Persistent exit-site/tunnel infection and subcutaneous cuff removal in PD patients

The purpose of our study was to investigate catheter outcome of persistent exit-site/tunnel infections (ESI/TIs) in peritoneal dialysis (PD) patients. The patients underwent removal of subcutaneous cuff due to persistent ESI/TI from January 1989 to December 1996 in a tertiary referral university hospital. Two hundred and twenty-three patients (138 male, 85 female) underwent 244 double-cuff coiled Swan neck catheter implantations surgically. Twenty-nine patients (11.8%) had persistent ESI/TI for more than 6 months with the same organism. Sixteen patients (52%) underwent subcutaneous cuff excision. Thirteen (48%) patients refused and were managed conservatively. Two hundred and forty-three episodes of ESI/TI were observed over 4970 patient-months with a rate of 0.58 episodes/patient/year. Twenty-nine patients (11.8%) had persistent ESI/TI with S. aureus in 19, Pseudomonas aeruginosa in 9 (31%), and Serratia marcescens in one (3%) patient. Fourteen (88%) persistent ESI/TIs resolved after subcutaneous cuff excision. None of the patients with ESI/TI responded to conservative treatment. ESI/TI-related peritonitis decreased from 11 episodes to 5 episodes after cuff excision. In contrast, episodes of peritonitis increased from one to 9 with conservative management during a follow-up of mean 18 months (4-38 months). Four (31%) catheters were lost in the conservative group, while 3 (19%) were lost after cuff excision. ESI/TI-related peritonitis decreased after subcutaneous cuff excision but increased with conservative management for ESI/TI. ESI/TI resolved in 88% of the patients after cuff excision, while none resolved with conservative treatment.

Contact lenses affect corneal stromal pH

Recent studies suggest that corneal acidosis may alter corneal structure and function. We determined whether the range of oxygen transmissibility (Dk/L) provided by a hydrogel lens could affect corneal stromal pH. Stromal pH was measured using a noninvasive fluorometric technique under both open- and closed-eye conditions on subjects who wore hydrogel lenses made of the same material but with different lens powers. Under closed-eye lens wearing conditions, central stromal pH was reduced substantially and there was no relation between degree of acidosis and lens Dk/L. Under open-eye lens wearing conditions, central stromal pH was also reduced but the degree of acidosis was dependent on lens Dk/L. These results suggest extended wear of hydrogel lenses can produce marked decreases in stromal pH which could remain reduced even after the eyes are opened.

Changes in the pattern of drug overdoses

OBJECTIVE

To describe changes in the pattern of patients with drug overdoses hospitalized over the past two decades.

DESIGN

Retrospective data review.

SETTING

A 719-bed university-affiliated hospital.

PATIENTS

All adults admitted to the hospital with drug overdoses in 1968, 1979, and 1989.

PRIMARY OUTCOME MEASURES

Changes in demographics, drugs used, and discharge disposition.

RESULTS

A majority of patients admitted with drug overdoses have had previous suicide attempts; and while women predominate, they make up a decreasing proportion of admissions over time (76% in 1968 to 52% in 1989 (p = 0.003). Benzodiazepines were the drugs most commonly used in 1979 and 1989, and cocaine has shown a marked increase in use over time, while barbiturate overdoses have progressively decreased. The use of two or more drugs is common and has been consistent over time, as has been the concomitant use of alcohol. The mortality rate has remained low at 1%, but mean length of stay has decreased dramatically from 6.6 days in 1979 to 3.2 days in 1989 (p < 0.001) and discharge disposition has shifted from out-patient to inpatient psychiatric care.

CONCLUSIONS

The majority of patients admitted to a general acute care hospital following a drug overdose have a history of previous suicide attempts and are followed by a mental health professional. The changing pattern of drugs used over two decades reflects trends in drugs used in the community in general and by patients with mental illness in particular. Discharge disposition has changed over time and is related to patients' insurance status.

Ocular effects of hard gas-permeable-lens extended wear

Thirty-five myopic subjects were fitted with rigid gas-permeable lenses for 6 months of extended wear (EW). These lenses had an average oxygen transmissibility of 37 x 10(-9) (cm x ml x O2)/(s x ml x mm Hg). For six monthly morning visits subjects reported with one eye patched; corneal thickness, corneal curvature, refractive error, endothelial photomicroscopy, and slitlamp examinations were done on both eyes. The average morning corneal swelling was 5.9 +/- 3.3%. Corneal curvature showed 0.24 +/- 0.44 D flattening in the steep meridian and 0.20 D steepening in the flat meridian. Spectacle refraction and corrected visual acuity changes were small in the spherical and cylindrical components. Complications that were important clinically included 10% lens adherence syndrome, 20% superficial limbal keratitis, 6.5% epithelial microcysts, and some increase in endothelial polymegathism. No infections, red eye responses, or infiltrative keratitis were observed during the 6-month follow-up period. These results suggest that hard-lens EW is feasible and that lenses with this Dk/L value will meet oxygen requirements for many patients; however, some patients will require lenses of higher oxygen transmissibility to avoid undesirable complications.

Development of physical profiles for specific jobs

Inherent risk of injury associated with heavy physical work tasks frequently obviates direct job analysis -- content validity -- for predictive or diagnostic purposes. A common alternative is an appraisal of the physical attributes manifest by the job requirements and the selection of tests of related physical factors. 241 job applicants were given a test battery composed of 40-items at the University of California Medical Center, Sacramento, California. A factor analysis reduced the initial 40-item test battery to an unweighted 6-item field test battery FTB. Standards scales were established for the FTB and applied to evaluate without prejudice a second group of 300 applicants. Since the present criterion for adequate job performance is simply the successful completion of climbing school, means for each test item of the FTB were evaluated for their predictive value. The mean scores for the step test and balance were found to be significantly different, smaller than .05 between the successful and unsuccessful applicants, whether male or female. Percent fat differed significantly only in the males and two strength tests and reaction times were not significant. Additional studies were conducted on two groups of young adults with known fitness levels to better characterize the strength factors which are considered essential to acceptable pole climb performance. Significant differences were found for both static and dynamic strengths, p equals smaller than .05. In summary, a FTB of simple, objective, job related test items can be identified and validated for predictive and diagnostic purposes. Probabilities for success can be established through a preliminary self-screening test program and administered by the employment office. The test items which comprise the FTB can be figuratively presented as a profile analysis and incorporated in the employee's medical file for longitudinalappraisal. If meaningful standards can be established for use in preemployment or job transfer screening, substantial financial benefits can accrue to the company in terms of reduced administrative and training costs and a reduction in "sick leave" and liability resulting from industrial accidents.