Nonuniform spatial patterns of respiratory activity within biofilms during disinfection

Fluorescent stains in conjunction with cryoembedding and image analysis were applied to demonstrate spatial gradients in respiratory activity within bacterial biofilms during disinfection with monochloramine. Biofilms of Klebsiella pneumoniae and Pseudomonas aeruginosa grown together on stainless steel surfaces in continuous-flow annular reactors were treated with 2 mg of monochloramine per liter (influent concentration) for 2 h. Relatively little biofilm removal occurred as evidenced by total cell direct counts. Plate counts (of both species summed) indicated an average 1.3-log decrease after exposure to 2 mg of monochloramine per liter. The fluorogenic redox indicator 5-cyano-2,3-ditolyl tetrazolium chloride (CTC) and the DNA stain 4',6-diamidino-2-phenylindole (DAPI) were used to differentiate respiring and nonrespiring cells in biofilms. Epifluorescence micrographs of frozen biofilm cross sections clearly revealed gradients of respiratory activity within biofilms in response to monochloramine treatment. These gradients in specific respiratory activity were quantified by calculating the ratio of CTC and DAPI intensities measured by image analysis. Cells near the biofilm-bulk fluid interface lost respiratory activity first. After 2 h of biocide treatment, greater respiratory activity persisted deep in the biofilm than near the biofilm-bulk fluid interface.

Clearance of funguria with short-course antifungal regimens: a prospective, randomized, controlled study

The effects of short-course antifungal regimens on funguria were studied in 180 hospitalized adults who did not have ascending urinary or deep fungal infections but did have > 1,000 cfu of yeast/mL in two consecutive urine cultures. Before treatment, efforts were made to eliminate factors conducive to funguria. No additional interventions were implemented in the management of the control group (group A), whereas five experimental groups received short-course therapy as follows: oral administration of fluconazole (group B); single-dose intravenous administration of amphotericin B (group C); and intermittent bladder irrigation with amphotericin B at low, medium, and high concentrations (groups D, E, and F, respectively). Urine was cultured on days 1 and 7 after antifungal treatment. The rate of spontaneous clearance of funguria in the control group was 40.0%. Rates of clearance in experimental groups B through F were 58.6%, 55.2%, 82.1% (P < .01), 86.7% (P < .001), and 83.3% (P < .001), respectively, on day 1 and 77.3% (P < .01), 72.0% (P < .05), 42.9%, 68.4%, and 68.2% (P < .05), respectively, on day 7. The decrement in yeast count was 60.8% for the control group. Decrements for experimental groups B through F were 80.5%, 74.2%, 94.2% (P < .01), 86.7% (P < .05), and 95.3% (P < .001), respectively, on day 1 and 85.5% (P < .05), 80.7%, 75.7%, 87.9% (P < .05), and 76.4%, respectively, on day 7.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional outcomes after inpatient rehabilitation of patients with end-stage renal disease

There is a paucity of information on functional benefits of inpatient rehabilitation of patients with end-stage renal disease (ESRD). This study examined admission and discharge Functional Independence Measure (FIM) scores of 45 ESRD patients admitted over a 33-month span to determine if these patients made functional gains similar to 2,324 concurrently admitted general rehabilitation patients without ESRD. FIM scores were transformed and reported as scaled (0 to 100) motor and cognitive subscores by the Rasch method. FIM scores were compared using multiple linear regression to control for differences in rehabilitation diagnosis and other confounding factors between the ESRD and other patients. ESRD subgroups were compared using one-way analysis of variance. The mean discharge motor FIM score unadjusted for confounders was lower in ESRD than general rehabilitation patients (45.18 vs 50.63), and the difference after regression analysis (7.63 points lower in the ESRD group) was significant (p < .01). The mean motor FIM score gain after regression analysis for the two groups showed only a near significant (p = .06) difference, with the gain among ESRD patients being 3.15 points lower. Discharge settings were similar, with 89% of ESRD patients and 87% of patients without ESRD being discharged home. ESRD patients on hemodialysis had similar FIM scores to patients with renal transplantation. ESRD patients with stroke had significantly lower (p < .05) discharge motor and cognitive scores than ESRD patients with generalized weakness or amputation. In addition, stroke patients with ESRD showed significantly lower motor FIM score gains than stroke patients without ESRD (5.09 vs 11.08; p = .002).(ABSTRACT TRUNCATED AT 250 WORDS)

[Arytenoid subluxation following endotracheal intubation--a case report]

A previously healthy 39-yr-old man was scheduled for exploratory laparotomy due to acute abdomen. There was no sign of difficult intubation. After induction of anesthesia with thiopental and succinylcholine, the trachea was easily intubated with a 7.0 mm cuffed endotracheal tube. Surgery for a ruptured appendix with 2 drainage tubes lasted for 75 min was uneventful. At the end of surgery, the endotracheal tube was removed without difficulty. On the 1st postoperative day, the patient developed stridor. The symptom persisted even after conservative treatment and removal of NG tube. On the 12th postoperative day, a telescopic videolarygoscopy revealed immobile right vocal cord with anterior and medial displacement to the right. Arytenoid cartilage was moderately edematous. A diagnosis of right arytenoid subluxation was then made. On the 17th postoperative day, a closed reduction of right arytenoid cartilage using direct laryngoscope was performed successively under general anesthesia. Eight weeks after the reduction, his voice and laryngoscopic findings were normal. There has been only 18 reports with 27 cases of this complication found in the literature. However, it is generally believed that it is not so unusual. The post-intubation syndromes, such as sore throat, dysphonia, odynophagia, difficulty in swallowing or breathing which persists beyond 5 days warrant ENT consultation. Abnormal mobility of vocal cord, edema over arytenoid area found by indirect laryngoscopy should suggest the complication. Further confirmation is then needed. Although the result of our case is good, the reduction should ideally be done within 24-48 h after the incidence to avoid unfavorable long-term sequelae.

Tuberculous splenic abscess--a case report and literature review

Splenic involvement of tuberculosis is common, especially in cases of miliary tuberculosis. However, abscess formation due to tuberculosis in the spleen is extremely rare. We present a tuberculous splenic abscess in an otherwise healthy male patient. This patient presented with fever of unknown origin (FUO). The chest X-ray was consistent with old pulmonary tuberculosis, inactive on presentation. Due to the nonspecific clinical picture the patient remained undiagnosed until laparotomy. We have also reviewed literatures on tuberculous splenic abscess and try to make some inference about the diagnosis and treatment of this disease.

[A comparison between the pain relief effect of electroacupuncture, regional never block and electroacupuncture plus regional never block in frozen shoulder]

BACKGROUND

Frozen shoulder is a kind of spontaneous, progressive peri-arthritis over the shoulder joint. The etiology is not yet clear. Traditional treatments for frozen shoulder included conservative medical therapy, physical therapy, nerve block and acupuncture and so on. The purpose of our study is to determine the pain relief effect of electroacupuncture (EAP), regional nerve block (RNB) and the combination of EAP + RNB for frozen shoulder.

MATERIALS & METHODS

One hundred and fifty patients with fresh frozen shoulder were, randomly divided into 3 groups. Group I patients (n = 50) had RNB with stellate ganglion block and suprascapular nerve block by 1% xylocaine 10 ml. Group II patients (n = 50) had EAP with local acupoint--Chien-Yu, Chien-Ching, Chien-Nei-Ling, Ah-Shih Hsueh treatment and Group III (n = 50) patients had RNB+EAP performed with acupuncture first, then followed by the regional nerve block. Six vectors of movements were checked in all methods. Four graded Bromage score was used for pain assessment, Grade 1 means complete painless; Grade 2 means slight pain (i.e. pain on motion); Grade 3 means moderate pain (i.e. pain on silence); Grade 4 means severe pain (i.e. need analgesics). The range of shoulder joint was also recorded. Patients were requested for second treatment if pain recurred. The onset (time from injection to maximal pain relief), duration (time from injection to grade 3) Bromage score and side effects were recorded.

RESULTS

The results showed that the combined EAP and RNB method had significant high pain control quality, longer duration, and better range of movement of the shoulder joint than that of EAP or RNB performed alone.

Spinal osteomyelitis due to Mycobacterium avium-intracellulare in an elderly man with steroid-induced osteoporosis

Disseminated mycobacterial infections are becoming widely appreciated among immunosuppressed and debilitated persons. Specific microbiologic diagnosis may take several weeks, requiring empiric therapy in the interim. A case of an elderly man undergoing steroid treatment who developed spinal osteomyelitis initially thought to be caused by Mycobacterium tuberculosis is described. He was eventually shown to have infection due to M. avium-intracellulare, which requires a different therapeutic approach. The importance of considering atypical mycobacteria in systemic infections and the value of aggressive antimicrobial therapy in conjunction with a comprehensive rehabilitation program during hospitalization are emphasized in order to provide optimal management and prevent further disability.

Role of monoconjugated bilirubin in pathogenesis of gallstones

In order to explore the substantial role of monoconjugated bilirubin (MCB) in gallstone formation, bile pigment precipitation and hemolytic jaundice, three experimental protocols have been studied, namely, (1) MCB and dietary induced pigment gallstone model, (2) MCB in human gallstone and incubated bile precipitates and (3) MCB in hemolytic jaundice. It was found that doubly increased MCB accounted for 1/3 of the total pigment in lithogenic guinea pig and CDCA plus glycine possessed certain protective effect from gallstone development; MCB was found in human gallstones both in bilirubinate and cholesterol type, and an unknown pigment, possibly an isomer of MCB, was found in black stone. During experimental hemolytic jaundice model preparation, both MCB and UCB were elevated, and MCB was found increased by 10 times, even exceeding the concentration of DCB when the injected bilirubin was about 4 mg/kg of body weight. It is reasonable to consider that MCB as a coprecipitant with UCB and a precursor of UCB played an essential role in the pathogenesis of gallstones.

[The content of ambulatory family practice in Kaohsiung Medical College Hospital]

To understand the content of ambulatory family practice and find effective ways to improve clinical service, education and research in the Department of Family Medicine of Kaohsiung Medical College Hospital, we surveyed 14,064 patients from Jan. 1984 to Feb. 1991 and analysed (a) their basic demographic data including sex, age, insurance type, source and residential district and (b) clinical health problems covering 25,679 diagnoses and 148,994 diagnostic visits. Clinical health problems were recorded by the ICHPPC-2 code system. Results of basic demographic survey were as follow: 49.1% of patients was male and 50.9% female; 58.9% fell in the age group of 16-40 years and 22.4%, 12.0% and 6.7% of patients fell into the age groups of 41-65, under 16 and over 65 years respectively; 62.8% was insured usually by labor insurance and 26.9% had no insurance; the commonest referrals were other patients, colleagues, company personnel, doctors, media ... etc.; 58.8% lived in Kaohsiung City and 19.6% in Kaohsiung county. As for clinical health problems, the data showed that the commonest thirty diagnoses encountered at our clinic accounted for 69.3% of 25,679 diagnoses and the commonest ten diagnoses in descending order were medical health examination, acute URI, abdominal pain, uncomplicated hypertension, prophylactic immunization, hepatitis B carrier, back pain, anxiety disorder, viral hepatitis and irritable bowel syndrome. By calculating the average value of each diagnosis in a sample of 148,994 diagnostic visits to evaluate the habits of practice, we found that the commonest ten diagnostic visits at clinic in descending order were diabetes mellitus, hypertension involving target organ, uncomplicated hypertension, gout, hyperthyroidism, duodenal ulcer, tuberculosis, lipid metabolism disorder, other peptic ulcer and depressive disorders; all were chronic diseases. We concluded it was very important and helpful for the development of family medicine program and primary care unit to understand the content of their own ambulatory practice.

Effect of cimetidine on wedged hepatic venous pressure in cirrhotic patients

According to our supposition that "humoral mechanism" plays an important role in the pathogenesis of portal hypertension due to cirrhosis, antagonists to some of humoral substances would lower the portal pressure in cirrhotic patients. Wedged hepatic venous pressure (WHVP) was used as an indicator for changes of portal pressure. Cimetidine was given intravenously to 8 cirrhotic patients, in whom an average lowering of 0.72 kPa (7.3 cm H2O) of WHVP was observed subsequently. This change was of clinical significance as compared with the previous results of splenorenal shunting operations.

Orthostatic hypotension after spinal cord injury: treatment with fludrocortisone and ergotamine

We report a case of a 28-year-old woman with C5 quadriplegia, unresponsive to conservative treatment for orthostatic hypotension. Ergotamine, daily combined with fludrocortisone, successfully prevented symptomatic hypotension. In this report, neural, renal, and hormonal blood pressure regulatory mechanisms are described. Experiences obtained from this case and the existing literature suggest that (1) in persons with quadriplegia, plasma catecholamine levels show little increase with sitting, indicating an inability to activate baroreceptor and chemoreceptor reflexes, (2) elevated plasma aldosterone and renin levels indicate a renal compensatory response to decreased renal perfusion secondary to low plasma volume and/or chronic hypotension, and (3) the net effect of ergotamine and fludrocortisone is probably a combination of plasma volume expansion and direct peripheral vasoconstriction.

[A preliminary study of family Apgar index in the Chinese]

The present study was designed to evaluate the clinical availability of family Apgar index in Chinese people. From August 1987 to February 1988, 113 samples from 45 Chinese families were collected from our record family patients. The family members who were over 12 years of age were asked to complete a family Apgar questionnaire and CHQ during a family visit. The patients age, sex, marital status, education, religion, family role, socioeconomic status were also recorded. The result showed that there was no significant correlation between the family Apgar scores and all of the patient's characteristics (sex, age, marital status, education, religion, family role, socioeconomic status) except the score of CHQ. It is suggested that the family Apgar index is a simple and useful instrument to screen out family dysfunctional patients in daily office practice.

Changes of blood humoral substances in experimental cirrhosis and their effects on portal hemodynamics

The changes of humoral substances in the blood of cirrhotic rats were studied together with their effects on portal hemodynamics at different stages during the development of cirrhosis. The profiles of humoral substances and hemodynamics in two different cirrhotic rat models were also investigated. During the development of cirrhosis, glucagon increased markedly in all stages, histamine and vasoactive intestinal polypeptide (VIP) increased in the early stage, serotonin (5-HT) and somatostatin (SS) increased in the middle and late stages. There were different patterns of humoral substances in different cirrhotic models. Glucagon was the main humoral substance elevated in CCL4 induced cirrhosis, but histamine and 5-HT were mainly elevated in the blood in thioacetamide (TAA) induced cirrhosis. The hemodynamics altered differently in different stages during the development of cirrhosis and differently in the two cirrhotic rat models. Exchange transfusions between normal and cirrhotic rats resulted in an elevation of portal flow in normal rats, but no such changes were found after exchange pressure and an increase of portal blood transfusions between normal rats. The relationship between the humoral substances and portal hemodynamics is discussed. The results of this study strongly support the hypothesis of "humoral mechanism" in the pathogenesis of portal hypertension due to cirrhosis.

Bond strength, microleakage, and scanning electron microscopy examination of the Prisma Universal Bond 2 adhesive system

Dentin shear bond strength and marginal microleakage of a new primer/adhesive system were evaluated in this study and compared to Tenure Solution, Gluma, XR Primer/XR Bond, and Scotchbond 2. In addition, scanning electron microscopy examinations were conducted to evaluate the effect of the new primer on the smear layer, determine the film thickness of the primer/adhesive, and examine the resindentin interface of restorations placed with the new system.

Selectivity of converting-enzyme inhibitors for angiotensin I versus bradykinin hydrolysis reactions

Selectivity of captopril, enalapril (MK-421), enalaprilat (MK-422), ketoace, and SA-300 for inhibiting kininase II when angiotensin (ANG) I versus bradykinin (BK) is the substrate has been studied in vitro. Potency for inhibiting purified rabbit lung ANG I-converting enzyme (ACE) using a tripeptide substrate with an ANG I-like (hippurylhistidylleucine, HHL) or a BK-like (hippurylphenylalanylarginine, HPA) cleavable dipeptide was determined. Inhibition of ANG I-induced and potentiation of BK-induced contractions of isolated guinea pig ileum strips was measured. For the enzyme assay, the inhibitor concentration which reduced the rate of HHL and HPA hydrolysis 50% (IC50) from the control value was estimated. All tested compounds more potently inhibited hydrolysis of the ANG I-related tripeptide by the purified enzyme. Ketoace, with a selectivity ratio (HPA IC50:HHL IC50) of 23, was the most substrate-dependent inhibitor. For the isolated ileum assay, the inhibitor concentration which augmented the contractile response to BK by 50% (AC50) or inhibited the contractile response to ANG I by 50% (IC50) was calculated. Only enalaprilat retained a selectivity ratio (BK AC50:ANG I IC50) in the guinea pig ileum system greater than one. Ketoace, with a ratio of 0.038, was the least ANG I-selective by this criterion. In vivo selectivity data on captopril seem more in accord with the ileum, rather than the enzyme, results. It was concluded that converting enzyme inhibitors differ in their relative selectivity for inhibiting kininase II reactions using different substrates.

Anemia in acute phase of spinal cord injury

Anemia is a frequent complication during the acute phase of spinal cord injury (SCI), even in the absence of detectable blood loss. Since an improved understanding of the etiology of anemia in this population is a prerequisite to its ultimate prevention, a prospective study was conducted on 28 persons with SCI whose lesions were between C3 and C7. The injuries were either neurologically complete, incomplete with sensory sparing only, or incomplete with nonfunctional motor preservation. Laboratory profiles were obtained during the first few weeks postinjury. No persons had below-normal plasma volumes, while 9% had below-normal blood volumes. However, 82% had below-normal red cell masses, 25% had below-normal serum erythropoietin levels, and 11% had below-normal reticulocyte counts. Other below-normal values included erythrocyte count (75%), hemoglobin (79%), hematocrit (71%), mean corpuscular volume (11%), mean corpuscular hemoglobin (11%), serum iron (50%), total iron binding capacity (86%), iron saturation (50%), serum total protein (57%), serum albumin (89%), serum globulin (32%), and serum transferrin (79%). Most persons (71%) were found to have normochromic, normocytic anemia, although 14% had normochromic, microcytic anemia. Only 14% did not develop anemia. Although these cases of anemia were not severe enough to require transfusions, they might be an important factor in the development of other secondary complications and may combine with other nutritional and hematologic deficiencies to prolong the rehabilitation process.

In vitro evaluation of two new dentin adhesive systems

Two new experimental dentin adhesive systems were evaluated to determine in vitro dentin bond strengths and marginal microleakage. Scanning electron microscopy examinations were also conducted on one of the systems that was designed to modify the smear layer. Mean shear bond strength for the two experimental systems were 6.77 +/- 1.94 MPa and 18.73 +/- 2.4 MPa. Marginal microleakage from the enamel margin was not observed and the experimental primer system limited leakage from the dentin margins. The SEM examinations showed that the primer did not significantly alter the smear layer on the prepared dentin surface.

[A study of the effect of patient load and diseases upon resident training in a family medicine clinic]

Patient appointments and scheduling of patients and physicians are the first step in family medicine practice. The goals of outpatient services are to train the family physicians, to provide comprehensive and continuing health care for the family and its members. We evaluated the effect of the appointment system upon residents' training in a family medicine clinic of the Kaohsiung Medical College Hospital. The results were as follows: during the period between Aug. 1985 and Nov. 1986, a total of 2,220 patients and 5,891 out-patient encounters was recorded in this module. The subject age was mostly in the range of 16-64 years for all trainees. The distribution of the chronic diseases was relatively even for all except two trainees. For 4 residents, there were 40-60% more than the ideal patient numbers per session. This abnormal situation interferes with the normal functioning of family medicine clinics. The provocative results of this study suggest at least two important avenues for improvement. The first is to modify the appointment system. The second is to schedule the ideal amount of patients and kinds of diseases in order to provide comprehensive and continuous care for the family and its members.

Nutritional status during the acute stage of spinal cord injury

This study was designed to help clinicians establish objective guidelines for meeting the nutritional requirements of spinal cord injury (SCI) patients during their initial hospitalizations. The nutritional status of 51 SCI patients treated between 1983 and 1986 was assessed at two, four, and eight weeks after injury. Nutrient deficiencies such as albumin (100% of patients), carotene (62%), transferrin (37%), ascorbate (25%), thiamine (24%), folate (20%), and copper (11%) were documented most frequently at two weeks postinjury. There was an average of 2.0, 1.6, and 1.2 nutrient abnormalities per patient at two, four, and eight weeks postinjury, respectively. Although most depressed nutrient parameters improved with time, diet-dependent plasma proteins such as albumin and transferrin remained low throughout the entire eight-week period. Mean body weight declined 1.3 +/- 3.9 kg during the first two weeks, 2.0 +/- 4.4 kg between two and four weeks, and 0.4 +/- 2.0 kg between four and eight weeks after injury. Significant findings also included a strong correlation between plasma albumin, ascorbate, and carotene levels and maximal inspiratory and expiratory pressure (p less than .05). Although nutrient status usually improved with time and was not definitely associated with an increased risk of secondary medical complications, prudence dictates that these deficiencies should be prevented by appropriate intervention.