Hip abscess due to Aerococcus urinae in a man with paraplegia: case report.

STUDY DESIGN: Single case report. OBJECTIVE: Present a case of hip abscess culture positive for Aerococcus urinae in a man with paraplegia. BACKGROUND: Aerococcus species are uncommonly reported and may be misinterpreted as alpha streptococci or staphylococci. This organism can cause significant morbidity due to urinary tract infection with septicemia or endocarditis. METHODS: Single case report. RESULTS: The patient required surgical incision and debridement. Open joint inspection was performed, which was complicated by superior dislocation. The patient later required a Girdlestone procedure. CONCLUSIONS: A. urinae was cultured from a hip abscess in a man with paraplegia. Bacteremia, with the bladder as the reservoir, likely led to this abscess. Aerococcus is pathogenic and should be considered when culture results reveal unusual staph or strep species.

Axillary reverse mapping (ARM): initial results of phase II trial in preventing lymphedema after lymphadenectomy.

INTRODUCTION: Axillary reverse mapping (ARM) is unproven in preventing lymphedema. The purpose of this study is to evaluate lymphedema rates with ARM added to lymphadenectomy. METHODS: In this IRB approved study, 156 cases of SLNB/ALND from May 2007 to March 2010 were prospectively accrued to the study. Patients with an increase in arm volume greater than 20% over the contralateral side were considered to have lymphedema. Data was collected on identification and variations in lymphatic drainage, nodal status, ARM lymphatics preservation rate, adjuvant treatment (XRT, chemo) and lymphedema rate. RESULTS: 114 patients underwent SLNB only and 42 patients underwent ALND after SLNB, with a SLN identification rate of 100%. Median age was 56.9(±12.5) and BMI was 29.4(±6.9). Mean follow up was 14.6±9.4 months. ARM lymphatics were near or in the SLN field in 45/114 (39%) of the SLNB cases and in 34/42 (81%) of the ALND. ARM nodes were preserved in 92.3% of the cases (144/156). A total of 12 ARM nodes were resected because of crossover or suspicious appearance. The 2 ARM nodes involved by malignancy were in heavily positive axilla (>5 positive nodes). Lymphedema was diagnosed in 3.5% (4/114) of the SLNB cases and 7%(3/42) of the combined SLNB+ALND cases. 2.9% (4/140) of the patients who had the ARM lymphatics preserved and 18.7%(3/16) who had it transected developed clinical lymphedema. No regional recurrences were seen. CONCLUSION: Preserving the ARM nodes is safe and resulted in a low incidence of postoperative lymphedema after SLNB and ALND.

Helicobacter pylori antibody profile in household members of children with H. pylori infection.

Intrafamilial spread is implicated as a major route for acquisition of Helicoobacter pylori infection. Investigating H. pylori cytotoxin-associated protein (CagA) and vacuolating toxin (VacA) antibodies within family members enabled the authors to evaluate this possibility further. Serum samples were collected prospectively from household members after their index children were diagnosed with active H. pylori infection. Serum samples were evaluated for anti-H. pylori immunoglobulin G antibody using the enzyme immunoassay (IEA) method and for H. pylori CagA and VacA antibodies with the commercially available immunoprobing Western blot kit. Ten different families participated in the study, including 10 pediatric patients and 31 household members. All patients and 28 household members (90%) were seropositive for H. pylori antibody by IEA and Western blot tests. Overall, 17 subjects (41.4%) were CagA positive, 14 (34.1%) were VacA positive, 11 (26.8%) were positive for both antibodies, and 22 (53.6%) were negative for both antibodies. A significant association in bacterial antibody profile was found between the patient index members and all household members (Cohen's kappa and Mentel-Haenszel methods). In four families, more than 66% of the household members harbored the same antibody profile, and in two families a completely different profile was observed. Moreover, a similar H. pylori antibody profile between the index patient and the mother was found in six families, and between the index patient and the father in two families. The data strongly suggest an intrafamiliar transmission for H. pylori infection.

Cast changes: synthetic versus plaster.

A review of the changes in casting since the introduction of improved synthetic casting materials in the 1970s is presented. There is very little in the literature on nursing implications regarding the newer casting materials. Improvements in synthetic materials used in the casting of children include a fiberglass-free, latex-free casting polymer, with child-friendly prints now available. Though the use of synthetic casting predominates the market, plaster of Paris is still the mainstay for serial casting and casting requiring superior moldability and conformability. The advantages and disadvantages of synthetic and plaster of Paris casting, as well as nursing care of the child in each type of cast are summarized.

Transboundary Conservation: An Ecoregional Approach to Protect Neotropical Migratory Birds in South America

/ Future conservation efforts will need to transcend geopolitical boundaries in efforts to protect entire landscapes and ecosystems. Neotropical migratory birds are as a group a useful conservation tool for linking diverse landscapes and people due to their dependence on multiple habitats, sensitivity to habitat changes, and universal public appeal. The conservation of neotropical migrants can therefore function as a powerful hemispheric umbrella for ecosystem protection. Efforts to protect neotropical migratory birds on their nonbreeding grounds have traditionally been focused on Mexico, Central America, and the Caribbean. To assess the importance of South America to neotropical migrants, an ecoregional classification system was used to determine species distributions in the Andean/Southern Cone Region (Bolivia, Colombia, Ecuador, Paraguay, Peru, and Venezuela). The occurrence of migrants in protected areas that are part of The Nature Conservancy's Parks in Peril program was also assessed. Of the 406 neotropical migrant species, nearly one third (132) occur as regular nonbreeding residents in the region and for almost half of these species (53), South America is their main nonbreeding ground. All Parks in Peril sites were found to harbor neotropical migrants. Forty-eight species (36%) have declining long-term North American Breeding Bird Survey population trends and/or high Partners in Flight concern scores and thus are of significant conservation concern. Most importantly, 29 species (22%) of conservation concern use South America as their primary nonbreeding ground, indicating a need for focused conservation action. The nature of the ecoregional approach used in this endeavor makes future prioritization of ecoregions and conservation strategies for neotropical migrants across national boundaries possible. The ability to link diverse landscapes using a common element such as migratory birds allows for unique transboundary partnerships and opportunities for habitat conservation, which support the goal of the Conservancy's new Migratory Bird Initiative.KEY WORDS: Neotropical migratory birds; Transboundary conservation; Ecoregions; Protected areas; South America

Postnatal development of T lymphocytes in a novel X-linked immunodeficiency disease.

We previously reported an X-linked combined immunodeficiency disease (CID) characterized by immune deficiencies and complicating infections that were more moderate than those found in severe CID (SCID). Since other unstudied males in the family died in infancy, we questioned whether this T cell defect was more profound in early life. Subsequently, the development of blood T cells in an affected newborn male was examined. T cells were virtually undetectable at 48 hr. Over the next several months, CD4+ T cells (principally CD45RO+) rose to levels similar to those found in older affected males, but CD8+ T cells developed more slowly and never attained levels found in other affected males. Thus, this disease in early life mimics SCID and may pose a higher risk of fatal infections to affected individuals during that period. Finally, we speculate that the genetic defect may disrupt intrathymic development or selection of T cells.

Activated and memory T lymphocytes in human milk.

Since activated macrophages and cytokines are found in human milk (HM), a flow cytometry study was conducted to determine whether T cells in HM display phenotypic markers of recent or previous activation. HM was collected during the first 3 d of lactation. The Paint-a-Gate program was used to optimize gating on the lymphocyte population. A mean +/- 1 SD of 4 +/- 3% of total HM leukocytes were lymphocytes and 96 +/- 3% were macrophages and granulocytes (N = 33 subjects). HM lymphocyte populations were further analyzed in five subjects. T cells (CD3+) represented 83 +/- 11% and B cells (CD19+) were 6 +/- 4% of HM lymphocytes. The mean CD4/CD8 ratio of T cells in HM was 0.88 (range 0.40-1.25). This ratio was significantly decreased compared to the peripheral blood (PB) of control adults (P less than 0.02) and postpartum women (P less than 0.02), due mostly to a significant increase in CD8+ CD3+ cells in HM compared to the PB of control adults (P less than 0.002) and postpartum women (P less than 0.05). T cells bearing markers of recent activation were significantly increased in HM compared to the PB of control adults: 85 +/- 7% of CD3+ cells in HM were HLA-DR+ (controls, 10 +/- 4%; P less than 0.001), and 15 +/- 6% of CD3+ cells in HM were IL-2R+ (controls, 6 +/- 2%; P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

A novel X-linked combined immunodeficiency disease.

A novel X-linked combined immunodeficiency disease was found in five living males in an extended family in the United States. The age of the affected males ranged from 2.5 to 34 yr. The most prominent clinical abnormalities were a paucity of lymphoid tissue; recurrent sinusitis, otitis media, bronchitis, and pneumonia; severe varicella; and chronic papillomavirus infections. The principal immunologic features of the disorder were normal concentrations of serum immunoglobulins but restricted formation of IgG antibodies to immunogens; normal numbers of B cells and NK cells but decreased numbers of CD4+ and CD8+ T lymphocytes, particularly the CD45RA+ subpopulations; diminished proliferative responses of blood T cells to allogeneic cells, mitogens and antigens; and decreased production of IL-2 by mitogen stimulated blood lymphocytes. Thus, affected males in this family carry an abnormal gene on their X chromosome that results in a combined immunodeficiency that is distinct from previously reported disorders.

Profile of patients from a Veterans Administration medical center.

Data were analyzed to establish a general patient profile that could be the basis for specific profiles to be utilized for infectious disease and microbiologic studies. The analysis revealed that the average patient in this institution is a 57-year-old, white, married, Protestant man residing in Oklahoma.A personal-interview survey of 42 inpatients showed that 95 percent had smoked for a number of years, and of the smokers, 60 percent were current smokers while the remaining 40 percent had stopped smoking for at least one year. Primary treatment services were medicine (47.9 percent) and surgery (31.6 percent) with 7.4 percent of the patients treated on both of these services. The ten most common diagnostic-related groups for the medicine and surgery services are also noted.

Bacteremia in adult men.

A prospective study was done to characterize positive blood cultures in adult male veterans. The research included 277 patients over a 15-month period. There were 348 organisms isolated, of which 65 percent were pathogens, 6 percent probable pathogens, 4 percent probable contaminants, and 25 percent contaminants. The most common isolates were coagulase-negative staphylococci (23 percent), Escherichia coli (12 percent), Klebsiella pneumoniae (10 percent), Staphylococcus aureus (9 percent), Streptococcus pneumoniae (6 percent), and Pseudomonas aeruginosa (5 percent). The number of positive blood cultures was significantly greater for pathogens (mean 1.8 bottles) than contaminants (mean 1.2). Patients with pathogens were more likely to have hypotension than those with contaminants. At least 40 percent of all patients with a positive blood culture died within 14 days after their first positive culture. The vast majority of bacteremias were community acquired. As lungs and wounds comprised about one half of the sites of entry for the bacteremias, it appears that more emphasis should be placed on early diagnosis and efficient treatment of infections from these sites to reduce subsequent mortality.

Understanding the blood culture report.

There are no hard-and-fast rules for judging whether an organism is a pathogen or contaminant. Experience is critical. In the end, the physician is responsible for determining whether an organism is a contaminant or a pathogen on the basis of laboratory and clinical data, which often include patient history, physical examination, body temperature, peripheral leukocyte count and differential, clinical course, and culture results. When blood culture results are given to a nurse, she or he should communicate this information to the attending physician as soon as possible, with greatest emphasis placed on positive cultures with probable pathogens. The assumption that a blood culture isolate is a pathogen, in the absence of other supporting facts, can lead to inappropriate therapy. On the other hand, assuming a pathogen to be a contaminant can ultimately lead to patient mortality if treatment is delayed. Questions as to how blood cultures are handled should be directed to microbiology personnel, whereas interpretation problems should be discussed with infectious disease specialists. Good communication among the nurses, laboratory personnel, and physicians involved with blood culture studies is invaluable to effective patient care.