Burkholderia pseudomallei traced to water treatment plant in Australia

Burkholderia pseudomallei was isolated from environmental specimens 1 year after an outbreak of acute melioidosis in a remote coastal community in northwestern Australia. B. pseudomallei was isolated from a water storage tank and from spray formed in a pH-raising aerator unit. Pulsed-field gel electrophoresis confirmed the aerator and storage tank isolates were identical to the outbreak strain, WKo97.

Factors affecting recurrence following incisional herniorrhaphy

The purpose of this study was to determine the influence of chronic illness, obesity, and type of repair on the likelihood of recurrence following incisional herniorrhaphy. The medical records of 77 patients who underwent elective repair of a midline incisional hernia at the Dallas Veterans Affairs Medical Center between 1991 and 1995 were reviewed. Demographic data, presence of chronic illnesses, type of repair, and presence of recurrence were noted. Ninety-six percent of the patients were men, with an average age of 59 years. More than 50% of the patients had chronic lung or cardiac diseases and more than 40% weighed > or = 120% of their ideal body weight and had a body mass index (BMI) > or = 30. Sixty-two percent of the patients underwent primary reapproximation of the fascia (tissue repair), whereas 38% underwent repair with prosthetic material (prosthetic repair). The overall recurrence rate was 45%, with a median follow-up of 45 months (range 6-73). Seventy-four percent of the recurrences presented within 3 years of repair. The recurrence rate for those patients undergoing a tissue repair was 54%, whereas the recurrence rate following prosthetic repair was 29%. The incidence of recurrence for patients with pulmonary or cardiac disease or diabetes mellitus was similar to that of patients without these illnesses. The percent ideal body weight and BMI of patients who developed a recurrent hernia, particularly following a prosthetic repair, were significantly greater than those of patients whose repairs remained intact. These data strongly support the use of prosthetic repairs for incisional hernias, particularly in patients who are overweight.

Acute melioidosis outbreak in Western Australia

A cluster of acute melioidosis cases occurred in a remote, coastal community in tropical Western Australia. Molecular typing of Burkholderia pseudomallei isolates from culture-confirmed cases and suspected environmental sources by pulsed-field gel electrophoresis (PFGE) of XbaI chromosomal DNA digests showed that a single PFGE type was responsible for five cases of acute infection in a community of around 300 during a 5 week period. This temporal and geographical clustering of acute melioidosis cases provided a unique opportunity to investigate the environmental factors contributing to this disease. B. pseudomallei isolated from a domestic tap at the home of an asymptomatic seroconverter was indistinguishable by PFGE. Possible contributing environmental factors included an unusually acid communal water supply, unrecordable chlorine levels during the probable exposure period, a nearby earth tremor, and gusting winds during the installation of new water and electricity supplies. The possible role of the potable water supply as a source of B. pseudomallei was investigated further.

Deliberate self-harm and substance dependence: the management of patients seen in the general hospital

The aim of this study was to examine management decisions made at the time of assessment of an episode of deliberate self-harm seen in the general hospital and examine the extent of referral to a specialized addiction unit. Factors involved in making a clinical decision regarding the appropriate management of self-harm cases when alcohol factors were identified are reviewed. Simply referring to a specialized addiction unit was found to be an unsatisfactory method of providing a comprehensive response to the problem of substance misuse and deliberate self-harm. It is suggested that services should be developed using active posthospital discharge community follow-up. Motivational interviewing used in such a setting may increase the number of patients who will go on to accept specialist care.

Recognizing the child with obsessive defiant disorder

Nurses may find themselves in a home situation where a child demonstrates characteristics of a child with ODD. While the nurse is not in the home to provide therapy for the child, it may be evident that the parents need help in determining an appropriate plan of action. While it is not the role of the nurse to diagnose the child, the nurse who is aware of the symptoms of ODD may play a very significant role in assisting the parents in dealing therapeutically with the child.

Methyl methacrylate levels in unwashed salvage blood following unilateral total knee arthroplasty

To evaluate the safety of autologous reinfusion of drain blood in total knee arthroplasty (TKA), eight patients were prospectively evaluated to quantify levels of methyl methacrylate (MMA) monomer in systemic blood, and in their drain blood after unilateral cemented TKA. The systemic blood was analyzed before and after reinfusion of the drain blood. The drain blood was analyzed before reinfusion, and both before and after filtration through a 40-microm filter. A separate study was performed on 10 patients to assess the effect of blood, time, and filtration on MMA levels. Levels of MMA monomer in salvage blood were low enough to allow safe reinfusion. Systemic blood showed no evidence of MMA monomer either before reinfusion of salvage blood or at 5 minutes after reinfusion. Elimination of MMA is dependent on the time that MMA is exposed to blood and is independent of filtration.

When your patient uses denial

There are may factors to consider when denial is encountered in a patient situation. Denial is a simple concept but is complicated by ego-maintaining mechanisms that denial may produce. It is important to evaluate each individual situation in order to identify suitable approaches for the situation. Denial may not be something that the nurse should take away since it can serve an important balancing function between depression and wellness.

A randomized clinical trial of ursodeoxycholic acid as adjuvant treatment to prevent liver transplant rejection

Acute rejection following orthotopic liver transplantation is a common problem despite current immunosuppressive regimens. Ursodeoxycholic acid (UDCA) has been shown in small, open-labeled studies to prevent rejection episodes, although its effects on complications such as infections, length of hospital stay, and survival have not been evaluated. We conducted a randomized, placebo-controlled, double-blind trial to determine if UDCA (10-15 mg/kg/d) added to a cyclosporine-based immunosuppressive regimen was associated with a decrease in the incidence of at least one episode of acute cellular rejection. Secondary end-points included determining differences in the total number of rejection episodes, the use of muromonab-CD3, the incidence of infections, length of hospital stay, and survival at 90 days and 1 year. Fifty-two patients were randomized, 28 to the treatment group and 24 to the placebo group. During the 3 months of the trial, there was no difference between the placebo and UDCA groups in the number of patients who were rejection-free; however, there were significantly fewer patients in the treatment group who had multiple episodes of acute rejection (0 vs. 6; P = .007). Patients in the treatment group experienced a significantly lower incidence of bacterial infections (4% vs. 29%; P = .02), shorter hospital stay (25 days vs. 34 days; P = .03), and better 90-day survival (100% vs. 83%; P = .04) and 1-year survival (93% vs. 79%). The addition of UDCA to a cyclosporine-based immunosuppressive regimen results in significantly fewer patients experiencing multiple episodes of rejection and improved survival at 90 days and at 1 year. The use of UDCA as adjuvant therapy for patients undergoing liver transplantation who are treated with a cyclosporine-based immunosuppressive regimen should be considered.

Improved detection of recurrent bladder cancer using the Bard BTA stat Test

OBJECTIVES

To evaluate the BTA stat Test in the detection of recurrent bladder cancer.

METHODS

Sensitivity and specificity were determined using frozen voided urine samples from patients with recurrent bladder cancer, volunteers, patients with nonurologic conditions, and patients with a history of bladder cancer but free of disease. Results of cytology and the original BTA Test were compared with the sensitivity of the BTA stat Test in a large subgroup of the patients with cancer.

RESULTS

The BTA stat Test detected 147 (67%) of 220 recurrent cancers. For those urine samples with previous cytologic and BTA Test results available, cytology had a sensitivity of 23%, the BTA Test 44%, and the BTA stat Test 58% for detection of recurrent cancer (P < 0.001, stat versus cytology). The specificity of the BTA stat Test was 72% for benign genitourinary disease and 95% in healthy volunteers.

CONCLUSIONS

The BTA stat Test has high sensitivity and is significantly superior to voided urine cytologic analysis in the detection of recurrent bladder cancer.

Coping with the inexorable rise in medical admissions: evaluating a radical reorganisation of acute medical care in a Scottish district general hospital

OBJECTIVE

To describe radical changes in acute medical care in a district general hospital and assess their impact on staff and patients.

DESIGN

A before and after comparison of structure, process and outcome indicators in the year preceding and following reorganisation.

SETTING

The Adult Medicine Clinical Directorate of the Royal Alexandra Hospital in Paisley, Scotland.

SUBJECTS

Staff in the Medical Directorate and a random sample of 400 patients.

INTERVENTIONS

The main stimulus for reorganisation was the pressure caused by a relatively steep rise in admissions. In response, the six existing general medical wards were converted into a 38-bed Medical Admissions Unit and five more specialised wards. A new acute receiving rota allowed each consultant to concentrate almost exclusively on acute receiving for one week at a time.

RESULTS

The boarding of patients in non-medical wards was eliminated through improved bed management. The needs of patients became better matched to the specialism of their consultant. The cardiologist's share of in-patients with cardiological problems rose from 34% of 2,877 cases to 58% of 3,085 cases (p < 0.001) and the respiratory physicians' share of respiratory in-patients grew from 53% of 1,281 cases to 67% of 1,287 cases (p < 0.001). After the reorganisation, medical staff had significantly fewer concerns about losing track of patients (p < 0.01) or about boarding (p < 0.01), however, concern about 'blocked beds' became greater (p < 0.05). Nurses reported more time for health promotion (p < 0.01) but also a rise in stress (p < 0.05). More patients reported that staff had time to explain their treatment (85/109 (79%) before, 93/105 (89%) after, p < 0.05) and a higher proportion felt ready for discharge (91/108 (84%) before, 99/106 (93%) after, p < 0.05).

CONCLUSIONS

Radical reorganisation of medical care in response to rising acute medical admissions is achievable and may lead to improvements in care.

Modeling drug residue uptake by eggs: yolks contain ampicillin residues even after drug withdrawal and nondetectability in the plasma

The present study was conducted to determine whether: 1) preovulatory yolks may be an important storage depot for drug residues in eggs laid days to weeks after drug withdrawal; and 2) the prediction model based on the pattern of drug incorporation in developing yolks is predictive of the pattern of residues contained in the sequence of eggs laid during and after drug withdrawal. To test these possibilities, 24 hens were dosed for either 1, 2, or 3 d with ampicillin, and the content and pattern of residues in laid eggs were evaluated during and after dosing. Hens were bled 24 h after the final dosing, and plasma ampicillin concentrations were determined. Ampicillin was used in this study because it has an extremely short plasma halflife in laying hens that limits additional drug transfer after drug withdrawal. Ampicillin concentrations were not detectable in plasma from hens injected with ampicillin for either 1, 2 or 3 d (assay sensitivity of 0.6 ng/ml or 0.6 ppb). Hens from all three injection groups produced eggs containing detectable ampicillin residues for 6 d after the last injection. These data demonstrate that drug residues are contained in eggs laid a number of days after drug withdrawal. Because plasma ampicillin was not detectable even 24 h after final dosing, the majority, if not all, of the incurred ampicillin residues contained in eggs laid after drug withdrawal were due to incorporation and storage of drug in preovulatory yolks during the dosing period. Additionally, accounting for ampicillin's stability, our model is predictive of the pattern of residues contained in eggs. These data emphasize the importance of transfer and storage of drugs in preovulatory yolks as a significant contributing mechanism for the production of incurred drug residues in eggs.

Microfibril-associated glycoprotein-1 (MAGP-1) is specifically located on the beads of the beaded-filament structure for fibrillin-containing microfibrils as visualized by the rotary shadowing technique

This study used immunoelectron microscopic techniques to define the ultrastructural location of MAGP-1 on the fibrillin-containing microfibrils of the ocular zonule. A specific anti-MAGP-1 monoclonal antibody (MAb), 11B, was produced that did not crossreact with fibrillin-1 or other microfibrillar proteins. MAb 11B was shown by immunofluorescence to localize intensely to zonular tissue. Postembedding immunoelectron microscopy showed that MAGP-1 was associated with microfibrils throughout the zonule, with the exception of a narrow band of microfibrils at the junction with the lens capsule. With preembedding labeling, the anti-MAGP-1 MAb was found to localize in a crossbanding pattern, at intervals of about 50 nm, to microfibrils throughout the zonule and along bundles of microfibrils in surrounding vitreous tissue. Rotary shadowing of isolated microfibrils showed a "beads on a string" morphology with a periodicity of about 50 nm. With immunogold labeling, the anti-MAGP-1 antibody specifically localized on the beads in a symmetrical manner. Occasionally two gold partides were attached to the same bead, suggesting that multiple MAGP-1 molecules were present in the structure. The results indicate that MAGP-1 is intimately and regularly associated with the bead regions of fibrillin-containing microfibrils. The findings are consistent with a major structural role for MAGP-1 in microfibril biology.

The Women's Health Trial Feasibility Study in Minority Populations: design and baseline descriptions

The Women's Health Trial: Feasibility Study in Minority Populations (WHT:FSMP), a randomized trial of 2208 women, was conducted to investigate three questions. First, can women from minority and low-socioeconomic-status populations be recruited in numbers sufficient to evaluate a dietary intervention designed to lower fat intake. Second, the efficacy of a low fat, increased fruit/vegetable/ grain product intervention for reducing fat consumption. Third, will participation in the intervention lower plasma cholesterol and estradiol levels relative to the controls. The baseline results showed that an adequate number of minority and low SES women could be recruited to test the study hypotheses. A diverse study population of postmenopausal women consuming a high fat diet was recruited: 28% of participants were Black, 16% were Hispanic, 11% had less than a high school level of education, and 15.5% had household incomes of < $15,000.

Assessment of two devices for measuring tympanic membrane temperature in swine, dairy cattle, and dairy calves

OBJECTIVE

To compare tympanic membrane temperature readings obtained with 2 commercially available devices with rectal temperature readings obtained with a standard mercury thermometer in dairy cattle, dairy calves, and swine.

DESIGN

Clinical trial.

ANIMALS

6 Holstein calves (approx 6 months old), 6 Holstein cattle (approx 4 years old), and 5 Landrace-Poland China swine.

PROCEDURE

Tympanic membrane temperatures were measured, and results were compared with rectal temperatures obtained with a standard mercury thermometer. Tympanic membrane temperatures were obtained before and after insertion of the rectal thermometer. Temperature readings in swine were obtained following passive restraint in a cage-like device or restraint using a snare to assess the effect of stress on tympanic membrane temperature.

RESULTS

Tympanic membrane temperature readings from both devices were lower than those obtained using a rectal thermometer for all animals. Repeated measurement of tympanic membrane temperature of individual cattle resulted in consistent readings for both devices.

CLINICAL IMPLICATIONS

Because all animals were visibly healthy, results suggest that tympanic membrane temperature readings obtained with either device may be an adequate assessment of health status.

In vitro modulation of bovine blood neutrophils and mononuclear cells by oxytetracycline

The effect of oxytetracycline (OTC) on bovine blood mononuclear cells and neutrophil functions was examined in vitro. Neutrophil functions tested include respiratory burst, peroxidase, and antibacterial activities. Neutrophils were treated with OTC (10 to 1,500 micrograms/ml) before exposure to either opsonized zymosan or bacteria. A dose-response inhibition of antibacterial activity to high concentrations of OTC (500 to 1,000 micrograms/ml) was observed. Beginning at a concentration of 15 micrograms/ml, OTC treatment of neutrophil lysates resulted in decreased peroxidase activity. A dose response was not observed. In contrast, respiratory burst, measured by nitroblue tetrazolium dye reduction, increased after OTC exposure, but only at high concentrations (500 and 1,000 micrograms/ml) of OTC. Mitogen-induced proliferation of blood mononuclear cells cocultured with OTC and concanavalin A, phytohemagglutinin-P, or pokeweed mitogen was inhibited at an OTC concentration of 100 micrograms/ml at 48 and 72 hours of culture. These results indicate that blood mononuclear cells are more sensitive to the inhibitory effects of OTC than are neutrophils. Furthermore, the OTC-mediated inhibition of neutrophil antimicrobial activity is inversely related to the increase in nitroblue tetrazolium reduction. This suggests that OTC is uncoupling the hexose monophosphate shunt from production of secreted oxygen radicals. These results also suggest that the peroxidase enzyme system has a large biological reserve capacity.