth muscle, and in rare perivascular histiocytes, associated with a sparse mixed inflammatory cell infiltrate.
The patient responded well to therapy with dapsone, rifampin, and clofazamine.
A classification and review of primarily neural leprosy is presented.
Our patient represents the first reported case of primarily neural borderline lepromatous leprosy in Canada.
|
C01
|
366
| 4,703
|
A 'silent' intracranial complication of frontal sinusitis.
Intracranial complications of frontal sinusitis, although rare today, do still develop despite widespread use of antibiotics.
We report a case which demonstrates how silently a frontal lobe abscess may present with subtle changes in mood and behaviour, with no focal neurological signs.
Diagnosis and management are discussed and a brief review of the incidence of intracranial complications of frontal sinusitis, mode of spread, clinical presentation, investigations, treatment and bacteriology is presented.
|
C01
|
367
| 5,923
|
Enterobacter bacteremia in pediatric patients.
Enterobacter has emerged as an important human pathogen, particularly in sick, hospitalized patients.
Previous reports of nonepidemic enterobacter bacteremia have focused on adult patients.
In this report, the epidemiologic factors, clinical characteristics, treatment, and outcome for 33 patients with enterobacter bacteremia in a large children's hospital during a 5-year period are reviewed.
The ratio of males to females was 1.2:1.
The patients' ages ranged from 2 days to 24 years, and 18 patients were less than 18 months old.
Twenty-two cases were nosocomially acquired; six were polymicrobial in nature.
Significantly underlying conditions were present in 32 patients.
The biliary tract and central venous catheters were the most common sources of bacteremia.
Two-thirds of patients had preceding antibiotic therapy.
The overall mortality was 24%; mortality attributable to enterobacter bacteremia was 18%.
Statistically significant differences in mortality were associated with an age less than 18 months (P = .031) or thrombocytopenia (P = .017); presence of fever was of borderline significance (P = .098).
Enterobacter bacteremia is an important cause of morbidity and mortality in pediatric patients.
|
C01
|
368
| 4,729
|
Adult immunization in a network of family practice residency programs.
A substantial proportion of morbidity and mortality associated with vaccine-preventable diseases occurs among adults.
Teaching residents about disease prevention is mandated in the curriculum guidelines for family practice programs.
A cooperative study among the Kansas City family practice residency programs was begun to look at immunization behaviors in these teaching programs.
A retrospective audit of medical records and a prospective survey of residents and faculty were performed.
From the medical records of 400 patients seen for health maintenance examinations, the frequency of tetanus-diphtheria immunizations recorded was 4.75%.
The pooled immunization rate recorded for pneumococcal vaccine was 25%, and for influenza vaccine, 24%.
Although 93% of respondents knew patients need tetanus-diphtheria immunization every 10 years, on a written questionnaire giving clinical examples, they were less likely to elect to immunize older patients eligible for tetanus-diphtheria vaccine.
The following immunization criteria were listed by respondents: for pneumococcal vaccine, age over 65 years (86%); for influenza vaccine, age over 65 years (85%), chronic diseases (69%), residence in a chronic care facility (7%), and being a health care worker (28%).
Educational interventions stressing the appropriate criteria and involvement of the patient are planned at the separate programs.
|
C01
|
369
| 5,962
|
Protection of mice against the Lyme disease agent by immunizing with recombinant OspA.
Lyme borreliosis is a tick-borne illness caused by Borrelia burgdorferi.
The gene for outer surface protein A (OspA) from B.
burgdorferi strain N40 was cloned into an expression vector and expressed in Escherichia coli.
C3H/HeJ mice actively immunized with live transformed E.
coli or purified recombinant OspA protein produced antibodies to OspA and were protected from challenge with several strains of B.
burgdorferi.
Recombinant OspA is a candidate for a vaccine for Lyme borreliosis.
|
C01
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370
| 5,393
|
Seizures and other neurologic sequelae of bacterial meningitis in children.
BACKGROUND.
Although the mortality rate among children with bacterial meningitis has decreased dramatically in recent decades, some patients are left with neurologic sequelae.
It has not been clearly established which features of the acute illness predict the chronic neurologic sequelae, including late seizures or epilepsy.
METHODS.
We followed 185 infants and children prospectively during and after acute bacterial meningitis.
The mean duration of follow-up was 8.9 years (range, 0.1 to 15.5).
During the first six years standard neurologic examinations were performed; telephone interviews were conducted thereafter.
RESULTS.
One month after meningitis, 69 children (37 percent) had neurologic abnormalities.
Many of these signs resolved within a year, leaving only 26 children (14 percent) with persistent deficits: 18 (10 percent) had only sensorineural hearing loss, and 8 (4 percent) had multiple neurologic deficits.
Thirteen children (7 percent) had one or more late seizures not associated with fever.
The presence of persistent neurologic deficits indicative of cerebral injury was the only independent predictor of late afebrile seizures (P less than 0.001).
CONCLUSIONS.
After bacterial meningitis only children with permanent neurologic deficits are at high risk for epilepsy.
Those with normal examinations after the acute illness have an excellent change of escaping serious neurologic sequelae, including epilepsy.
|
C01
|
371
| 6,339
|
"Spontaneous sump syndrome": Successful treatment by duodenoscopic sphincterotomy.
"Sump syndrome" is a rare complication of side-to-side choledochoenterostomy operations which develops in the distal, nonfunctioning limb of the common bile duct where lithogenic bile, gastrointestinal contents, and debris accumulate.
We report here a patient who developed spontaneous sump syndrome as a result of the formation of choledochoduodenal fistula, and who presented with multiple pyogenic liver abscesses.
The patient's symptoms and liver abscesses resolved completely after treatment by endoscopic sphincterotomy and antibiotics.
This case demonstrates that sump syndrome may occur spontaneously, that it can be a cause for pyogenic liver abscess formation, and that it may be treated effectively by endoscopic sphincterotomy.
|
C01
|
372
| 8,319
|
Sexually transmitted causes of gastrointestinal symptoms in homosexual men.
The possible etiologic agents that may cause gastrointestinal complaints in homosexually active men are multiple, and their diagnosis is complex.
This article presents a logical approach to the work-up and diagnosis of gastrointestinal complaints in homosexually active men and to discuss their treatment and disease intervention.
|
C01
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373
| 5,609
|
Apical closure of mature molar roots with the use of calcium hydroxide.
Calcium hydroxide may induce apical root closure in affected mature teeth as well as in immature teeth.
Once an apical hard tissue barrier is formed, a permanent root canal filling can be safely condensed.
Two cases are described in which calcium hydroxide induced apical root closure in mature molar teeth where the apical constriction was lost because of chronic inflammatory process.
|
C01
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374
| 642
|
Adjuvant antibiotic therapy in duodenal ulcers treated with colloidal bismuth subcitrate.
Persistence of Helicobacter pylori after duodenal ulcer healing is associated with high rates of ulcer relapse.
We compared colloidal bismuth subcitrate alone with CBS combined with one of four antibiotic regimens in the treatment of duodenal ulcers.
Endoscopy and antral biopsies were performed before treatment and four weeks afterwards.
Biopsy specimens were examined for histological evidence of gastritis and by Gram stain and culture for H pylori infection.
Altogether 141 patients were allocated to one of five treatment groups.
Giving CBS and metronidazole (400 mg tid for 7 days) with and without amoxycillin (500 mg tid) achieved higher clearance rates of H pylori than treatment with CBS alone (p less than 0.01).
These two combinations also achieved higher rates of antral gastritis healing than CBS alone (p less than 0.01 and p less than 0.05 respectively).
Susceptibility to metronidazole was tested in 29 isolates before and in seven isolates after treatment with metronidazole by disc diffusion test and minimum inhibitory concentration assay.
Twenty seven (93%) of the isolates were sensitive before treatment while six of seven (86%) were resistant afterwards.
Four of the six resistant strains had acquired resistance during treatment and one of these had acquired metronidazole resistance despite concomitant treatment with amoxycillin, to which it remained sensitive.
CBS with adjuvant metronidazole at a dose of 400 mg tid for seven days significantly improves the eradication of H pylori compared with CBS alone.
Acquired metronidazole resistance, however, seems to be an important cause of failure to eradicate H pylori.
|
C01
|
375
| 5,387
|
The agent of bacillary angiomatosis. An approach to the identification of uncultured pathogens
BACKGROUND.
Bacillary angiomatosis is an infectious disease causing proliferation of small blood vessels in the skin and visceral organs of patients with human immunodeficiency virus infection and other immunocompromised hosts.
The agent is often visualized in tissue sections of lesions with Warthin-Starry staining, but the bacillus has not been successfully cultured or identified.
This bacillus may also cause cat scratch disease.
METHODS.
In attempting to identify this organism, we used the polymerase chain reaction.
We used oligonucleotide primers complementary to the 16S ribosomal RNA genes of eubacteria to amplify 16S ribosomal gene fragments directly from tissue samples of bacillary angiomatosis.
The DNA sequence of these fragments was determined and analyzed for phylogenetic relatedness to other known organisms.
Normal tissues were studied in parallel.
RESULTS.
Tissue from three unrelated patients with bacillary angiomatosis yielded a unique 16S gene sequence.
A sequence obtained from a fourth patient with bacillary angiomatosis differed from the sequence found in the other three patients at only 4 of 241 base positions.
No related 16S gene fragment was detected in the normal tissues.
These 16S sequences associated with bacillary angiomatosis belong to a previously uncharacterized microorganism, most closely related to Rochalimaea quintana.
CONCLUSIONS.
The cause of bacillary angiomatosis is a previously uncharacterized rickettsia-like organism, closely related to R.
quintana.
This method for the identification of an uncultured pathogen may be applicable to other infectious diseases of unknown cause.
|
C01
|
376
| 4,633
|
Prevention of catheter-associated urinary tract infection with a silver oxide-coated urinary catheter: clinical and microbiologic correlates.
In a prospective clinical trial involving 482 acutely hospitalized patients, the overall incidence of catheter-associated urinary tract infection (UTI; 10%) was similar in recipients of a silver oxide-coated urinary catheter (silver catheter) or a control silicone catheter.
However, female sex and absence of antimicrobial use were independently associated with an increased risk of UTI.
After stratification for these variables, the silver catheter reduced the incidence of UTI among women not receiving antimicrobial agents (19% for control catheter vs.
0 for silver catheter, P = .04; confidence interval for the difference in incidence, 0.4%-38%) but not in the other subgroups.
Gram-positive UTI was associated with absence of antimicrobial use, the control catheter, and catheter care violations.
Gram-negative and candidal UTIs were more common after 7 days of catheterization, and candidal UTI was associated with being female and antimicrobial use.
These findings demonstrate that several clinical variables influenced the incidence and microbiology of catheter-associated UTI and that the silver catheter appeared to prevent UTI among women not receiving antimicrobials.
|
C01
|
377
| 3,714
|
Prevention of nosocomial lung infection in ventilated patients: use of an antimicrobial pharyngeal nonabsorbable paste.
A comparative, prospective study was made of the incidence of infection in the lower airway (purulent tracheobronchitis and pneumonia) in long-term patients who were mechanically ventilated due to respiratory failure of noninfectious origin.
Twenty-eight patients were randomly allocated into a study group (A, n = 13) in which a nonabsorbable paste containing 2% tobramycin, 2% amphotericin B, and 2% polymyxin E was administered locally to decontaminate the oropharynx, and a control group (B, n = 15) in which a paste without antibiotics was also applied to the oropharynx.
We studied the effectiveness of the prophylactic technique in decontaminating the oropharynx and trachea of organisms potentially pathogenic for the respiratory system.
Decontamination was successful in ten of 13 patients in group A vs.
one of 15 patients in group B (p less than .001).
The results demonstrated a lower rate of infection in the lower respiratory tract in the study group (three patients with tracheobronchitis and no pneumonias) than in the control group (three patients with tracheobronchitis and 11 with pneumonia), the difference between both being highly significant (p less than .001).
Two (15%) patients in group B developed sepsis of pulmonary origin.
None of the patients on prophylactic treatment developed this complication.
Although the overall mortality was similar in both groups (group A, 30% vs.
group B, 33%), we believe that infection contributed to a great extent to the death of two of five patients in group B.
We conclude that nosocomial pneumonia, which is a frequent complication in critically ill patients on mechanical ventilation, could be prevented by local application of nonabsorbable antibiotics to the oropharynx.
|
C01
|
378
| 6,911
|
Empiric treatment of fungal infections in the neutropenic host. Review of the literature and guidelines for use.
Persistent fever that is refractory to broad-spectrum antibacterials is common in neutropenic patients undergoing induction chemotherapy of acute leukemia.
Clinical experience suggests that many of these patients are infected with fungi.
Until recently, data supporting the role of empiric antifungal therapy in this setting were limited to small groups of patients or postmortem reports.
Evolving evidence in larger patient populations supports data from smaller series: febrile neutropenic patients who have failed to respond to a 4- to 7-day course of broad-spectrum antibacterials may benefit from the early initiation of antifungal therapy.
Patients with fungal colonization or pulmonary infiltrates and adult patients who have not received previous fungal prophylaxis may especially benefit from the early use of antifungal drugs.
Amphotericin B has been the "gold standard" for empiric antifungal therapy, although the newer azoles may be useful in certain situations.
|
C01
|
379
| 7,747
|
A study of immunoglobulin G in the cerebrospinal fluid of 1007 patients with suspected neurological disease using isoelectric focusing and the Log IgG-Index. A comparison and diagnostic applications.
Cerebrospinal fluid and serum immunoglobulin G from 1007 patients with suspected neurological disease were analysed by 2 methods: isoelectric focusing for the detection of oligoclonal banding, and quantitative measurement of IgG and albumin for the formulation of a Log IgG-Index.
A comparison of the 2 methods in the detection of local synthesis of IgG showed that isoelectric focusing not only gave a much higher yield overall, with 282 patients showing local synthesis versus 225 for the Log IgG-Index, but also a higher specificity, with a false positive rate of 0% versus 3.5%.
In addition, of the 282 patients positive by isoelectric focusing only 163 (58%) were positive by the Log IgG-Index.
Of the 1007 patients studied, 206 had multiple sclerosis (MS), and isoelectric focusing showed local synthesis in 95% of clinically definite cases, with a 90% detection rate overall.
The Log IgG-Index was positive in only 67% of clinically definite cases, with an overall 59% detection rate.
Thus with the exceptions noted above, local synthesis of IgG as defined by isoelectric focusing is confined to demyelinating, inflammatory, infectious and postinfectious disorders.
Our results compare very favourably with the published sensitivities of magnetic resonance imaging in the detection of abnormalities in multiple sclerosis, and better than those for evoked potentials.
Where both these investigations are readily available isoelectric focusing provides a useful adjunct.
For the majority of physicians and neurologists who do not have ready access to magnetic resonance imaging, isoelectric focusing is an excellent alternative.
We would also recommend that it become the standard for the measurement of IgG abnormalities in the cerebrospinal fluid and that the use of quantitative data be abandoned for routine purposes.
|
C01
|
380
| 7,731
|
Streptococcal endocarditis temporally related to transesophageal echocardiography.
A case of streptococcal sanguis endocarditis temporally related to a transesophageal echocardiogram is reported; and the literature on the incidence of bacteremia occurring during transesophageal echocardiography is reviewed.
On the basis of this case and review of the literature, a reevaluation of the current guidelines for endocarditis prophylaxis during this procedure is recommended.
|
C01
|
381
| 5,698
|
Mycoplasmal pneumonia. Are you thinking of atypical presentations?
The presentations of mycoplasmal pneumonia can be varied and sometimes complicated.
The atypical nature of this illness, as opposed to the clear pattern of findings in classic bacterial pneumonias, leads the physician to the diagnosis.
Appropriate therapy then allows quick improvement as a rule, with few sequelae.
|
C01
|
382
| 875
|
Treatment of fungal skin infections: state of the art.
The number of cases of mycotic infections are increasing, presenting physicians today with an unprecedented challenge in handling the treatment and prophylactic control of these disorders.
The increase in mycotic disorders is due to many factors, such as longer life span, organ transplantation, and the acquired immunodeficiency syndrome.
The pharmaceutical industry is providing physicians with newer, more potent drugs to manage mycoses.
An overview of current practice in the use of topical and oral agents, especially ketoconazole, are given in the following specific mycoses: tinea capitis, pityriasis versicolor, seborrheic dermatitis, Trichophyton rubrum infections, vaginal candidiasis, and moist intertriginous tineas.
The efficacy of ketoconazole in various vehicles and dosage schedules and of traditional agents such as griseofulvin are discussed with relation to each of the mycoses.
|
C01
|
383
| 2,440
|
Hyperplastic gastric polyps associated with persistent Helicobacter pylori infection and active gastritis.
We report two cases of patients with 3-yr histories of upper gastrointestinal symptoms, hyperplastic gastric polyps, and active chronic gastritis.
Biopsies retrospectively stained with Giemsa revealed the persistent presence of Helicobacter pylori (HP) in gastric biopsies of both patients throughout the 3 yr.
After treatment with amoxicillin and bismuth subsalicylate, both became asymptomatic, one demonstrating disappearance and recurrence of the gastric polyps in conjunction with the HP.
These cases demonstrate 3 yr of hyperplastic gastric polyps associated with HP and active gastritis.
|
C01
|
384
| 5,340
|
Disseminated histoplasmosis in the acquired immune deficiency syndrome: clinical findings, diagnosis and treatment, and review of the literature.
Histoplasmosis is a serious opportunistic infection in patients with AIDS, often representing the first manifestation of the syndrome.
Most infections occurring within the endemic region are caused by exogenous exposure, while those occurring in nonendemic areas may represent endogenous reactivation of latent foci of infection or exogenous exposure to microfoci located within those nonendemic regions.
However, prospective investigations are needed to prove the mode of acquisition.
The infection usually begins in the lungs even though the chest roentgenogram may be normal.
Clinical findings are nonspecific; most patients present with symptoms of fever and weight loss of at least 1 month's duration.
When untreated, many cases eventually develop severe clinical manifestations resembling septicemia.
Chest roentgenograms, when abnormal, show interstitial or reticulonodular infiltrates.
Many cases have been initially misdiagnosed as disseminated mycobacterial infection or Pneumocystis carinii pneumonia.
Patients are often concurrently infected with other opportunistic pathogens, supporting the need for a careful search for co-infections.
Useful diagnostic tests include serologic tests for anti-H.
capsulatum antibodies and HPA, silver stains of tissue sections or body fluids, and cultures using fungal media from blood, bone marrow, bronchoalveolar lavage fluid, and other tissues or body fluids suspected to be infected on clinical grounds.
Treatment with amphotericin B is highly effective, reversing the clinical manifestations of infection in at least 80% of cases.
However, nearly all patients relapse within 1 year after completing courses of amphotericin B of 35 mg/kg or more, supporting the use of maintenance treatment to prevent recurrence.
Relapse rates are lower (9 to 19%) in patients receiving maintenance therapy with amphotericin B given at doses of about 50 mg weekly or biweekly than with ketoconazole (50-60%), but controlled trials comparing different maintenance regimens have not been conducted.
Until results of such trials become available, our current approach is to administer an induction phase of 15 mg/kg of amphotericin B given over 4 to 6 weeks, followed by maintenance therapy with 50 to 100 mg of amphotericin B given once or twice weekly, or biweekly.
If results of a prospective National Institutes of Allergy and Infectious Disease study of itraconazole maintenance therapy document its effectiveness, alternatives to amphotericin B may be reasonable.
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C01
|
385
| 7,677
|
Toxic shock syndrome associated with use of latex nasal packing.
We treated a previously healthy young man who developed toxic shock syndrome 2 days after elective septoplasty with nonabsorbent latex packing.
This case emphasizes that non-menstrual wound-associated toxic shock syndrome can occur after surgery that does not involve absorbent splinting or packing and should be considered in patients who present within a few days after surgery with fever, sunburnlike rash, hypotension, and multisystem complaints and laboratory abnormalities.
|
C01
|
386
| 2,385
|
Cerebrospinal fluid changes after 48 hours of effective therapy for Hemophilus influenzae type B meningitis.
Interval cerebrospinal fluid (CSF) analysis is often performed to assess efficacy of treatment for bacterial meningitis.
The authors reviewed 101 cases of pediatric bacterial meningitis resulting from Hemophilus influenzae type b in which analysis of CSF occurred on admission and between 48 and 72 hours after initiation of parenteral antibiotic therapy; of these, only one patient had a positive repeat CSF culture.
Of the 100 cases with sterile CSF on repeat culture, there was no instance of recrudescence of infection during hospitalization.
The following characterized the interval changes in CSF profile of this group: 100 (100%) with persistence of pleocytosis; 14 (14%) with differential cell count conversion from polymorphonuclear neutrophil leukocyte (PMN) predominance to relative lymphocytosis; 96 of 98 (98%) with initial positive Gram-stained smear with negative results for organisms; 53 of 75 (71%) with normalization of initial hypoglycorrhachia; and 10 of 94 (11%) with normalization of initial abnormally elevated protein levels.
The differences in mean values of CSF total white blood cell counts, percentage PMNs, and glucose and protein concentrations on presentation and between 48-72 hours of therapy were highly significant (P less than 0.0001).
After 48 hours of effective antibiotic therapy for H.
influenzae type b meningitis, CSF pleocytosis and abnormally elevated protein concentration are usually preserved, whereas hypoglycorrhachia usually resolves; it is not uncommon for the differential cell count to convert from a PMN predominance to a relative lymphocytosis.
Significant alteration in all CSF parameters associated with H.
influenzae type b meningitis can occur after 48 hours of effective parenteral antibiotic therapy.
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C01
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387
| 21
|
Augmentation mentoplasty using Mersilene mesh.
Many different materials are available for augmentation mentoplasty.
However, the optimal implant material for chin implantation has yet to be found.
During the past several years, a number of experienced surgeons have turned to the use of Mersilene mesh.
Mersilene mesh is a non-absorbable Dacron polyester fiber that can be conformed easily into layers to achieve tailored dimensions and shape.
At the McCollough Plastic Surgery Clinic PA, Birmingham, Ala, 277 patients over a 10-year period underwent chin augmentation with Mersilene mesh implants.
The material provides excellent tensile strength, durability, and surgical adaptability.
The overall complication rate was 3.2% (nine patients); infection rate, 2.5% (seven patients); and removal secondary to infection, 1.7% (five patients).
Based on this 10-year experience, Mersilene mesh remains our material of choice for chin augmentation.
|
C01
|
388
| 6,271
|
Effects of common illnesses on infants' energy intakes from breast milk and other foods during longitudinal community-based studies in Huascar (Lima), Peru.
To assess the effects of common infections on dietary intake, 131 Peruvian infants were observed longitudinally.
Home surveillance for illness symptoms was completed thrice weekly, and food and breast-milk consumption was measured during 1615 full-day observations.
Mean (+/- SD) energy intakes on symptom-free days were 557 +/- 128 kcal/d (92.4 +/- 26.5 kcal.kg-1.d-1) for infants aged less than 181 d and 638 +/- 193 kcal/d (77.7 +/- 25.7 kcal.kg-1.d-1) for infants aged greater than 180 d.
Statistical models controlling for infant age, season of the year, and individual showed significant 5-6% decreases in total energy intake during diarrhea or fever.
There were no changes with illness in the frequency of breast-feeding, total suckling time, or amount of breast-milk energy consumed.
By contrast, energy intake from non-breast-milk sources decreased by 20-30% during diarrhea and fever, and the small decrements in total energy consumption during illness were explained entirely by reduced consumption of non-breast-milk foods.
|
C01
|
389
| 571
|
Prevention of necrotizing enterocolitis in the rat with prenatal cortisone.
Cortisone acetate is known to accelerate maturation of the immature intestine.
The effect of prenatal administration of cortisone acetate on the morbidity and mortality of necrotizing enterocolitis was examined in a rat pup model.
Pregnant rats were administered cortisone acetate, 20 mg/100 g of body weight, or normal saline by daily IP injection from day 18-21 of gestation.
Rat pups were taken from the mothers before suckling was initiated, fed a simulated rat milk formula, and subjected to daily ischemic insults to produce an animal model of necrotizing enterocolitis.
Both morbidity and the mortality rates were significantly improved with prenatal cortisone treatment.
Maturation of the intestinal mucosal barrier was accelerated with the cortisone treatment as measured by decreased serum concentrations of a fed antigen, ovalbumin.
Aerobic bacterial colonization of the small intestine and translocation of bacteria to the liver were decreased in the pups pretreated with steroids.
These changes observed in a rat model of necrotizing enterocolitis may explain the decreased incidence of necrotizing enterocolitis in human infants born to mothers who received corticosteroids late in gestation.
|
C01
|
390
| 8,106
|
Reduction of contamination at total hip replacement by special working clothes.
We assessed wound, air and operative field contamination at 50 total hip operations, performed in a zonal ventilation system.
Theatre staff wore either a specially designed polypropylene non-woven coverall or conventional cotton shirt and trousers.
The surgeons wore partially impermeable operating gowns.
The polypropylene coverall was associated with significantly lower air and wound counts.
The coverall was warmer than cotton but judged to be acceptable.
The combined use of zonal ventilation and the coverall achieved ultra-clean air conditions.
|
C01
|
391
| 4,625
|
Monoclonal antibody to mouse lipopolysaccharide receptor protects mice against the lethal effects of endotoxin.
Specific endotoxic lipopolysaccharide (LPS) binding sites on the cell membranes of murine lymphocytes and macrophages that may serve as functional receptors for LPS have recently been identified using photoactivatable cross-linking LPS derivatives.
A monoclonal antibody (Mab 5D3) with specificity for this 80-kDa protein has also been generated and characterized.
The capacity of MAb 5D3 to protect mice against the lethal effects of endotoxin was investigated.
Pretreatment of CF1 mice with as little as 15 micrograms of MAb 5D3 provided virtually complete protection against a dose of endotoxin 10-fold greater than that required to kill all mice in an untreated control group using the galactosamine sensitization model.
Significant protection was also afforded normal mice given MAb 5D3 relative to saline.
Several lines of evidence suggest that MAb 5D3-mediated protection is due to the agonist properties of this antibody rather than a receptor blockade mechanism.
|
C01
|
392
| 886
|
Itraconazole in opportunistic mycoses: cryptococcosis and aspergillosis.
Striking results were obtained with oral itraconazole therapy in two opportunistic mycoses.
Of 28 patients with cryptococcal meningitis, 18 achieved complete responses, including 16 of 24 patients with acquired immunodeficiency syndrome.
Other manifestations of cryptococcosis were similarly responsive.
In aspergillosis 12 of 15 patients responded, including 8 of 10 immunocompromised hosts.
These patients included those with invasive pulmonary disease (4/5), skeletal disease (2/2), pleural disease (1/2), and pericardial, sinus, mastoid, hepatosplenic, or nail disease (1/1).
These results with itraconazole compare favorably to conventional (parenteral) therapy, and toxicity was minimal.
This suggests that comparative trials are now in order.
|
C01
|
393
| 4,344
|
Oral terbinafine versus griseofulvin in the treatment of moccasin-type tinea pedis.
The safety and effectiveness of oral terbinafine, 125 mg twice daily, and griseofulvin, 250 mg twice daily, in patients with moccasin-type tinea pedis were examined in a double-blind randomized trial.
At the end of the 6-week treatment period, both a clinical and mycologic cure or a mycologic cure with minimal signs of infection was noted in 12 (75%) of the 16 terbinafine-treated patients compared with only 3 (27%) of the 12 patients treated with griseofulvin.
The overall response rate 2 weeks after the completion of treatment was 88% in the terbinafine-treated group and 45% in the griseofulvin-treated group.
When contacted again 6 to 15 months after completion of the study, 94% of the terbinafine-treated patients reported sustained clearing of tinea pedis, and 88% of those with nail involvement at the time of treatment reported improvement.
In contrast, tinea pedis remained cured in only 30% of the patients who had received griseofulvin, and onychomycosis improved in only 14%.
|
C01
|
394
| 6,095
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Giant basilar aneurysm in the course of subacute bacterial endocarditis.
We describe a man aged 42 years with mitral valve regurgitation who suffered from subacute bacterial endocarditis caused by Streptococcus morbillorum.
The clinical picture began with a toxic syndrome.
Five months later, the patient had an embolic episode and a right rostral pontine stroke, which was followed a few days later by an adversive focal seizure on the right.
Despite antibiotic treatment, he suffered complete third nerve palsy.
Arteriography, magnetic resonance imaging, and computed tomography of the brain showed a giant aneurysm in the rostral end of the basilar artery; the aneurysm was clipped.
We discuss the clinical features, radiology, and characteristics of this aneurysm as a unique case of a giant bacterial aneurysm in the vertebrobasilar system.
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C01
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395
| 3,449
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Unusual case of pacemaker lead migration.
Pulmonary artery migration of pacemaker lead is rare and may result in pulmonary emboli originating from the thrombus around the infected catheter and causing multiple pulmonary infarcts.
We report an unusual case of pacemaker lead migration to the right pulmonary artery with septic pulmonary embolism.
While being treated with intravenous Cefuroxamine, the patient had spontaneous migration of the lead to the left pulmonary artery with subsequent left pulmonary embolism.
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C01
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396
| 5,019
|
Clinical course and pharmacokinetics following a massive overdose of amphotericin B in a neonate.
Amphotericin is the drug of choice for the treatment of fungal infections in infants and children.
When used in the recommended doses, amphotericin therapy is associated with high rates of adverse effects, including nephrotoxicity, hepatotoxicity, decrease in white blood cells, platelets and hemoglobin, chills, fever and even death (1).
We report a case involving a neonate who was exposed to a 50 fold overdose of Amphotericin over a three day period.
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C01
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397
| 7,527
|
Brain stem tuberculoma in adult patients: diagnosis and treatment.
A consecutive series of six adult patients ranging in age from 29 to 53 years is presented.
The clinical and radiological features in each patient are described.
Attention is drawn to the features demonstrated on computed axial tomography.
In only one patient, the first encountered, was surgical excision undertaken and histological verification obtained.
One patient died before any form of treatment could be instituted.
The remaining four patients were treated with antituberculous chemotherapy alone and their progress monitored by sequential computed tomography.
The excellent response and good outcome in this conservatively treated group are documented.
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C01
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398
| 6,864
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Antimicrobial prophylaxis for open heart operations.
Between 1986 and 1988, 450 adults undergoing coronary artery bypass, cardiac valve replacement, or both were enrolled into a prospective, randomized, comparative trial of cephalothin versus cefamandole as perioperative prophylaxis.
They were assessed during their hospitalization and at 6 weeks and 6 months after discharge for postoperative infectious complications.
Eleven patients had major postoperative infections including 5 with sternal wound infections (three bacteremic), 6 with bacteremia, 1 with prosthetic valve endocarditis, and 3 with severe venous donor graft site infections.
Eight major infections occurred in patients receiving cephalothin prophylaxis and three in patients receiving cefamandole, with all five sternal wound infections occurring in the cephalothin group.
Postoperative pathogens responsible for the major infections included gram-negative aerobes in 5 patients, Staphylococcus aureus in 4, and Staphylococcus epidermidis in 2.
Preoperative colonizing staphylococcal isolates were not predictive of postoperative staphylococcal pathogens.
Although there was no statistically significant difference in rate of major postoperative infectious complications using either cephalothin or cefamandole prophylaxis, there was a trend in favor of cefamandole.
Gram-negative aerobes are becoming increasingly important pathogens in this setting.
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C01
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399
| 3,285
|
Seven-day administration of recombinant human granulocyte colony-stimulating factor to newborn rats: modulation of neonatal neutrophilia, myelopoiesis, and group B Streptococcus sepsis.
Single-pulse administration of rhG-colony-stimulating factor (CSF) to neonatal rats was previously demonstrated to induce peripheral neutrophilia and modulate bone marrow (BM) neutrophil storage and proliferative pools (NSP + NPP).
In this study, we investigated the prolonged effects of 7 days of rhG-CSF therapy (5 micrograms/kg/per day).
Sprague-Dawley newborn rats (less than or equal to 24 hours) were injected intraperitoneally (IP) (daily for 7 days) with rhG-CSF or phosphate-buffered saline/human serum albumin (PBS/HSA).
RhG-CSF induced a significant early and late peripheral neutrophilia: 6,905 +/- 1,625 (day 1) and 9,223 +/- 515 microL (day 7) v 1,275 +/- 90/microL (P less than or equal to .0001).
In addition, 7 days of rhG-CSF resulted in a significant increase in the BM NSP: 3,247 +/- 190/microL v 1,677 +/- 339/microL (P less than or equal to .001).
There was, however, no depletion or significant change in the BM NPP.
Seven days of rhG-CSF also induced a mild increase in BM CFU-GM colony formation (P less than or equal to .01).
There was, however, no significant change in liver/spleen CFU-GM colonies or in the CFU-GM proliferative rate in either the BM or liver/spleen cultures.
Finally, 7 days of prophylactic rhG-CSF therapy resulted in a synergistic response with antibiotic therapy and significantly modulated the mortality rate during experimental group B streptococcal sepsis (GBS) (100% v 50%) (GvsC) (P less than or equal to .001).
Pulse rhG-CSF administered at 6 hours or 18 hours after GBS inoculation, however, failed to act synergistically with antibiotics to improve survival or prevent peripheral neutropenia.
This study suggests that 7 days of prophylactic rhG-CSF therapy induces peripheral neutrophilia, myeloid maturation, increases neutrophil BM reserves and also may provide immunologic enhancement of neonatal host defense during experimental GBS in term neonatal rats.
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C01
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