Haig Donabedian

Disseminated cutaneous and meningeal sporotrichosis in an AIDS patient

We report the first proven case of Sporothrix meningoencephalitis in an AIDS patient. The patient had dramatic, wide-spread ulcerative and infiltrative disease with progressive meningoencephalitis in spite of amphotericin and itraconazole therapy. Sporothrix was cultured from premortem cerebrospinal fluid and seen in the meninges and in brain vessels at autopsy.

Rupture of a pulmonary artery mycotic aneurysm associated with candidal endocarditis

Candidal endocarditis can develop if candidemia occurs during Swan-Ganz catheterization. Candida endocarditis may persist for many months and is fatal unless the infected valve is resected. Herein is reported the first case of rupture of a mycotic pulmonary artery aneurysm caused by chronic candidal endocarditis. The endocarditis followed Swan-Ganz catheterization and aneurysm progressed despite appropriate medical and surgical therapy.

A randomized controlled trial evaluating the efficacy and safety of intermittent 3-, 4-, and 5-day cycles of intravenous recombinant human Interleukin-2 combined with antiretroviral therapy (ART) versus ART alone in HIV-seropositive patients with 100–300 CD4+ t cells

The effect of length of therapy on the safety and efficacy profile of continuous intravenous (CIV) interleukin-2 (IL-2) in combination with antiretroviral therapy (ART) was evaluated in 81 HIV-seropositive patients with CD4(+) T-cell counts of 100-300/mm(3). Patients were randomized to CIV IL-2 (12 mIU/day) for 3, 4, or 5 days plus ART every 8 weeks for six cycles, or to ART alone. The mean percent increase in CD4(+) T-cell counts was 24.5% for IL-2 recipients compared with a mean percent decrease of 30.5% for control patients (P = 0.005). Increasing duration of CIV IL-2 therapy resulted in improved CD4(+) T-cell response. The most frequent clinical adverse events and laboratory abnormalities were predominantly of grade 1 or 2 severity. However, grade 3 or 4 events were reported in 57%, 60%, and 84% of the 3-, 4-, and 5-day CIV IL-2 patients, respectively. Serious adverse events, mainly due to the requirement of hospitalization, occurred in 20% of IL-2 recipients, compared with 10% of control patients. Viral load during the course of the study was not different among the treatment groups. IL-2 therapy in cycles of 5 days resulted in an optimal increase in CD4(+) T-cell counts and is the preferred cycle length for IL-2 therapy geared toward increasing CD4(+) T-cell numbers.

Pathogenesis and treatment of endocarditis

The rabbit model has been invaluable for in vivo studies in the pathogenesis and treatment of bacterial endocarditis. Both of the features of the mature bacterial vegetations in this rabbit model, i.e., absence of phagocytosis and decreased metabolic activity, provide evidence to support the concept that a rapidly bactericidal antimicrobial agent provides the optimal approach to the successful treatment of endocarditis. Imipenem, a carbapenem with a very broad spectrum of in vitro activity, has been shown to be rapidly bactericidal in animals and highly effective in the treatment of experimental bacterial endocarditis. In addition, twenty-six patients with endocarditis, caused largely by Staphylococcus aureus, have been successfully treated with imipenem/cilastatin.

Inhibition of neutrophil shape change by an inhibitor of chemotaxis.

Human mononuclear cells exposed to staphylococcal peptidoglycan in serum‐free culture rapidly produce an inhibitor of neutrophil chemotaxis which we have previously described. We found that this inhibitor of chemotaxis has its most potent effect on the inhibition of neutrophil shape change from a spherical to a polarized configuration. In order to quantify this shape change inhibition, we developed an assay using flow cytometric techniques. Neutrophils exposed to a chemoattractant simultaneously change their shape and decrease their forward angle light scattering intensity (δFLS) with a correlation coefficient of 0.886 (p < 0.001). In 51 experiments, neutrophils pretreated with the inhibitor of chemotaxis decreased their FLS by only 6.8 ±1.3 channels, while neutrophils pretreated with medium or control culture supernatants decreased theirs by 26.4 ±1.9 and 20.5 ± 3.0 channels respectively (p < 0.001). The factor which causes inhibition of shape change was indistinguishable from the inhibitor of chemotaxis by physical properties and chromatography. We conclude that this inhibitor of chemotaxis may act by inhibiting a physiologic step at or before shape change.

Inappropriate Use of Oxygen: Loss of a Valuable Healthcare Resource

ABSTRACT: Oxygen (O2) use is well established in hospitalized patients with hypoxemia. However, its value in patients without hypoxemia is not well documented. The authors conducted a retrospective study to evaluate the excess use of O2 and the resulting loss of resources. They established criteria for O2 use by faculty consensus. Ninety‐six patients (102 admissions) receiving O2 between August and October 1991 were identified. Principal discharge diagnoses included cardiac diseases (37%), pulmonary diseases (26.5%), and miscellaneous (36.5%). Cumulative oxygen use was 9,742 hours. Appropriate O2 amounted to 3,272 hours (34%), and inappropriate O2 use was 6,470 hours (66%). The billing for O2 use was

Novel abnormality in subpopulations of circulating lymphocytes. T gamma delta and CD2-, 3+, 4-, 8- lymphocytes in histoplasmosis-associated immunodeficiency.

38,468, of which

Expansion of a T Lymphocyte Subpopulation (CD3+,4––,8––) after Immunodepression Associated with Disseminated Histoplasmosis

25,880 constituted inappropriate use. In 1991, there were 7,743 admissions, with oxygen charges of

Enhancing faculty participation and interest in quality improvement in academic centers.

1.06 million. Extrapolation of the data shows billing for inappropriate oxygen was

Norwegian Scabies in a Patient with AIDS

697,000. The authors conclude that inappropriate use of oxygen results in significant loss of resources. Educational efforts to decrease this loss and evaluate its impact on patient outcome is needed.