Use of intravenous polymyxin B during continuous venovenous hemodialysis.

Described here is the case of a 23-year-old male with Acinetobacter baumannii sepsis and acute renal failure requiring continuous venovenous hemodialysis treated successfully with intravenous polymyxin B. The drug was administered as a loading dose of 2.5 mg/kg, followed by 2 doses of 1 mg/kg on days 4 and 8, then 0.8 mg/kg daily to complete a 24-day course. A discussion of dosing recommendations for polymyxins in dialysis is presented.

Fatal infection caused by Francisella tularensisin a neutropenic bone marrow transplant recipient.

Francisella tularensis is one of the most infectious pathogenic bacteria known. Even though immunity against this organism is thought to be primarily T cell mediated, some evidence suggests that neutrophils may also play an important protective role. We report a case of tularemia in a neutropenic bone marrow transplant recipient that sheds light on the importance of neutrophils in protection against this infection and review clinical aspects of this fascinating infection emphasizing areas of interest for immunocompromised hosts.

Hand infections in patients with diabetes mellitus.

Fifty diabetic patients with hand infections were studied retrospectively. The cause of infection varied, and the infections were divided into two groups: superficial infections and abscesses. The amputation rate was 14%. Only patients who presented with an abscess required amputation, and of those patients with abscesses, 17.5% required amputation. Eighteen of 38 cultured infections were polymicrobial, 4 contained Enterococcus, 11 contained gram-negative bacteria, and 3 contained anaerobic organisms. Bacteriologic culture analysis initiated a two-drug protocol: ampicillin with sulbactam (Unasyn; Pfizer, New York, NY) or piperacillin with tazobactam (Zosyn; Lederle, Pearl River, NY) and gentamicin (renal adjusted).

Polychlorinated biphenyls, dibenzo-p-dioxins, and dibenzofurans and birth weight and immune and thyroid function in children.

None of the publications reviewed provide clinical evidence that PCBs (polychlorinated biphenyls) and related chemicals adversely affect weight, immune, or thyroid function in infants or children born to healthy mothers. Birth weights of term infants fell within the normal range in all studies. The greatest difference between comparison groups was reported by G. G. Fein et al. (1984a, Intrauterine Exposure of Humans to PCBs: Newborn Effects, EPA-600/3-84-060, Environmental Protection Agency; 1984b, J. Pediatr. 105, 315-320). P. R. Taylor et al. (1989, Am. J. Epidemiol. 129, 395-406) reported smaller differences in occupationally exposed women and E. Dar et al. (1992, Environ. Res. 59, 189-201) found that women with higher PCB serum levels had larger babies. S. Patandin et al. (1998, Pediatr Res. 44, 538-545) found a negative association of PCB concentrations in maternal or cord plasma and birth weight of breast and formula-fed infants combined but not when breast-fed infants were analyzed separately. L. Rylander et al. (1995, Scand. J. Work Environ. Health 21, 368-375) reported decreased birth weights with higher dietary intake of contaminated fish. Thus, correlations between PCB exposure or polluted fish ingestion and birth weight were inconsistent. Thyroid and immune function were also within the normal range. In none of the papers were normal laboratory reference values provided and overall the statistically significant differences accounted for little of the variance.

Infections caused by Kluyvera species in humans.

Kluyvera is a relatively newly described genus in the family Enterobacteriaceae that infrequently causes infections in humans. The organism has been isolated from various clinical specimens, but its significance has not been clearly established. In fact, it has been regarded alternatively as saprophytic, opportunistic, or pathogenic. Since the redefinition of this genus in 1981, case reports of diverse clinical infections occurring under various host conditions have been published. Here we present a critical review of all Kluyvera infections reported in the literature, along with our experience involving 5 additional cases. Most patients received prompt antimicrobial treatment on the basis of susceptibility testing, and overall the clinical outcomes were good. Antimicrobial agents active against most Kluyvera strains include third-generation cephalosporins, fluoroquinolones, and aminoglycosides. In contrast, the resistance to ampicillin, extended-spectrum penicillins, and first- and second-generation cephalosporins is significant. Kluyvera is a potentially virulent pathogen that deserves aggressive treatment designed with an awareness of the organism's antimicrobial resistance patterns.

Analysis of research studying the effects of polychlorinated biphenyls and related chemicals on neurobehavioral development in children.

During the past 25 y numerous studies have been performed in infants and children to determine whether environmental exposure to polychlorinated biphenyls (PCBs), dibenzo-p-dioxins, dibenzofurans (PCDFs) and dichlorodiphenyl trichloroethane is causally associated with neurobehavioral effects. In addition, 1 episode of poisoning with PCDFs occurred in Taiwan in 1978. This poisoning outbreak is referred to as Yu-Cheng, oil disease, since the PCDFs and PCBs had accidentally contaminated cooking oil. In the aggregate the studies reviewed here show no conclusive evidence that environmental exposure to these chemicals affect the neurobehavioral development of infants and children.

Haemophilus influenzae osteomyelitis in adults: a report of 4 frontal bone infections and a review of the literature.

Haemophilus influenzae occasionally causes hematogenous long-bone osteomyelitis in children. In adults, however, bone infections caused by this organism are extremely rare. We report four adult cases of H. influenzae frontal bone osteomyelitis and review 12 cases from the literature.

Anaerobic bacteremia in a neutropenic patient with oral mucositis.

An increasing number of anaerobic bloodstream infections in neutropenic cancer patients have been reported in the last decade. The type of anaerobes isolated from most of these patients suggests an oral source of infection. We describe a case of anaerobic bacteremia in a neutropenic patient with oral mucositis that highlights the importance of considering these organisms when selecting empiric prophylactic or therapeutic antimicrobial regimens, especially in the setting of periodontal disease or oral mucositis.

Salmonella enteritidis brain abscess: case report and review.

Intracranial infections are unusual manifestations of salmonellosis. Even with adequate medical and surgical interventions these infections are often associated with significant morbidity and mortality. We report a case of brain abscess caused by Salmonella enteritidis associated with a brain neoplasm and review previous reports in the literature.

Mortality in male and female capacitor workers exposed to polychlorinated biphenyls.

A mortality study was conducted in workers with at least 90 days' exposure to polychlorinated biphenyls (PCBs) between 1946 and 1977. Vital status was established for 98.7% of the 7075 workers studied. In hourly male workers, the mortality from all cancers was significantly below expected (standardized mortality ratio [SMR] = 81; 95% confidence interval [CI], = 68 to 97) and comparable to expected (SMR = 110; 95% CI, 93 to 129) in hourly female workers. No significant elevations in mortality for any site-specific cause were found in the hourly cohort. All-cancer mortality was significantly below expected in salaried males (SMR = 69; 95% CI, 52 to 90) and comparable to expected in salaried females (SMR = 75; 95% CI, 45 to 118). No significant elevations were seen in the most highly exposed workers, nor did SMRs increase with length of cumulative employment and latency. None of the previously reported specific excesses in cancer mortality were seen. This is the largest cohort of male and female workers exposed to PCBs. The lack of any significant elevations in the site-specific cancer mortality of the production workers adds important information about human health effects of PCBs.

Selected other effects and TEFs.

The half-lives and tissue distribution of chlorinated dibenzodioxins and dibenzofurans in humans are reviewed. An attempt is made to correlate adverse effects observed in humans such as chloracne, Yusho, Yucheng, and Seveso with tissue levels. No causal inferences should be made in the Ranch Hand studies because TCDD serum levels are slightly higher in older persons and in persons who have diseases related to their lipid metabolism and their age. These differences cannot be used in the context of a dose-response relationship but should be used in the context of variations in the distribution of PCDD and PCDF levels within different subpopulations. Based on these observations in humans, TEF values for mixtures of PCDD and PCDF are poor predictors of human risk.

An in vitro investigation of the efficacy of CPC for use in toothbrush decontamination.

PURPOSE: A product designed as a toothbrush disinfectant containing cetylpyridinium chloride (CPC), a quaternary ammonium compound, recently was introduced. The purpose of this study was to provide additional evidence that CPC provides a practical solution for destroying residual microorganisms on air-dried toothbrushes and toothbrushes stored in a travel container. METHODS: Sterile synthetic toothbrushes were inoculated with optical density standardized laboratory cultures of Staphylococcus epidermidis or Candida albicans. Half were then disinfected with CPC and half were used as untreated controls. The toothbrushes were vortexed in sterile saline solution, diluted in a ten-fold series, and plated on 5% blood agar or Sabouraud dextrose agar. The plates were incubated at 37 degrees C in a normal atmosphere for 48 hours, and colonies were counted. RESULTS: CPC produced significant decreases in residual microorganisms. Using the CPC spray treatment on air-dried toothbrushes, Staphylococcus epidermidis essentially was reduced 100-fold, while Candida albicans had a 94% reduction of growth. Bacterial counts were higher in the samples stored in closed containers as compared to the air-dried samples. CONCLUSION: CPC appeared to be an effective toothbrush disinfectant for the organisms evaluated. It is practical and economical. CPC could easily fit into the recommendations of a practice committed to infection control.

The good gift: a comparison of the Eli Lilly presentation copies of Aequanimitas.

The Eli Lilly Pharmaceutical Company of Indianapolis, Indiana distributed some 150,000 copies of the third edition of Sir William Osler's Aequanimitas to graduating medical students between 1932 and 1953. Bibliophiles have considered these volumes identical. However, there were at least seven different printings in English and one in Spanish and one in Portuguese. The size of the book and type of paper changed over the years. The title page, spine information, and printing information also changed. A congratulatory letter from Eli Lilly and Company was placed in the front of each book. These letters have many differences. Thus, the volumes are not identical and the recognition of these differences opens a new field for research and collecting.

Survey of lead exposure around a closed lead smelter.

OBJECTIVE: To test the hypothesis that elevated lead in soil is positively correlated with blood lead (BPb) levels in children in an urban population surrounding a closed lead smelter, a US Environmental Protection Agency Superfund clean-up site was surveyed. METHOD: A total of 827 volunteers including 490 children under 6 years of age participated. A questionnaire was administered. Blood lead was determined as was lead content of samples of house dust, soil, paint, and water of the participants' homes. RESULTS: The arithmetic mean venous BPb in 490 children between 6 and 72 months of age was 6.9 micrograms/dL (0.33 mumol/L) range 0.7 to 40.2 micrograms/dL (0.03 to 1.94 mumol/L). The BPb of 78 (16%) children in this group was > or = 10 micrograms/dL (0.48 mumol/L). Based on multiple regression modeling, lead in house dust accounted for 18% of the variance in BPb. Lead in paint together with the condition of the house were the main contributors to the dust lead variance (26%) with soil lead accounting for an additional 6%. Lead in paint alone accounted for 3% of the BPb variance. Lead in paint together with the condition of the house accounted for 12% of BPb variance, and lead in soil accounted for an additional 3%. Factors other than environmental lead such as education of parents, household income, and behavior were associated with BPb levels. CONCLUSIONS: The mean BPb in children was below the present level of concern of the Centers for Disease Control and Prevention. Children with BPb of > or = 10 micrograms/L (0.48 mumol/L) tended to live in poorly maintained older houses. Based on these findings lead in soil and paint in well-maintained homes contributed little to the lead exposure of children.

Polychlorinated biphenyls (PCBs) and human health: an update.

Polychlorinated biphenyls (PCBs) are a mixture of 209 different chlorinated biphenyl congeners (forms) of which 36 are environmentally relevant. PCBs are lipid (fat)-soluble, stable compounds. PCBs may be contaminated with more highly toxic polychlorinated dibenzofurans (PCDFs). Some PCDFs were primarily responsible for the two poisoning outbreaks--Yusho and Yu-Cheng. Based on the reports on workers and the general population, no clear and convincing evidence that PCB exposures were casually associated with adverse health effects was advanced; this included cancer for a wide range of body burdens and exposures for serum PCB concentrations > 1000 ppb (micrograms/l) and adipose PCB levels > 400 ppm (mg/kg). No meaningful reproductive problems have been identified in female capacitor workers. In the opinion of the review author, the available evidence for cancer and for reproductive effects is inconclusive. Adverse neurobehavioral effects in infants and young children have been reported in a study of women in the general population and a study of fish eaters and their offspring. The adverse effects observed in the two studies were not the same; the exposure assessments in both studies are not well defined and have many uncertainties. Subhuman primates appear to be more sensitive to reproductive and other adverse effects of PCBs than humans. Obvious external clinical signs are observed in the offspring of subhuman primates at dosage levels below those experienced by female capacitor workers and members of the general population prior to the control of PCBs.