Leland S. Rickman

Correlation Between CD4+ Counts and Prevalence of Cytomegalovirus Retinitis and Human Immunodeficiency Virus--related Noninfectious Retinal Vasculopathy in Patients With Acquired Immunodeficiency Syndrome

We prospectively studied 132 patients with acquired immunodeficiency syndrome (AIDS) to determine the cross-sectional prevalence of cytomegalovirus retinitis. All patients had serum CD4+ lymphocyte counts to determine the degree of immune dysfunction. Correlations between CD4+ counts, the presence of cytomegalovirus retinitis or human immunodeficiency virus (HIV)-related noninfectious retinal vasculopathy, and ocular symptoms were made. The study disclosed that 26 of 132 patients with AIDS (20%) had cytomegalovirus retinitis. However, subset analysis according to CD4+ count disclosed that in patients with CD4+ counts of 50 cells/mm3 or less, 26 of 87 (30%) had cytomegalovirus retinitis, whereas in patients with CD4+ counts of 50 cells/mm3 or more, none of 45 was noted to have cytomegalovirus retinitis. Similarly, 46 of 132 patients (35%) were noted to have HIV-related noninfectious retinal vasculopathy, with a trend toward increasing prevalence associated with declining CD4+ count. In patients with CD4+ counts of 50 cells/mm3 or less, 39 of 87 (45%) had HIV-related noninfectious retinal vasculopathy, whereas seven of 45 patients (16%) with CD4+ counts of 50 cells/mm3 or more were noted to have these changes. We confirmed the clinical impression that cytomegalovirus retinitis and HIV-related noninfectious retinal vasculopathy are late manifestations of AIDS, demonstrated an increased risk for patients with low CD4+ counts, and suggested a basis for coherent chemoprophylaxis and screening strategies for cytomegalovirus retinitis.

Infectious Complications of Body Piercing

Body piercing appears to be gaining in popularity and social acceptance. With the increase in the number of piercings, it is likely that health care providers may see an increase in the complications resulting from these piercings. These may include the transmission of hepatitis viruses and bacteria at the time of the piercing or in the course of wound care. We review the infectious complications that have resulted from body piercing and have been documented in the medical literature.

Infectious Diseases on Cruise Ships

Travel by sea is one of the earliest forms of transportation. From ancient times to the present, people have traveled by ship for purposes of food obtainment, trade of goods, conquest, employment, and leisure. Before ships were built large enough to take long ocean voyages, the most relevant medical problems included drownings, injuries, and attacks by alligators, sharks, whales, or other sea creatures. It was only after ships sailed for more than a day or two that questions of food and water supply, sanitation, ventilation, care of the sick and injured on board, spread of plagues, and transmission of infectious diseases began to arise. An estimated 4.5 million passengers travel on cruises in North America annually [1].

Examiner dependence on physical diagnostic tests for the detection of splenomegaly: A prospective study with multiple observers

Objective: To determine the reliability and validity of various physical diagnostic techniques (including three methods of palpation and three methods of percussion) in detecting ultrasonographically identified splenomegaly.Design: Prospective, double-blind study.Setting: University hospital.Patients: Twenty-seven hospitalized male patients with suspected human immunodeficiency virus (HIV) infection.Interventions: Three methods of palpation (bimanual, ballottement, and palpation from above) and three methods of percussion (as described by Nixon, Castell, and Barkun et al.) were performed on each patient by eight examiners. Splenic ultrasonography was performed within 96 hours of admission.Measurements and main results: The prevalence of splenomegaly by ultrasonography (defined as a spleen ≥ 13 cm on the longitudinal scan) in this population was 33.3%. The sensitivity and specificity of each method of palpation and percussion varied by examiner. The ranges of sensitivity across examiners for the three methods of palpation and the three methods of percussion were 0%–64.3% and 7.7%–75%, respectively. The ranges of specificity across examiners for the three methods of palpation and the three methods of percussion were 50%–100% and 60%–100%, respectively. Likelihood ratios pooled across observers revealed that for palpation, palpation from above, and percussion, Castell’s method had the highest likelihood ratios [LR=2.66 and 1.97, respectively; 95% CI=1.52–4.64 and 1.22–3.19, respectively]. A combination of tests (either palpation or percussion) increased the diagnostic accuracy.Conclusion: Physical diagnostic techniques for the detection of splenomegaly are relatively insensitive but specific. In this study there was high interobserver variability, which did not appear to be associated to the level of experience. Combining tests increases diagnostic accuracy.

Brucellosis in San Diego: Epidemiology and Species-related Differences in Acute Clinical Presentations

Abstract: Although aggressive public health measures have greatly reduced the number of brucellosis cases in the United States, there is a resurgence of interest in this worldwide zoonosis because of its potential as a bioweapon and its 8-fold higher incidence in California, Texas, and the other borderlands between the United States and Mexico compared with the national rate. Accordingly, we reviewed the clinical records of 28 patients diagnosed at a university hospital in San Diego, CA, between 1979 and 2002 to look for new epidemiologic trends and to test the hypothesis that there are species-specific differences in clinical presentations. In contrast to the latest California-wide study completed in 1992, Brucella abortus infections were more common (73%) than Brucella melitensis after 1992, and women were more commonly infected (77% compared with 39%) than men. Major risk factors remained Hispanic ethnicity, travel to Mexico, and ingestion of nonpasteurized dairy products. Analysis of diagnostic procedures suggested that the traditional practice of prolonged incubation of blood cultures increased their sensitivity for Brucella, even in automated radiometric systems. Direct comparison of the clinical manifestations of infections with B. abortus and B. melitensis strongly supported differences in acute presentations. B. melitensis presented more acutely as fevers of unknown origin with statistically significant higher rates of abdominal tenderness, hepatomegaly, splenomegaly, thrombocytopenia, pancytopenia, and hepatic dysfunction. These results suggest that the epidemiology of brucellosis in California may be evolving, and they show, to our knowledge for the first time in a single series, that species-specific differences in presentations may account for some of the protean manifestations of brucellosis. Familiarity with manifestations of brucellosis and the optimal laboratory techniques for its diagnosis could help physicians protect the public against this reemerging, under-recognized zoonosis. Abbreviations: FUO = fever of unknown origin, SAT = slide agglutination test.

Improved rates of compliance with hand antisepsis guidelines: a three-phase observational study.

Overview:Hand antisepsis is arguably the single most effective means of preventing and controlling nosocomial infection. Yet its often neglected, although nosocomial infections threaten the lives of approximately two million patients in the United States annually. Among the reasons health care work

Expanding the role of the infection control professional in the cost-effective use of antibiotics.

There is a growing demand that health care expenses be contained and that excessive and inappropriate use of antibiotics be eliminated. At the University of California, San Diego Medical Center, strategies aimed at controlling drug usage and subsequently reducing costs have been implemented and found to be effective. Mechanisms designed to achieve such goals without diminishing quality of care involve expanding the role of the infection control professional (ICP) while implementing antibiotic control stratagems such as antimicrobial utilization teams, antibiotic order sheets, audits of use, automatic stop orders, computer-assisted management, drug use reviews, educational efforts, formulary practice, restricted drug policies, and target drug monitoring. The infection control professional, as well as other members of the antimicrobial utilization team, contributes to the promotion of the appropriate use of antibiotics in part by identifying individual cases in which antibiotics might be used inappropriately, such as for the treatment of colonization rather than infection or when appropriate microbiologic testing has not been carried out.

Initial worker evaluation of a new safety syringe

A prospective evaluation of a new safety syringe requiring a one-step activation was carried out at the University of California, San Diego Medical Center. Only 59.5% of 390 syringes were activated, and user acceptance and satisfaction were unfavorable. The development of safety devices should incorporate passive activation and take end-user satisfaction into consideration.

Ascites and the acquired immunodeficiency syndrome. Report of 54 cases.

We identified 54 patients with AIDS and ascites seen over a 4.5-year period at a university hospital. This retrospective study is the largest reported series of patients with AIDS and ascites. Patients with AIDS who are evaluated for ascites should be stratified by the CD4 + cell count and the presence or absence of portal hypertension based upon the serum-ascites albumin gradient and clinical presentation. Awareness of possible surgery-related causes of ascites is crucial, as these patients may not manifest the usual signs and symptoms of peritonitis or abdominal catastrophes seen in immunocompetent hosts. Patients with evidence of portal hypertension due to hepatic cirrhosis and an elevated ascitic neutrophil count should be suspected to be infected with common bacterial pathogens associated with peritonitis unless the CD4 + cell count is below 50 cells/mm3. When the CD4 + cell count declines below this threshold, infections due to Mycobacterium avium complex, cytomegalovirus, and other opportunistic infections should be considered.

Pathogens, old and new: an update for cardiovascular nurses.

Infectious diseases remain the major cause of death throughout the world, and this is not likely to change in the foreseeable future. However, there are steps that can be taken to combat them, including both the recognition of and interventions against emerging infectious diseases. This article will provide general information about emerging infectious organisms, mechanisms of resistance to antimicrobial agents, and comments on a variety of prevention strategies. In addition, the reader is directed to a number of comprehensive references for additional information.