Challenges in the identification of Chryseobacterium indologenes and Elizabethkingia meningoseptica in cases of nosocomial infections and patients with cystic fibrosis

Rare nonfermenting Gram-negative bacilli, such as Chryseobacterium indologenes and Elizabethkingia meningoseptica, have clinical importance in nosocomial infections and cystic fibrosis (CF), and their identification is a challenge to microbiology laboratories. Thus, the objective of this study was to verify the performance of phenotypic and mass spectrometry (matrix-assisted desorption ionization–time of flight mass spectrometry, MALDI-TOF MS) methods to identify C. indologenes and E. meningoseptica. In this context, the results obtained with phenotypic methods—namely manual biochemical and automated VITEK 2 (bioMérieux, Marcy l’Etoile, France) and Phoenix tests (Becton Dickinson (BD), San Diego, CA, USA)—and by MALDI-TOF MS—namely MALDI-TOF VITEK MS (MALDI-MS; bioMérieux) and MALDI-TOF BioTyper (MALDI-BD; BD)—of 22 isolates (blood cultures of patients with nosocomial infection (n = 15) and from patients with CF (n = 7)), initially identified as C. indologenes and E. meningoseptica, were compared. As result, using the manual phenotypic method, it was possible to identify the species level in 18/22; no identification was found in 4/22. There was a low agreement level between manual and VITEK 2 automated phenotypic methods when considering the genus level. The greatest agreement for genus-level identification occurred in MALDI-TOF MS equipment (15/22). When comparing all methods to identify the 22 isolates, there was agreement of 4/22 at the genus level and of 4/22 at the species level. In conclusion, there is low agreement level among identification methods of C. indologenes and E. meningoseptica. Although MALDI-TOF MS equipment shows a higher agreement level among them, results present low levels of confidence.

UriSed as a screening tool for presumptive diagnosis of urinary tract infection

BACKGROUND

Although a quantitative urine culture is essential for the final diagnosis of urinary tract infection, it is time-consuming and an expensive procedure. Effective screening tests would be a promising alternative to provide immediate results for the clinician and eliminate unnecessary culturing for most of the negative samples. The aim of this study was to evaluate the performance of an automated sediment analyzer (UriSed) as screening tool for presumptive diagnosis of urinary tract infection.

METHODS

We studied 1379 fresh midstream clean-catch urine samples from children to elderly. All samples were submitted to automated sediment analysis (UriSed) and quantitative urine culture (CLED medium agar).

RESULTS

The sediment analyzer detected leukocyturia and/or significant bacteriuria with sensitivity of 97%, specificity of 59%, positive predictive value of 27%, negative predictive value of 99%, and accuracy of 64% at cutoff values of bacteria count ≥12.6 elements/hpf and WBC ≥6 cells/hpf. These data suggest a potential 52% reduction of unnecessary urine cultures.

CONCLUSION

The UriSed seems to be an efficient tool for screening UTI with high sensitivity and low rate of false-negative results.

Changes in vancomycin-resistant Enterococcus faecium causing outbreaks in Brazil

Enterococci have been implicated in severe human infections as a consequence of associated determinants of virulence and antimicrobial resistance. The majority of vancomycin-resistant Enterococcus faecium (VRE(fm)) connected to outbreaks worldwide pertains to the clonal complex 17 (CC17). In Brazil, the majority of VRE(fm) involved in outbreaks reported so far are not related to CC17. VRE(fm) strains responsible for an outbreak and sporadic cases in hospitals located in the city of Campinas, Brazil, were compared to other VRE(fm) strains in the country. Twenty-two out of 23 E. faecium were vancomycin-resistant and harboured the vanA gene. One vancomycin-susceptible E. faecium (VSE(fm)) strain was included in this study because it was isolated from a patient who one week later harboured a VRE(fm). All strains, except VSE, showed the same alteration in the VanA element characterised by deletion of the left extremity of the transposon and insertion of IS1251 between the vanS and vanH genes. Genes codifying virulence factors such as collagen-adhesin protein, enterococcal surface protein and hyaluronidase were detected in the VRE(fm) and VSE(fm) studied. Both pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) revealed that VRE(fm) and VSE(fm) strains have a clonal relationship. New sequence types (STs) were identified by MLST as ST447, ST448, ST478 and ST412 but all belonged to the CC17. The present study revealed that VRE(fm) outbreaks in Brazil were caused by strains that did not share a common evolutionary history, and that VRE(fm) strains belonging to CC17 could be predominant in Brazil as in other countries.

Evaluation of antimicrobial effectiveness of C-8 xylitol monoester as an alternative preservative for cosmetic products

Xylitol is a natural sugar derived from plants, fruits and vegetables, whose antimicrobial properties are described in the literature. This study aimed to evaluate the antimicrobial effectiveness of C-8 xylitol monoester, for its use as a preservative in cosmetic formulations. The minimum inhibitory concentration (MIC) was determined by the broth macrodilution method, and the antimicrobial effectiveness of C-8 xylitol monoester was determined by using challenge test method. The results obtained in the determination of minimum inhibitory concentration are between 1.0% and 1.25% for Staphylococcus aureus, Escherichia coli and Candida albicans and between 1.0% and 1.5% for Pseudomonas aeruginosa and Aspergillus niger. The amount of 1% of C-8 xylitol monoester was added to the lotion used in the challenge test, observing a rapid decline in the number of CFU g(-1) in stages of evaluation after contamination of the product by all bacteria. The same occurs in relation to C. albicans, which shows a 90% reduction in the number of CFU g(-1). Regarding A. niger, similar reduction is observed when pH value of the lotion is adjusted from 5.5 to 7.0. The results indicate that under the tests conditions, C-8 xylitol monoester has antimicrobial activity and could be considered as an alternative preservative for cosmetic formulations.

Cytotoxic activity of clinical Stenotrophomonas maltophilia

AIMS

To determine the potential virulence factors produced by culture supernatants of clinical isolates of Stenotrophomonas maltophilia.

METHODS AND RESULTS

Culture supernatants of clinical isolates of S. maltophilia were assayed for haemolytic, enzymatic (lipase, protease and phospholipase) and cytotoxic activity. Cytotoxic activity was assayed in Vero (African green monkey), HeLa (human cervix) and HEp-2 (human larynx epidermoid carcinoma) cells. Microscopic analyses revealed intensive rounding, loss of intercellular junctions and membrane alterations (blebbing) followed by death of HEp-2 cells. In Vero and HeLa cells, the cytotoxic effects were characterized by vigorous endocytosis and cell aggregation. The viability of cultured mammalian cells was determined with neutral red and demonstrated that the sensitivity among the cells was different. This activity was inactivated by heating at 56 degrees C for 15 min and protease inhibitors did not inhibit cytotoxic activity. The clinical S. maltophilia presented a cell-free haemolytic activity similar to the 'hot-cold' haemolysins.

CONCLUSIONS

S. maltophilia culture supernatants caused vigorous endocytosis and cell aggregation in HeLa and Vero cells, produced haemolytic and enzymatic activities.

SIGNIFICANCE AND IMPACT OF THE STUDY

This work revealed the presence of putative virulence factors that could be associated with human infections involving Stenotrophomonas maltophilia strains.

Resident research education in physical medicine and rehabilitation: a practical approach

The Accreditation Council for Graduate Medical Education includes training in research as a required component of physical medicine and rehabilitation residency programs. Unfortunately, there is a lack of practical information on how to meet this requirement. In this paper, information is provided for individuals involved in resident education on how to teach residents about research.

Characterization of the Brazilian endemic clone of methicillin-resistant Staphylococcus aureus (MRSA) from hospitals throughout Brazil

The objective of this study was to characterize patterns of the Brazilian endemic clone of methicillin-resistant Staphylococcus aureus (MRSA) from hospitals throughout Brazil. We studied 83 MRSA strains isolated from patients hospitalized in 27 public and private hospitals in 19 cities located in 14 Brazilian states from September, 1995, to June, 1997. The MRSA strains were typed using antibiograms, bacteriophage typing and pulsed field gel electrophoresis (PFGE). The analysis of genomic DNA by PFGE showed that 65 isolates presented the same PFGE pattern. This pattern was present in all of the hospitals studied indicating the presence of an endemic MRSA clone widely disseminated throughout Brazilian hospitals (BEC). All isolates belonging to the BEC proved to be resistant to ciprofloxacin, erythromycin, lincomycin, trimethoprim-sulphamethoxazole, and tetracycline. Variable susceptibility to these drugs was found only in isolates belonging to clones other than the BEC. The results show that, among MRSA, the BEC is common in Brazil. The best method for mapping changes in the frequency of this clone among MRSA is pulsed field gel electrophoresis. Use of molecular mapping is an important tool for monitoring the spread of potentially dangerous microbes.

Isolation in Brazil of nosocomial Staphylococcus aureus with reduced susceptibility to vancomycin

OBJECTIVE

To evaluate the possible presence of vancomycin-resistant Staphylococcus aureus (VRSA) in a Brazilian hospital.

DESIGN

Epidemiological and laboratory investigation of nosocomial VRSA.

METHODS

140 methicillin-resistant S aureus strains isolated between November 1998 and October 1999 were screened for susceptibility to vancomycin. The screening was carried out by using brain-heart infusion agar (BHIA) supplemented with 4, 6, and 8 microg/mL of vancomycin. The minimum inhibitory concentration (MIC) determination was carried out as standardized by the National Committee for Clinical Laboratory Standards using the broth macrodilution, agar-plate dilution, and E-test methods.

PATIENTS

Hospitalized patients exposed to vancomycin.

RESULTS

5 of the 140 isolates had a vancomycin MIC of 8 microg/mL by broth macrodilution, agar plate dilution, and E-test methods. Four VRSA strains were isolated from patients in a burn unit who had been treated with vancomycin for more than 30 days, and one from an orthopedic unit patient who had received vancomycin treatment for 7 days. Pulsed-field gel electrophoresis characterized four of the VRSA strains as belonging to the Brazilian endemic clone. All five strains were negative for vanA, vanB, and vanC genes by polymerase chain reaction. Transmission electron microscopy of the five strains revealed significantly thickened cell walls. One patient died due to infection caused by the VRSA strain.

CONCLUSIONS

This is the first report of isolation of VRSA in Brazil and the first report of isolation of multiple VRSA strains from one facility over a relatively short period of time. This alerts us to the possibility that VRSA may be capable of nosocomial transfer if adequate hospital infection control measures are not taken.

Acquired limb deficiencies. 4. Troubleshooting

This self-directed learning module offers practical analyses of and solutions for common clinical problems of amputees. It is part of the chapter on acquired limb deficiencies in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The information presented here has been designed to be useful also to other interested professionals, including prosthetists, physical therapists, occupational therapists, and nurses. Topics covered include the management of typical obstacles encountered in upper limb amputees, and the diagnosis and treatment of phantom and residual limb pain. Diagnostic and treatment approaches to skin breakdown in the transtibial amputee and to knee instability in the transfemoral amputee are also presented.

OVERALL ARTICLE OBJECTIVE

To analyze common clinical problems of amputees.

Sports and recreation for persons with limb deficiency

Opportunities for persons with limb deficiency to participate in sport and recreational activities have increased dramatically over the past 20 years. Various factors have contributed to this phenomenon, including an increased public interest in sports and fitness as well as improvements in disability awareness. An even more essential element has been a consumer-driven demand for advances in prosthetic technology and design. Whether the activity is a music performance, a friendly round of golf, or a high-level track-and-field competition, the benefits of participation in sports and recreation are numerous both at the individual and at the societal level. This article provides an overview of the development and scope of sport and recreational opportunities available to persons with limb deficiency. In addition, specific prosthetic considerations for several common sport and recreational activities are presented in a case-discussion format.

OVERALL ARTICLE OBJECTIVE

To review the development and scope of sport and recreational opportunities available to persons with limb deficiency.

Acquired limb deficiencies. 3. Prosthetic components, prescriptions, and indications

This self-directed learning module highlights indications for prosthetic components and prescription formulation for adults with acquired limb deficiency. It is part of the chapter on acquired limb deficiencies in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Advantages and disadvantages of specific components of upper and lower limb prostheses are discussed, and a sample prescription sheet for upper limb devices is included. Recent innovations in terminal devices for upper limb prostheses are reviewed. Special considerations for the adult with acquired multilimb deficiency are also examined.

OVERALL ARTICLE OBJECTIVE

To describe indications for prosthetic components and prescription formulation for adults with acquired limb deficiency.

Functional MRI evidence of cortical reorganization in upper-limb stroke hemiplegia treated with constraint-induced movement therapy

OBJECTIVE

The purpose of this pilot study was to test constraint-induced movement therapy for chronic upper-limb stroke hemiparesis and to investigate the neural correlates of recovery with functional magnetic resonance imaging (MRI) in two subjects. Both subjects had been discharged from traditional therapy because no further improvement was anticipated.

DESIGN

Constraint-induced movement therapy consisted of 6 hr of daily upper-limb training for 2 wk; a restrictive mitt was worn on the nonparetic limb during waking hours. Functional MRI was performed on a 1.5-T MRI with echo-planar imaging; at the same time, the subjects attempted sequential finger-tapping.

RESULTS

Compared with baseline, performance time improved an average of 24% immediately after training and also continued to improve up to 33% 3 mo after training. Lift, grip strength, and Motor Activity Log scores likewise improved. Initially, on functional MRI, subject 1 activated scattered regions in the ipsilateral posterior parietal and occipital cortices. Subject 2 showed almost no areas of significant activation. After training, subject 1 showed activity bordering the lesion, bilateral activation in the association motor cortices, and ipsilateral activation in the primary motor cortex. Subject 2 showed activation near the lesion site.

CONCLUSION

Constraint-induced movement therapy produced significant functional improvement and resulted in plasticity as demonstrated by functional MRI.

Using the Internet to enable access to medical conferences

OBJECTIVE

The goal of expanding access to individuals with disabilities to scientific and medical conferences is supported by both the Americans with Disabilities Act and the National Institutes of Health.

DESIGN

Live-streaming video broadcast over the internet is widely available, although it has been used only in a limited fashion by the medical community. A consumer-oriented medical and rehabilitation conference concerning the rare disabling disease, fibrodysplasia ossificans progressiva, was broadcast via the world wide web. The address of a web page was announced before the conference to three computer users' groups that were considered likely to have an interest in the conference. The web page presented a live-streaming video broadcast of the conference. A phone line was installed, thereby allowing viewers to ask questions of the presenters during the question and answer periods.

RESULTS

Sixteen users logged in 83 times to view the conference over a 2-day period. Five (23%) of 22 members of a fibrodysplasia ossificans progressiva internet users' group tuned in from distant places as The Netherlands and Israel.

CONCLUSIONS

The internet is a viable tool to expand access to and increase the participation of individuals with disabilities in scientific and medical conferences. This technology should be used routinely in conferences of interest.

Clinical relevance and virulence factors of pigmented Serratia marcescens

Pigmented Serratia marcescens isolated in a Brazilian hospital were studied with respect to frequency of isolation, serotyping, antibiotic resistance and virulence factors. The serotype most frequent was O6:K14 (53%) and all isolates were resistant to ampicillin, cephalothin and tetracycline. The majority of the isolates (92%) were resistant to the action of human serum and all produced cytotoxins on Vero, CHO, HEp-2 and HeLa cells. These isolates were virulent for mice (LD(50)=10(7) bacteria ml(-1)) and showed virulence factors, but were isolated with low frequency (3. 4%) and caused infection in only 31% of cases. Analysis of serotyping, phage typing and chromosomal DNA revealed at least 13 unrelated strains among pigmented S. marcescens. In conclusion, this work describes a low frequency of isolation of pigmented S. marcescens from clinical specimens, indicating that non-pigmented strains are clinically more significant.

Comparison of three methods for recording tibial H reflex: a clinical note

Recording the tibial H reflex from the calf is routine in clinical electromyography. Two widely used methods are Hugon's and Braddom and Johnson's. Both methods produce an H wave with an initial positive deflection. Another method, the "half and half" method, generates an H wave with an initial negative deflection. To compare these methods, H-reflex responses were recorded in the right calf of 20 normal adults with each method using identical amplifier and stimulator settings. Stimulus current was increased by increments of 0.5-1.0 mA until the H reflex and motor (M) wave responses reached maximum amplitudes (Hmax, Mmax). H wave to M wave (H/M) amplitude ratios were calculated. The half-and-half method produced greatest Hmax, Mmax, and H/M ratio. Wave form configuration for the half-and-half method was biphasic with an initial negative deflection; it was triphasic with an initial positive deflection with the other methods. The shapes of M and H waves were similar in two methods but dissimilar in one. Because of the greater amplitude and the initial negative deflection, the H wave may be easier to detect with the half-and-half method and may present a latency that is more easily determined. For these reasons, the half-and-half method is recommended for measuring amplitude and latency in clinical settings.

Nosocomial infections caused by multiresistant Pseudomonas aeruginosa

A case-control study was done to evaluate factors associated with nosocomial infections by multiresistant Pseudomonas aeruginosa (MRPA). Results showed that MRPA was associated with the use of immunosuppressive and antimicrobial drugs. Five typing methods indicated that the MRPA infections were due to multiple strains rather than a single strain.

Conductive hearing loss in individuals with fibrodysplasia ossificans progressiva

Fibrodysplasia ossificans progressiva (FOP) is a very rare genetic disorder that is characterized by progressive heterotopic ossification of soft tissues and congenital malformation of the great toes. Although previous case studies have reported hearing loss in individuals with FOP, there have been no large-scale studies regarding the nature or cause of the hearing loss. Here, we report the findings of a two-part study. In Part I, we report the findings of a postal survey regarding hearing loss that was sent to 102 individuals with FOP. In Part II, we report the findings of on-site hearing evaluations of eight individuals with FOP. The findings of both studies indicate that individuals with FOP are at risk for hearing loss and that the type of loss is predominantly conductive in nature, similar to that seen in individuals who have otosclerosis.

Evaluation of malaria surveillance using retrospective, laboratory-based active case detection in four southwestern states, 1995

The global resurgence of malaria has raised concerns of the possible reintroduction of indigenous transmission in the United States. The Centers for Disease Control and Prevention's National Malaria Surveillance System, using data supplied by state and local health departments (SLHDs), is maintained to detect local malaria transmission and monitor trends in imported cases. To determine the completeness of reporting of malaria cases to SLHDs, cases identified by local surveillance systems were compared with those identified through active case detection conducted at all laboratories that receive clinical specimens from 11 metropolitan areas in Arizona, California, New Mexico, and Texas. Of the 61 malaria cases identified through either local surveillance or active case detection, 43 (70%) were identified by SLHDs (range by metropolitan area = 50-100%) and 56 (92%) through active case detection. High percentages of cases were identified by SLHDs in New Mexico (80%) and San Diego County (88%), where laboratories are required to send positive blood smears to the SLHD laboratory for confirmation. Completeness of reporting, calculated using the Lincoln-Peterson Capture-Recapture technique, was 69% for SLHD surveillance systems and 89% for laboratory-based active case detection. The high percentage of cases identified by the 11 SLHDs suggests that the National Malaria Surveillance System provides trends that accurately reflect the epidemiology of malaria in the United States. Case identification may be improved by promoting confirmatory testing in SLHD laboratories and incorporating laboratory-based reporting into local surveillance systems.

Climatic and environmental patterns associated with hantavirus pulmonary syndrome, Four Corners region, United States

To investigate climatic, spatial, temporal, and environmental patterns associated with hantavirus pulmonary syndrome (HPS) cases in the Four Corners region, we collected exposure site data for HPS cases that occurred in 1993 to 1995. Cases clustered seasonally and temporally by biome type and geographic location, and exposure sites were most often found in pinyon-juniper woodlands, grasslands, and Great Basin desert scrub lands, at elevations of 1,800 m to 2,500 m. Environmental factors (e.g., the dramatic increase in precipitation associated with the 1992 to 1993 El Niño) may indirectly increase the risk for Sin Nombre virus exposure and therefore may be of value in designing disease prevention campaigns.

Short report: Decrease in seroprevalence of antibodies to hantavirus in rodents from 1993-1994 hantavirus pulmonary syndrome case sites

Rodent trapping was conducted at seven hantavirus pulmonary syndrome (HPS) case sites from June 1993 to March 1994 during the HPS outbreak in the southwestern United States. To determine if there were changes in the rodent population or the hantavirus seroprevalence in rodents since the HPS outbreak, rodents were trapped at the same sites three years later using the same trapping protocol. The trap success decreased from the numbers trapped during the outbreak, however, the number of Peromyscus, as a percentage of the total rodents captured, did not noticeably decrease. In addition, the seroprevalence of hantavirus antibodies in Peromyscus decreased significantly (P < 0.0001).

Detection of cytotoxic activity on Vero cells in clinical isolates of Serratia marcescens

Cytotoxin production was studied in 60 Serratia marcescens strains isolated from hospitalized patients. Association of cytotoxic activity with serotype, source of isolation and presence of plasmids was also evaluated. Thirteen of the 60 S. marcescens strains produced a cytotoxic effect on Vero cells. These strains were isolated from distinct clinical sources and classified into seven different serotypes (O1:H7; O4:NM; O10:NT; O19:NM; O6,14:H4; O6,14:NM and O6,14:H1). No relationship was observed between cytotoxic activity and clinical source or serotypes of the strains. Plasmids from five cytotoxin-producing S. marcescens strains were transferred to E. coli K12/711. The transconjugants did not exhibit cytotoxicity, indicating that the cytotoxic effect is not plasmid-mediated among these strains. Although a cytotoxic activity was demonstrated in filtrates of some S. marcescens strains, further studies should be performed to assess the role of this toxin in pathogenesis.

Definition of agitation following traumatic brain injury: I. A survey of the Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation

OBJECTIVE

To determine national patterns of defining agitation after traumatic brain injury (TBI) by physiatrists with expressed interest in treating TBI survivors.

DESIGN

A random sample of 70% of the members of the Brain Injury Special Interest Group (SIG) of the American Academy of Physical Medicine and Rehabilitation (AAPM&R) were surveyed by telephone.

RESULTS

The 129 members who responded yielded an 82% response rate. Respondents rated 18 characteristics from established rating scales on a 5-point scale according to each characteristic's relation to its clinical definition of agitation. Physical aggression, explosive anger, increased psychomotor activity, impulsivity, verbal aggression, disorganized thinking, perceptual disturbances, and reduced ability to maintain or appropriately shift attention were rated by at least 50% of the sample as very important or essential to agitation. Delirium, as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), has been proposed as a standard definition of agitation. The degree to which all characteristics from the 3rd revised edition of the DSM (DSM-IIIR), considered together, were perceived to relate to agitation predicted 24% of the degree to which the term "delirium" was perceived to relate to agitation (Canonical correlation r = .48, p = .0002). Physicians' ratings of individual delirium characteristics from the DSM-IIIR were examined to determine if a sufficient number were similarly ranked to fulfill the diagnostic criteria for delirium. A significant number of physicians rated diagnostic criteria for delirium in one direction, yet did not rank the term "delirium" accordingly (McNemar's p = .04).

CONCLUSIONS

There is considerable variation among physiatrists in their rating of characteristics that define agitation. Many define agitation during the acute recovery phase as posttraumatic amnesia plus an excess of behavior such as aggression, disinhibition, and/or emotional lability. Less support was given to defining agitation by the DSM-IIIR or DSM-IV diagnostic criteria for delirium. Delirium appears related to, but is not sufficient for, a diagnosis of agitation.

Measurement and treatment of agitation following traumatic brain injury: II. A survey of the Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation

OBJECTIVE

Determine national patterns of measuring and treating agitation after traumatic brain injury (TBI) by physiatrists with expressed interest in treating TBI survivors.

DESIGN

A 70% random sample of members of the Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation was surveyed by telephone.

MAIN OUTCOME MEASURE

The survey instrument was designed to determine the most common pharmacologic interventions for agitation and, where possible, match each drug with the target behavioral and cognitive characteristics for which it is prescribed. Data were also collected on the manner in which participants measured agitation and judged treatment efficacy.

RESULTS

One hundred twenty-nine of 157 responded, yielding an 82% response rate. The majority of respondents were not measuring agitation in a standard fashion. The five most frequently prescribed drugs by the expert stratum were carbamazepine, tricyclic antidepressants (TCAs), trazodone, amantadine, and beta-blockers. In comparison, the nonexperts most often reported prescribing carbamazepine, beta-blockers, haloperidol, TCAs, and benzodiazepines. Desyrel (p = .06) and amantadine (p = .001) were significantly more likely to be chosen by experts than by nonexperts. Experts chose haloperidol significantly less often than nonexperts (p = .01). Prescription of sedating drugs such as haloperidol or benzodiazepines was not found to be associated with the acuity of injury of TBI patients in the respondent's practice, practice setting, or years of practice since completing residency. Choice of haloperidol to treat agitation was not significantly associated with the degree to which explosive anger, verbal aggression, or physical aggression were considered important to the respondent's definition of agitation.

CONCLUSIONS

The majority of physiatrists surveyed did not formally measure agitation. Treatment strategies differ significantly between general physiatrists and those who specialize in the treatment of patients with TBI. The breadth of pharmacologic agents and strategies identified in this survey probably reflects the lack of research specific to the pathophysiology of the disorder of posttraumatic agitation.

Patterns of association with host and habitat: antibody reactive with Sin Nombre virus in small mammals in the major biotic communities of the southwestern United States

The distribution and prevalence of antibody reactive with Sin Nombre virus were determined in mammals in biotic communities of the southwestern United States. Small mammals (n = 3,069) of 69 species were trapped in nine communities from lower Sonoran desert to alpine tundra. Antibody was found in rodents from all communities (overall prevalence = 6.3%); prevalence was lowest at the altitudinal and climatic extremes (0.4% in desert and 2.0% in alpine tundra). Antibody occurred in 11% of 928 deer mice, 20% of 355 brush mice, 23% of 35 western harvest mice, and 12% of 24 Mexican voles. No infected deer mice were found in desert habitat; prevalence varied from 4% in chaparral to 17% in pinyon-juniper. Brush mice were frequently infected in chaparral and montane forest (25%). Seropositivity was higher in males and in heavier animals, suggesting horizontal transmission among adult males. Decreasing prevalence with age among the youngest deer mice suggests that infected dams confer passive immunity to pups.

Recovery of upper limb motor function in tetraplegia with stellate ganglion block treatment of reflex sympathetic dystrophy: a case report

Recovery of motor function in spinal cord injury usually does not occur beyond 2 yr from the date of injury and is rare beyond 8 yr. We present a case of a gentleman with a right C-5 motor, left T-5 motor, bilateral T-5 sensory tetraplegia, sustained after a fall in September 1985, who developed reflex sympathetic dystrophy of his right arm. This pain failed to resolve during the next 8 yr, despite conservative treatment consisting of range of motion, contrast baths, transcutaneous electrical nerve stimulation unit, and tricyclic antidepressants. Furthermore, his pain was refractory to dorsal rhizotomy in 1987. Subsequent follow-up visits documented ongoing pain and weakness of the right arm, with a stable injury pattern. Approximately 8 yr after initial injury, the patient underwent a series of eight stellate ganglion blocks, with the surprising result of improvement in Kendall graded motor function. This improvement was enough to represent a change in the motor level of spinal cord injury from C-6 to C-7, with a resultant increase in functional abilities. The improvement of motor function after stellate ganglion blocks for treatment of reflex sympathetic dystrophy is unprecedented and indicates that its aggressive treatment in patients with myelopathies may hasten motor recovery and, thus, functional gains. Physiologic explanations for this phenomenon include (1) resolution of pain inhibition, (2) improvement in disturbed microcirculation, and (3) resolution of sympathetic inhibition of mu-motor neurons via internuncial neurons.

Biotypes, serovars and antimicrobial resistance patterns of Acinetobacter baumannii clinical isolates

255 Acinetobacter strains, from clinical specimens of inpatients and outpatients, were identified phenotypically according to the new taxonomy proposed by Bouvet and Grimont. A. baumannii was the most frequent species (80.8%). This species underwent biotyping and serotyping according to the scheme of Bouvet and Grimont, and that of Traub, respectively, 81.2% of samples belonged to biotypes 2, 6 and 9 with a predominance of biotype 2. 86.6% of the strains could be serotyped; 2 new serotypes were encountered. The new serotype 29, being the most frequently isolated, was related to biotype 2 (86.6%), whereas serotype 13 was related to biotype 6 (84.8%). These clones presented marked multiple resistance patterns and were widespread in different wards. No outbreak was reported during the period studied. These phenotypical methods proved to be useful in differentiating strains of A. baumannii and, if used together, they showed a high discriminatory power.

Three-dimensional vector graphing of the H reflex

Comparison of latencies of the H reflex from side-to-side is considered a valid indicator of pathology, but amplitudes are too variable to allow similar comparison. Three pairs of electrodes were placed circumferentially and longitudinally along the calf to record the H reflex in three axes simultaneously. An H reflex with the greatest amplitude was produced by incrementally increasing submaximal stimulation to the tibial nerve. Three-dimensional vector graphs were constructed at three levels in each calf in ten normal individuals. Best fit curve Procrustes statistical analysis showed an average of 82.2 to 90.6% agreement of 3-D shape left-to-right with greater agreement at distal levels. Standard deviation ranged from 11.3% proximally to 8.2% distally. This represents much closer agreement than established norms for amplitude, which can vary from two to four times side-to-side. Three-dimensional vector analysis holds promise to further understanding of peripheral and central electrophysiologic phenomena.

Effects of temperature on motor unit action potentials during isometric contraction

The effect of temperature on motor unit action potential (MUAP) configuration and recruitment was studied using automatic decomposition electromyography (ADEMG) recordings from a concentric needle electrode placed in the first dorsal interosseous (FDI) muscle of 10 normal adult subjects during isometric contraction. Focally cooling the FDI resulted in prolonged MUAP duration (P < 0.001, ANOVA), a finding congruent with those of Buchthal. Focal ulnar cooling at the elbow resulted in the increased MUAP frequency. In contrast to previous studies, there were no significant differences in amplitude or turns. Greater understanding of normal motor unit electrophysiology is necessary to improve diagnostic accuracy of EMG testing.

[Plasmid size determination using 3 methods]

Analysis of bacterial plasmid profiles has been shown to be very important in epidemiological studies, especially those involving outbreaks of nosocomial infections. The molecular weight size of unknown plasmids is determined by comparing their band pattern obtained in agarose gel electrophoresis with those obtained with plasmids that have been used as molecular weight or size standards. In this study, we determined the size of plasmids present in clinical samples of Enterobacter cloacae comparing their electrophoresis mobility with seven plasmids of known size, using three different mathematical methods. For plasmids with molecular weight ranging from 2 kb to 100 kb. The most accurate determinations were obtained by power-function. Analyses using the exponential variables obtained with these plasmids were accurate for two types of plasmids, those with size ranging from 50 kb to 100 kb and those with size ranging from 2 kb to 30 kb. We also observed discrepancies among the methodologies described, including one used by a computer software designed for calculating the size of plasmids DNA.

Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colorectal surgery

A total of 149 patients admitted for elective colorectal surgery were randomly allocated to receive preoperative mechanical bowel preparation (group 1) or no mechanical bowel preparation (group 2). All patients received antimicrobial prophylaxis with cephalothin and metronidazole. The overall incidence of wound infection was 17.4 per cent (24 per cent for group 1, 12 per cent for group 2) and that of dehiscence 7.4 per cent (10 per cent for group 1, 5 per cent for group 2). The incidence of wound infection was significantly higher in group 1 (P < 0.05) but that of anastomotic dehiscence did not differ significantly between groups. Mechanical bowel preparation is unnecessary and may be harmful in terms of preventing wound infection and anastomotic dehiscence in patients undergoing elective colorectal surgery.

Distribution of serotypes and antimicrobial resistance of Streptococcus pneumoniae strains isolated in Brazil from 1988 to 1992

Forty-two serotypes were identified among 288 Streptococcus pneumoniae strains isolated from patients living in Brazil. Serotyping was determined by the capsular typing test (Quellung reaction). Types 14 (10.4%), 6B (9.8%), 23F (8.0%), 5 (7.3%), 19F (6.9%), 6A (6.0%), and 1 and 4 (4.6%) were the most commonly identified strains. Two hundred twenty (76.4%) of the strains were of serotypes that are included in the 23-valent pneumococcal polysaccharide vaccine. If vaccine-related serotypes are also considered, the proportions of coverage in the vaccine are 82.3% (if type 6B alone is added) and 85.7% (if all the vaccine-related types are considered to be cross-protecting). Decreased susceptibility to penicillin, which was identified by using the 1-microgram oxacillin disk method as a screening test, was detected in 70 (26.7%) strains. The MICs of nine antimicrobial agents were determined by using the procedures recommended by the National Committee for Clinical Laboratory Standards. Seventy (35.9%) of the strains were resistant to tetracycline, 57 (29.2%) were resistant to sulfamethoxazole-trimethoprim, 3 (1.5%) were resistant to rifampin, 2 (0.80%) were resistant to penicillin, and 1 (0.5%) was resistant to chloramphenicol. The two penicillin-resistant strains were also resistant to or had decreased susceptibilities to cephalosporins. Forty-seven (17.9%) of the strains were intermediately resistant to penicillin, 17 (8.7%) were intermediately resistant to tetracycline, 13 (6.7%) were intermediately resistant to chloramphenicol, 12 (6.1%) were intermediately resistant to erythromycin, and 6 (3.1%) were intermediately resistant to rifampin.

Serum albumin level as a predictor of geriatric stroke rehabilitation outcome

This study examined the value of serum albumin level as a predictor of medical complications and functional outcomes in 79 patients, age 65 years or older, who underwent comprehensive inpatient interdisciplinary rehabilitation for a first-time, unilateral, thromboembolic stroke. We recorded serum albumin levels at the time of admission to an inpatient rehabilitation unit, reports of the medical complications during rehabilitation, and Modified Barthel Index (MBI) Scores on admission and discharge. The mean (+/- SD) serum albumin level for all patients was 3.3 +/- 0.4g/dL. Forty-two patients (53%) had a total of 69 medical complications during rehabilitation. Mean serum albumin levels were 3.2 +/- 0.4g/dL for the group with complications and 3.5 +/- 0.3g/dL for the group without complications (t = -4.34, p < 0.001). Of the 37 patients with albumin levels > or = 3.5g/dL, only 32% had complications; of the 28 patients with levels from 3.0 to 3.4g/dL, 68% had complications; of the 14 patients with levels < or = 2.9g/dL, 79% experienced complications (chi 2 = 12.4, p = 0.002). There were positive correlations between serum albumin levels and the discharge MBI Self-Care Subscores, Mobility Subscores, and Total Scores (p < 0.001). There were also correlations between serum albumin levels and the Mobility and Total MBI Improvement Scores (p = 0.002 and p = 0.008, respectively). The relationship between serum albumin levels discharge destination approached statistical significance. Neither age nor side of lesion were related to serum albumin level, medical complication rate, or functional outcomes. Serum albumin levels appear to be related to medical complication rate and functional outcome in geriatric stroke patients. This suggests that older stroke patients with hypoalbuminemia may warrant closer medical attention or therapeutic intervention before and during rehabilitation.

Nocardia infection in renal transplant recipient: diagnostic and therapeutic considerations

In the present report the authors discuss the diagnostic difficulties, therapeutic measures and the clinical course of Nocardia infection which occurred among renal transplant recipients at the University Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (UH-FRP), from 1968 to 1991. Among 500 individuals submitted to renal transplant, 9 patients developed Nocardiosis at varying times after transplant (two months to over two years). All the patients had pulmonary involvement and their most common symptoms were fever, cough and pleural pain. Dissemination of the process is common and three patients presented cutaneous abscesses, four CNS involvement and one had pericarditis due to Nocardia. The diagnostic is quite difficult since there is no specific clinical picture, concomitant infections are frequent and the microorganism presents slow growth in culture (ranging from four to forty days, in our experience). In this report, three cases were only diagnosed by necropsy. The treatment of choice is a combination of Sulfamethoxazole and Trimethoprim (SMX-TMP). In the present series, overall mortality was 77% (7 cases) and in five of the patients who died the diagnosis was late. All the patients who had CNS involvement died.

[Cryptococcus meningitis: clinical course, development and histopathologic aspects depending on the predisposing factors]

Seventeen consecutive cases of cryptococcal meningitis diagnosed at Hospital das Clínicas of Ribeirão Preto Medical School (São Paulo State Brazil) between 1969 and 1985 were reviewed. For analysis the patients were separated in 3 groups: I. three patients without immunodeficiency; II. six patients with associated disease: cancer (3), diabetes (2) and alcoholism (1); III. Eight renal transplant recipients that developed cryptococcosis after 18 to 67 months of immunosupression with steroids and azathioprine. The median interval between onset of symptoms and diagnosis of infection was greater in Group II (53 days) than in Groups I (25 days) or III (28 days). Neck stiffness, cranial nerve involvement and papilledema were more frequent in Group I than in Group II or III, but fever and focal neurological signs were observed only in patients of two last groups. Cerebrospinal fluid examination showed a mild lymphocytic pleocytosis in most patients, but transplant cases had polymorphonuclear cells more frequently. Late mortality was higher in patients with underlying disease and the prognosis was better for transplant patients that received effective antifungal therapy. Besides cryptococci, autopsy findings in 8 cases revealed granuloma formation in tissues, except in patients of Group II (2 cases). The differences between the groups suggest that clinical characteristics, evolution and postmortem findings of the cryptococcal meningitis are changed according to type of immunodeficiency presented by the patient.

[Meningoencephalitis due to Pasteurella multocida: clinico-laboratory study of a case in an infant]

The authors report a case of Pasteurella multocida meningoencephalitis in a 5 week-old female infant, with special attention to clinical, laboratory and evolutive features. A moderate neurological sequel was observed at follow-up examinations. A brief review of the importance of P. multocida in human pathology is presented on the basis of the international literature, since the authors did not find any Brazilian reports. The most important feature on P. multocida is the prevalence of bacterial meningitis at the extremes of age. Otherwise, significant mistaken was found between Gram stained smears of body fluids for P. multocida and Haemophilus influenzae or Neisseria meningitidis. Because its role in infections following animal bite or scratch and its opportunistic feature, P. multocida must be included among the possible etiologic agent of bacteremia or sepsis in patients with liver cirrhosis or immunosuppression.

[Brazilian purpuric fever: preliminary results of the etiological research]

Em várias regiões do interior do Estado de São Paulo, notificou-se a partir do final de 1984 a 1986, a ocorrência de doença até então desconhecida, com características clínicas, em muitos aspectos, semelhante à meningococcemia. Esta síndrome foi denominada Febre Purpúrica Brasileira (FPB). Em quinze dos casos com quadro clínico compatível com a síndrome, o Haemophilus aegyptius foi isolado a partir de culturas de sangue, de líquido cefalorraquidiano sanguinolento, de secreção conjuntival e orofaríngea. Analisa-se a importância deste achado, face à existência de somente um relato na literatura, de infecção sistêmica por bactérias desta espécie.

[Intravenous catheters--a study of bacteriological conditions and evaluation of nursing care]

Embora organizações de saúde Internacionais e autores nacionais tenham emitido há alguns anos diretrizes a serem aplicadas aos cateteres intravenosos, tanto introduzidos através de agulhas como de flebotomias, tem-se observado que estas não têm sido respeitadas. Os autores realizaram estudos junto a pacientes internados em um hospital de Ribeirão Preto, com os objetivos de verificar o tempo de permanência desses cateteres, relacionando-o com suas condições bacteriológicas e dos curativos realizados, avaliando a eficácia da assistência de enfermagem ministrada.