Introducing case management to a general medicine ward team of a teaching hospital.

PURPOSE: To introduce case management to a general medicine ward team of a teaching hospital to improve patient care and ensure comprehensive longitudinal care. METHOD: The Department of Veterans Affairs Medical Center is one of four hospitals used by University of Oklahoma School of Medicine residents. There are five medicine teams, each comprising a second- or third-year resident, one or two interns, two medical students, and a faculty physician. The case-management program was initiated in November 1994. No attempt was made to limit the residents assigned to the case-managed team (i.e., many residents who worked with the case-managed team subsequently rotated through the other teams). Patients were assigned to the teams by rotation, and no attempt was made to adjust for the severity of illness among admissions. The teams were separated as follows: pre-case-management teams (all five teams prior to the case-management program), non-case-management teams (the four teams without case managers after the program's initiation), and the case-management team. The study periods were January-July 1994 (pre-case management) and January-July 1995 (after case management). RESULTS: The numbers of patients treated by the three groups were 1,305, 1,139, and 289, respectively. The median length of stay for pre-case-management patients was 5 days (interquartile range, 3-9 days); for non-case-management patients, 5 days (range, 3-8 days); and for case-management patients, 5 days (range, 3-7 days). The cumulative distribution of lengths of stay for case-management patients was significantly different from those of the other study groups by the Kolmogorov-Smirnov test (p = .02). More case-management patients were discharged by day 7. Rates of readmission were not significantly different between the teams. CONCLUSION: In this study a case-management program was effectively implemented in a teaching hospital, resulting in reduced lengths of stay for patients. As academic health centers become more concerned with efficiency and cost, case management should be seriously considered as a way to deal with such issues.

Overwhelming sepsis with Vibrio vulnificus: a coastal pathogen in Oklahoma.

Vibrio vulnificus has been associated with three main clinical syndromes; primary septicemia; wound infection, and gastroenteritis. This organism has increased virulence for persons with underlying medical conditions that predispose to iron overload or an impaired immune system. Since the organism proliferates more readily in warm, coastal waters, such infections are more commonly found in those regions. Infection can result from the ingestion of contaminated, undercooked seafood; contact of a wound with seawater; or a puncture wound sustained from a contaminated surface. Vibrio infections rarely occur in inland areas, but when they do occur, they are usually a result of the contact of wounds with contaminated, brackish water or the ingestion of raw shellfish. Because infections with this organism occur less frequently in non-coastal regions, the diagnosis may not be suspected initially in susceptible individuals and a delay of treatment may result. We present a case of V. vulnificus sepsis occurring in a man with underlying liver disease and a history of row oyster consumption in Oklahoma and discuss the clinical manifestations of primary sepsis with this organism as well as prevention strategies.

Rhodococcus equi infections of humans. 12 cases and a review of the literature.

Increased recognition of Rhodococcus equi as a human pathogen has occurred since 1983, when the first review article summarized the world's literature of 12 cases. In this article, we present 12 cases from the University of Oklahoma Health Sciences Center and review 60 from the literature. Most cases occur in immunocompromised hosts and present as chronic cavitary pneumonias. Associated extrapulmonary disease is seen at diagnosis in 7% of patients with pneumonia, and relapse occurs at extrapulmonary sites in 13%, often without reappearance of pulmonary disease. Relapse may follow a course of antimicrobial therapy that is too brief, but can also occur during treatment. Infections also occur in the gastrointestinal tract, causing enteritis and regional adenitis with abscesses. Contaminated wounds may become infected. Isolated bacteremias may be a manifestation of latent infection recurring during a period of immune suppression. A common feature of human R. equi infection is delay in diagnosis. The insidious course of disease contributes to delay, as does failure to identify the organism. R. equi is easily cultured on nonselective media but commonly mistaken for a diphtheroid or occasionally for a mycobacterium based on acid-fast appearance. Form and duration of treatment are closely related to host immune status. Immunocompromised patients require prolonged or indefinite therapy with multiple antibiotics. Infections in immunocompetent hosts are easily treated with short courses of single agents. Infections related to contaminated wounds are treated primarily by irrigation and debridement. Infections in immunocompromised hosts are increasing in frequency largely due the AIDS epidemic. Infections in immunocompetent hosts, reported rarely before this series, may be underdiagnosed, perhaps because R. equi resembles common commensals and has limited virulence in this population. This report demonstrates that R. equi infections, including community-acquired pneumonias, occur in immunocompetent hosts.

Invasive pneumococcal disease in central Oklahoma: emergence of high-level penicillin resistance and multiple antibiotic resistance. Pneumococcus Study Group.

Relatively penicillin-resistant pneumococci have caused 10% of invasive pneumococcal disease in central Oklahoma during the last decade, but almost no high-level penicillin or other antibiotic resistance has been described. This study evaluated antibiotic susceptibility and serotype distribution in invasive pneumococcal disease in the Oklahoma City metropolitan area (1990 population 848,000). A total of 144 cases of invasive infection was collected in 1 year (17 with meningitis, 120 with other bacteremic infections, and 7 with other invasive infections), for a rate of 16.9/100,000 (95% confidence interval [CI], 14.0-19.5). For the population aged > or = 60, invasive pneumococcal disease rates were higher among nursing home residents (352/100,000) than among nonresidents (25.6/100,000; relative risk, 13.7; 95% CI, 7.7-24.7). Antibiotic-resistant organisms caused 19.4% of the cases: relative penicillin resistance, 7.6%; high-level penicillin resistance, 1.4% (2 cases), and 11% resistance to erythromycin, trimethoprim-sulfamethoxazole, or both, with 5% sharing both resistances plus a MIC of penicillin of 0.06 microgram/mL.

Clinical experience with HIV-infected patients at the University of Oklahoma Health Sciences Center: an update.

We reviewed the course of 545 human immunodeficiency virus (HIV)-infected patients seen between 1983 and March 30, 1991. A majority were Caucasian homosexual or bisexual men, while parenteral drug abusers represented a smaller proportion than seen nationwide. In the 274 patients with the acquired immunodeficiency syndrome (AIDS), the distribution of AIDS-defining conditions was generally consistent with those reported in studies from elsewhere in the United States. However, toxoplasmosis remained relatively uncommon. There was a slightly higher incidence of disseminated histoplasmosis compared to other studies. HIV encephalopathy (AIDS dementia) was likely underdiagnosed. Although data suggested prolongation of the asymptomatic phase of HIV infection, median survival after AIDS diagnosis remained approximately 12 months.

Relapsing pneumococcal bacteremia in immunocompromised patients.

Relapse of Streptococcus pneumoniae bacteremia after appropriate therapy is thought to be rare, even in immunocompromised patients. We describe three immunodeficient patients who experienced repeated episodes of pneumococcal bacteremia within 8 weeks after receiving appropriate therapy. Serotyping and DNA fingerprinting of respective isolates strongly suggested that each patient's bacteremic relapse was caused by the same pneumococcal strain. Relapsing and recurrent infections with an identical pneumococcal strain, especially in immunodeficient individuals, may be more common than is generally appreciated.

Rocky Mountain spotted fever. A clinical review based on 48 confirmed cases, 1943-1986.

We reviewed 48 cases of Rocky Mountain spotted fever seen between 1943 and 1986. The data provided a view of the diverse presentations and manifestations of this disease. Exposure to a rural environment or to dogs was the rule, and over two-thirds of patients specifically remembered tick exposure. Clinical presentation was highly variable. Although fever, headache, and rash were each common, only 62% had the complete triad. Neurological symptoms and signs were common in this series. Cerebrospinal fluid abnormalities, particularly leukocytosis, were the rule in those patients who underwent lumbar puncture. Neurologic sequelae occurred in several patients. Multiple other organ systems were involved at presentation or during the course of illness--gastrointestinal, cardiovascular, pulmonary, renal, muscular, hematologic. These manifestations could, and often did, confuse physicians seeing these patients initially. They further accounted for the diverse complications seen. Outcome was good in this series. Mortality rate was 2%, and most patients recovered without sequelae. However, morbidity during hospitalization was often severe. Even in an endemic area with high index of suspicion, the diagnosis of RMSF was often delayed, usually because of failure of the physician to consider this possibility at initial presentation. This series emphasizes the importance of considering RMSF in any febrile patient in an endemic area, regardless of "atypical" presentation or apparent lack of tick exposure.

Genetic analysis of Streptococcus pneumoniae serotypes with the use of DNA fingerprinting.

Molecular genetic similarities among a Streptococcus pneumoniae library were examined by comparing DNA restriction endonuclease banding patterns (fingerprints) after nuclease digestion and agarose gel electrophoresis. Densitometric scanning graphs of DNA fingerprints on photonegative film were compared for similarity, i.e., the percentage of shared bands. Comparison of serotypes 1, 3, 12, 14, and 25 revealed 54% +/- 9% similarity. Fingerprints within serogroups IX and XVIII did not differ from non-cross-reactive types. Intraserotypic comparison of strains of type 25 (n = 5) revealed 89% +/- 4% similarity. Five strains of type 3 were 75% +/- 19% similar; however, two of these strains had 96% similarity and three strains had 98% +/- 2% similarity, perhaps suggesting subtypes with serotype 3. Substantial DNA fingerprint differences were found among serotypes and significantly greater similarity among strains of a given type. Thus, DNA analyses used on other gram-positive bacteria are applicable to pneumococci.

Clinical experience with HIV-infected patients at the University of Oklahoma Health Sciences Center.

Two hundred seventy-two patients infected with human immunodeficiency virus (HIV) have received care from the members of the adult infectious disease section at the University of Oklahoma Health Sciences Center. The majority of these patients met the diagnostic criteria for acquired immunodeficiency syndrome. This group of patients was characterized by relatively few parenteral drug abusers, a high incidence of disseminated histoplasmosis, and an unexpectedly low frequency of toxoplasmosis. The prevalence of risk behaviors and endemic disease may be responsible for these particular case distributions.

Analysis of humoral and phagocytic defenses against Streptococcus pneumoniae serotypes 1 and 3.

To better define relationships among pneumococcal anticapsular antibodies, opsonophagocytosis, and in vivo mouse protection, we measured these functions in sera from healthy individuals who had not received pneumococcal vaccine. For serotype 1 pneumococci, the level of antibody measured by radioimmunoassay did not predict mouse protection, as has been noted by others. For some sera, opsonic requirements for antibody and complement could be clearly demonstrated and a strong correlation obtained between concentration of antibody and degree of phagocytic killing. However, for most sera, antibody concentration did not correlate with opsonic activity, as measured by phagocytic bactericidal assay or uptake of radiolabeled bacteria. Sera with high concentrations of anticapsular antibody did not always support in vitro bacterial killing by leukocytes. Conversely, highly opsonic sera did not necessarily have substantial levels of measurable antibody. Moreover, in vitro opsonophagocytic activity failed to predict in vivo protection; sera could be opsonic in vitro but not protective in vivo and vice versa. For serotype 3 pneumococci, antibody concentrations correlated strongly with mouse protective titers, as has been noted by others for type 3. Opsonophagocytosis, as measured by leukocyte bactericidal activity, required both complement and heat-stable substance(s) present in high-antibody sera, presumably antibody. Furthermore, increasing concentrations of serum enhanced phagocytic killing in a fashion that could be correlated with anticapsular antibody content. However, correlation with opsonophagocytosis was not so strong as with mouse protection, and there was no correlation between antibody concentration and opsonization as measured by uptake of radiolabeled bacteria. These observations suggest that opsonophagocytosis (with the definitive end point of bacterial killing) cannot be the standard against which to measure antibody concentrations. Furthermore, host protective mechanisms against pneumococci remain to be clearly defined. Even if opsonization by anticapsular antibody is the primary mechanism, there is need for development of improved functional assays of protection.

Activation of the alternative complement pathway by Sporothrix schenckii.

We studied the activation of complement by Sporothrix schenckii yeast cells. Total complement activity, and the effect of various activators on this activity, were assayed on aliquots of fresh nonimmune human serum with and without prior treatment with chelators. Both total hemolytic complement and C3 were consumed (activated) in serum chelated with magnesium ethylene glycol-bis(beta-aminoethyl ether)-N,N,N',N'-tetraacetic acid, which blocks the classical pathway but leaves the alternative pathway intact. Further, C3 was consumed, but C4 (exclusively a component of the classical pathway) was preserved, in nonchelated serum after challenge by S. schenckii yeast cells. Absorption of serum with S. schenckii yeast cells to deplete antibodies did not alter these results. Furthermore, immunofluorescence studies demonstrated that C3, but not immunoglobulin G, was deposited on yeast cells during incubation with nonimmune serum. These data indicate that S. schenckii yeast cells activate the alternative complement pathway in vitro independently of antibody. These data do not define a role for the alternative pathway in in vivo host defenses against infection with this organism but provide a foundation for studies to evaluate such a role.

Familial exercise-induced anaphylaxis.

An 18-year-old hispanic male, his two brothers, father, two paternal uncles, and paternal grandfather experienced cutaneous and cardiorespiratory symptoms during vigorous exercise beginning at about 10 years of age. The propositus was challenged by running to exhaustion and by immersion in hot water. In neither case were allergic signs or symptoms noted; however, plasma histamine rose from undetectable levels to 1.0 and 3.7 ng/ml, respectively. Furthermore, C2 and C5 were significantly reduced and fell during exercise.

Chronic relapsing colitis due to Strongyloides stercoralis.

The small intestine is the usual site of chronic infection with Strongyloides stercoralis. Colonic involvement has generally been seen in the hyperinfection syndrome in immunosuppressed individuals. We describe an immunologically competent female who underwent multiple abdominal operations over a 5-year period for hematochezia and diffuse abdominal pain of obscure etiology. Eosinophilia had been present but never investigated until 1981, at which time stool examination revealed S. stercoralis larvae. Pathological specimens from operations in 1977 and 1981 demonstrated extensive colonic wall invasion with filariform larvae consistent with S. stercoralis. Involvement of other organs was never documented. We believe this case is consistent with chronic colitis due to strongyloidiasis. This entity has not been previously described, and expands the spectrum of this disease.

Meningococcal meningitis in a women with inherited deficiency of the ninth component of complement.

A 17-year-old woman presented with acute pyogenic meningitis; Neisseria meningitidis group C was isolated from blood on culture. Complement assays demonstrated a hemolytic complement titer of 12 u/ml; individual components were normal except for C9, which was absent by both functional and antigenic analysis. Family studies were consistent with a familial C9 deficiency, autosomal co-dominant inheritance. This is the first report of the association of C9 deficiency and disseminated neisserial infection; whether this complement deficiency predisposes to the neisserial infection remains to be established.