Molecular analysis of imipenem-resistant Acinetobacter baumannii isolated from US service members wounded in Iraq, 2003-2008.

Global dissemination of imipenem-resistant (IR) clones of Acinetobacter baumannii - A. calcoaceticus complex (ABC) have been frequently reported but the molecular epidemiological features of IR-ABC in military treatment facilities (MTFs) have not been described. We characterized 46 IR-ABC strains from a dataset of 298 ABC isolates collected from US service members hospitalized in different US MTFs domestically and overseas during 2003-2008. All IR strains carried the bla(OXA-51) gene and 40 also carried bla(OXA-23) on plasmids and/or chromosome; one carried bla(OXA-58) and four contained ISAbal located upstream of bla(OXA-51). Strains tended to cluster by pulsed-field gel electrophoresis profiles in time and location. Strains from two major clusters were identified as international clone I by multilocus sequence typing.

Methicillin-resistant Staphylococcus aureus infection in combat support hospitals in three regions of Iraq.

SUMMARYStaphylococcus aureus is a leading cause of infections in deployed service members. Based on a molecular epidemiological study of 182 MRSA isolates from patients in three U.S. Army combat support hospitals in separate regions in Iraq, USA300 clone was the most predominant (80%) pulsotype. This finding suggested that strain carriage from the home country by military personnel is epidemiologically more important than local acquisition.

An overview of osteopathic medicine.

Despite an initial lack of acceptance by mainstream medicine, and amidst projections of a serious oversupply of physicians, the osteopathic profession continues to grow, successfully competing for shrinking health care resources and attracting the attention of insurers and those in managed care. However, a recent telephone survey of 800 health maintenance organization beneficiaries suggested that the public is not yet familiar with osteopathic medicine. The history, philosophy, and current status of the osteopathic profession are presented, along with theories of the physiologic basis of and supporting evidence for palpatory diagnosis and manipulative therapy.

Is pH paper an acceptable, low-cost alternative to the blood gas analyzer for determining pleural fluid pH?

BACKGROUND: Our laboratory uses pH paper rather than a blood gas analyzer to measure pleural fluid pH to decrease cost and avoid analyzer malfunction due to viscous fluids. METHODS: To compare these two methods of determining pleural fluid pH, 42 patients undergoing diagnostic or therapeutic thoracentesis had two 1-mL aliquots of pleural fluid anaerobically collected in a heparinized syringe and placed on ice. pH measurements were made using litmus paper (pHydron Vivid 6-8 brand litmus paper; MicroEssential Labs; Brooklyn, NY) and the model 995-Hb blood gas analyzer (AVL Instruments; Roswell, GA) within 1 h of collection. Agreement analysis was performed in three ways: on the entire group; in subcategories of complicated or uncomplicated parapneumonic effusions (<7.1, 7.1 to 7.3, >7.3); and in subcategories of poor prognosis or better prognosis malignant effusions(<7.3, >7.3). RESULTS: pH measured with pH paper was significantly more variable (SD=0.55, coefficient of variation [CV]=7.5%) than was pH measured with the blood gas analyzer (SD=0.11, CV=1.5%). There was no significant correlation between values obtained with the two techniques (r=-0.26, SD of the differences=0.59). Using the pH subcategories, there was 72% discordance in classification between litmus paper and arterial blood gas (ABG) determinations for patients with parapneumonic effusions. In patients with malignant effusions, there was 30% discordance. The pH values obtained by the ABG analyzer predicted tube thoracostomy 72% of the time, whereas the pH values obtained using pH paper were consistent only 36% of the time. CONCLUSION: Determination of pleural fluid pH using pH paper is unreliable and should not be considered an acceptable alternative to the blood gas analyzer. There is no need to determine pH on purulent samples. Hospital laboratories will be more likely to allow the use of the ABG analyzer on fluids other than blood if clinicians keep this in mind.

Can tuning forks replace bone scans for identification of tibial stress fractures?

PURPOSE: To compare the performance of the tuning fork test (TFT) with nuclear scintigraphy for the identification of tibial stress fractures. METHODS: Fifty-two patients with a history and physical examination suggestive of tibial stress fracture underwent a TFT followed by a bone scan. The TFT was performed by applying a 128-Hz tuning fork to the anterior surface of the bared tibia. If the patient reported a marked exacerbation or reproduction of shin pain in a localized area of the tibia, the TFT was considered positive. All patients also underwent a bilateral lower-extremity bone scan. RESULTS: The sensitivity and specificity of the tuning fork test were 75 and 67%, respectively. The positive and negative predictive values were 77 and 63%, respectively. The positive and negative likelihood ratios with 95% confidence intervals were 2.33 (1.17-4.60) and 0.34 (0.16-0.71), respectively. CONCLUSION: The tuning fork test is not sensitive enough to rule out a stress fracture on the basis of a negative test. However, in a setting in which there is a moderate to high pretest likelihood of stress fractures, such as military installations with new basic training recruits, it may be reasonable to avoid the cost and delays associated with nuclear imaging by instituting treatment for tibial stress fractures without obtaining a bone scan when the TFT is positive.

Fatal duodenocaval fistula caused by peptic ulcer.

Gastrointestinal bleeding caused by a duodenocaval fistula is rare, diagnostically challenging, and associated with a high mortality rate. We describe the case of a patient with polymicrobial fungemia and fatal gastrointestinal bleeding related to a duodenocaval fistula caused by peptic ulcer. Polymicrobial fungemia, which has not previously been associated with this condition, raises the possibility of candidal endocarditis.

Planning a medical relief mission.

Surveillance of drug consumption and disease incidence from medical relief missions in two locations--southeast Asia and eastern Africa--revealed close similarities. Analgesics, antibiotics, antimalarials, antihistamine or decongestant preparations (or both), bronchodilators, and scabicides were the 10 most commonly used drugs. Orthopedic, respiratory, gastrointestinal, dermatologic, and ophthalmic conditions, malaria, sexually transmitted diseases, and parasitic infestations were encountered most frequently. Recognition and early treatment of xerophthalmia, trachoma, and onchocerciasis, which are rare in more developed countries but common at tropical latitudes, can prevent the blindness that results from untreated disease progression. Pulse-temperature relationships and fever patterns may offer diagnostic clues to physicians deprived of laboratory support. Important logistic considerations, disease incidences, and selected topics and idiosyncrasies of humanitarian aid missions to tropical communities are discussed in hopes of aiding providers who are planning future relief missions.

Recognition and management of von Hippel-Lindau disease.

Manifestations of von Hippel-Lindau disease include cerebellar tumors; renal, pancreatic and epididymal cysts; retinal angiomatosis; pheochromocytomas, and renal cell carcinoma. Patients who present with manifestations from one of the lesions associated with the disease are often incorrectly assumed to have an isolated lesion. First-degree relatives of a patient with von Hippel-Lindau disease have a 50 percent chance of developing the disease. Therefore, these individuals require close surveillance and careful management.

Can glucose-6-phosphate dehydrogenase deficiency be correlated with ABO blood type?

To determine if the presence of glucose-6-phosphate dehydrogenase deficiency (G6PDD) was correlated with a particular ABO blood type, results from a predeployment screening for G6PDD were categorized according to ABO blood type. The prevalence of G6PDD in blacks, Asians, and Mediterraneans (11.6%) mirrored that of other researchers. The most common blood type associated with G6PDD was O positive. Unlike those of other authors, this study did not disclose a statistically significant correlation (chi 2 = 11.354, df = 3, p < 0.01) between any one blood type and the presence of G6PDD.

Supply consumption and disease surveillance during an overseas training exercise in Southeast Asia.

In order to assist future medical officers in planning for overseas deployment to austere areas where resupply is non-existent and support from higher echelons is extremely limited, we surveyed the most common medical problems and most frequently used drugs during a 6-week deployment of 1,159 troops to Khorat, Thailand, from April 21 to June 1, 1992. We consumed 358 l of parenteral fluids--markedly less than anticipated. Ophthalmic solutions, especially antiviral and steroid, were needed more than anticipated. With an attack rate of 9.7%, orthopedic injuries were encountered most frequently. Overall attack rate for all injuries and diseases combined was 34%. Eight patients required hospitalization at local native hospitals longer than 24 hours, and two patients required evacuation to tertiary care centers in CONUS.

Metastatic renal cell carcinoma presenting as a breast mass.

Metastasis of primary renal cell carcinoma to the breast, as in the patient described here, is rare. However, this case illustrates the importance of a high index of suspicion, further diagnostic evaluation based on results of routine tests, and use of appropriate imaging techniques in the workup of a patient with breast cancer.

Leishmaniasis. Another threat to Persian Gulf veterans.

Leishmaniasis, a protozoal infection transmitted by sand flies, is one of the most common parasitic diseases worldwide. As US military troops return from endemic areas, it is likely that physicians will encounter cases of this previously seldom seen disease. The incubation period is long, and initial infection is often insidious and difficult to diagnose. To prevent the high mortality of untreated visceral forms and the potentially disfiguring scarring of the cutaneous form, primary care physicians (especially those caring for Persian Gulf veterans) should be aware of the disease and familiar with its treatment.