Reactive arthritis, psoriasiform lesions and protein loosing enteropathy secondary to Strongyloidiasis.

Reactive arthritis is associated with demonstrable infection at a distant site without evidence of sepsis at the affected joint(s). We present a rare case reactive arthritis where no bacterial or chlamydial infections could be established, rather larvae of Strongyloides stercoralis could be demonstrated in the stool and duodenal biopsy. Reactive arthritis, psoriasiform lesions and malabsorption with hypoproteinaemia, responded to successful treatment with antihelminthic drugs. Early recognition and adequate treatment for gastrointestinal infections and infestations before complications is important.

Improved compliance with universal precautions in the operating room following an educational intervention.

Observation of surgical personnel in four specialties (cardiothoracic, general, gynecologic, and orthopedic) in the operating room was performed prior to implementation of an educational intervention designed to improve compliance with Universal Precautions and at 1- and 2-years post-intervention. Use of protective eyewear and double gloving increased following the intervention, whereas the incidence of documented blood and body fluid exposures decreased.

Evaluation of a preclinical, educational and skills-training program to improve students' use of blood and body fluid precautions: one-year follow-up.

BACKGROUND: Little is known about long-term improvements in medical students' knowledge, attitudes, and use of blood and body fluid precautions following preclinical training. METHODS: We evaluated an educational and skills-training program emphasizing double gloving for high-risk surgical procedures. Baseline surveys measuring knowledge, attitudes, and readiness to use specific precautions were completed by second-year (experimental) students before skills training and by third-year students (control) after their first clinical year. Follow-up surveys were completed 1 year later. Use of double gloves and protective eyewear during surgery clerkships was observed at baseline and follow-up. RESULTS: Of 149 students returning both surveys, the experimental group (n = 91) showed improvements in attitudes toward double gloving (P = 0.038) and use of double gloves during surgery at follow-up (relative risk = 1.95, 95% confidence interval = 1.06, 3.59). They expressed better attitudes toward (P = 0.003) and greater readiness to use (P = 0. 020) double gloves compared with controls at follow-up. They expressed better attitudes toward (P = 0.002) and greater readiness to use (P = 0.001) double gloves compared with controls when each had completed their first clinical year. CONCLUSION: The intervention was associated with improved attitudes toward and use of double gloves during surgery. The experimental group also expressed better attitudes and readiness to use double gloves compared with controls at follow-up.

Compliance with Universal Precautions among emergency department personnel: implications for prevention programs.

BACKGROUND: We developed a 50-item questionnaire to assess emergency department (ED) staff members' knowledge of bloodborne pathogen transmission, compliance with Universal Precautions, and the use of personal protective equipment. METHOD: A questionnaire was administered to 103 ED staff members including physicians, nurses, and technicians at Barnes-Jewish Hospital in St Louis, a Level-I trauma center. RESULTS: ED personnel had inadequate knowledge of bloodborne pathogen infection risk, underreported exposures, and underused personal protection equipment during trauma cases. CONCLUSION: Further educational interventions for ED personnel are needed to increase their compliance with Universal Precautions.

Use of personal protective equipment and operating room behaviors in four surgical subspecialties: personal protective equipment and behaviors in surgery.

OBJECTIVE: To evaluate Universal Precautions (UP) compliance in the operating room (OR). DESIGN: Prospective observational cohort. Trained observers recorded information about (1) personal protective equipment used by OR staff; (2) eyewear, glove, or gown breaks; (3) the nature of sharps transfers; (4) risk-taking behaviors of the OR staff; and (5) needlestick injuries and other blood and body-fluid exposures. SETTING: Barnes-Jewish Hospital, a 1,000-bed, tertiary-care hospital affiliated with Washington University School of Medicine, St Louis, Missouri. PARTICIPANTS: OR personnel in four surgical specialties (gynecologic, orthopedic, cardiothoracic, and general). Procedures eligible for the study were selected randomly. Hand surgery and procedures requiring no or a very small incision (eg, arthroscopy, laparoscopy) were excluded. RESULTS: A total of 597 healthcare workers' procedures were observed in 76 surgical cases (200 hours). Of the 597 healthcare workers, 32% wore regular glasses, and 24% used no eye protection. Scrub nurses and medical students were more likely than other healthcare workers to wear goggles. Only 28% of healthcare workers double gloved, with orthopedic surgery personnel being the most compliant. Sharps passages were not announced in 91% of the surgical procedures. In 65 cases (86%), sharps were adjusted manually. Three percutaneous and 14 cutaneous exposures occurred, for a total exposure rate of 22%. CONCLUSION: OR personnel had poor compliance with UP. Although there was significant variation in use of personal protective equipment between groups, the total exposure rate was high (22%), indicating the need for further training and reinforcement of UP to reduce occupational exposures.

Compliance with universal precautions among emergency department personnel caring for trauma patients.

STUDY OBJECTIVE: Emergency department personnel are at high risk of occupational infection with bloodborne pathogens. The objective of this study was to observe and analyze the use of barrier precautions among ED personnel caring for trauma patients. METHODS: This observational study used videotapes of trauma cases seen at an urban Level I trauma center. Study participants were ED and trauma team personnel. Trained observers scored breaks in the use of barrier precautions during the first 15 minutes of 88 videotaped Level I trauma cases. "Major" breaks were scored when ED personnel performed invasive procedures without gloves, mask, gown, and adequate eye protection. "Minor" breaks were scored when ED personnel were adjacent to a trauma patient (within 1 m) without wearing these items. RESULTS: We observed 1 or more major breaks in 33.6% of 304 invasive procedures. The most common major break was failure to wear a mask (32.2% of procedures), followed by inadequate eyewear (22.2%), no gown (5.6%), and no gloves (3.0%). We observed minor breaks during 55.5% of 752 patient encounters. Large and statistically significant variations were seen in use rates of barrier precautions among different groups of personnel; surgery residents were most likely to use precautions, whereas attending surgeons were least likely. CONCLUSION: Compliance with universal precautions is poor in this high-risk clinical setting. These data provide a baseline for measuring the effectiveness of interventions to improve compliance. Videotaped observations are a novel and effective tool in this setting.

Does clinical experience affect medical students' knowledge, attitudes, and compliance with universal precautions?

OBJECTIVE: To investigate differences in second-, third-, and fourth-year medical students' knowledge of bloodborne pathogen exposure risks, as well as their attitudes toward, and intentions to comply with, Universal Precautions (UP). DESIGN: Cross-sectional survey. PARTICIPANTS AND SETTING: Surveys about students' knowledge, attitudes, and intentions to comply with UP were completed by 111 second-year (preclinical), 80 third-year, and 60 fourth-year medical students at Washington University School of Medicine in the spring of 1996. RESULTS: Preclinical students knew more than clinical students about the efficacy of hepatitis B vaccine, use of antiretroviral therapy after occupational exposure to human immunodeficiency virus, and nonvaccinated healthcare workers' risk of infection from needlestick injuries (P<.001). Students' perceived risk of occupational exposure to bloodborne pathogens and attitudes toward hepatitis B vaccine did not differ, but preclinical students agreed more strongly that they should double glove for all invasive procedures with sharps (P<.001). Clinical students agreed more strongly with reporting only high-risk needlestick injuries (P=.057) and with rationalizations against using UP (P=.008). Preclinical students more frequently reported contemplating or preparing to comply with double gloving, wearing protective eyewear, reporting all exposures, and safely disposing of sharps, whereas students with clinical experience were more likely to report compliance. Clinical students also were more likely to report having "no plans" to practice the first three of these precautions (P<.001). CONCLUSIONS: Differences in knowledge, attitudes, and intentions to comply with UP between students with and without clinical experience may have important implications for the timing and content of interventions designed to improve compliance with UP.

Healthcare workers' attitudes and compliance with universal precautions: gender, occupation, and specialty differences.

We describe variations in healthcare workers' attitudes toward double gloving and reporting needlesticks, and in their readiness to comply with double gloving and hepatitis B vaccine. Differences related to occupation, specialty, and gender have implications for the need to tailor interventions for specific groups of healthcare workers to improve compliance with Universal Precautions.

Insights into medical students' career choices based on third- and fourth-year students' focus-group discussions.

PURPOSE: To identify previously unrecognized factors influencing medical students' career choices and to better characterize the effects of educational experiences, role models, and educational debt on career decisions. METHOD: Fifty-two third- and fourth-year students were recruited from three California medical schools to participate in focus-group discussions. The students were assembled into 12 groups of about four classmates from the same school, each facilitated by a medical student from another school. Focus-group discussions were audiotaped and qualitatively analyzed using content analysis. RESULTS: The students' perceptions of their abilities to influence patients' outcomes and to cope with a large knowledge base differentiated those interested in primary care fields from those attracted to procedure-oriented specialties. Negative role models, based on the students' assessments of interpersonal interactions and career satisfaction, were particularly influential in closing doors to certain fields. Many of the women reported an absence of role models. Most of the students denied any effect of debt or potential income on career choice; while many cited their small debts, some of the women alluded to the anticipation of being in dual-income families. CONCLUSION: Students' career decisions are complex, dynamic, and individualized processes. The use of qualitative measures helps bolster understanding of these processes by identifying new factors (such as mastery of knowledge) and by further characterizing known factors (such as role models and financial considerations). A comprehensive and valid understanding of students' career-decision making is necessary to develop successful strategies to sustain and encourage the choice of primary care careers.

Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis.

OBJECTIVE: To systematically review the medical literature on the prognosis and outcomes of patients with community-acquired pneumonia (CAP). DATA SOURCES: A MEDLINE literature search of English-language articles involving human subjects and manual reviews of article bibliographies were used to identify studies of prognosis in CAP. STUDY SELECTION: Review of 4573 citations revealed 122 articles (127 unique study cohorts) that reported medical outcomes in adults with CAP. DATA EXTRACTION: Qualitative assessments of studies' patient populations, designs, and patient outcomes were performed. Summary univariate odds ratios (ORs) and rate differences (RDs) and their associated 95% confidence intervals (CIs) were computed to estimate a summary effect size for the association of prognostic factors and mortality. DATA SYNTHESIS: The overall mortality for the 33,148 patients in all 127 study cohorts was 13.7%, ranging from 5.1% for the 2097 hospitalized and ambulatory patients (in six study cohorts) to 36.5% for the 788 intensive care unit patients (in 13 cohorts). Mortality varied by pneumonia etiology, ranging from less than 2% to greater than 30%. Eleven prognostic factors were significantly associated with mortality using both summary ORs and RDs: male sex (OR = 1.3; 95% CI, 1.2 to 1.4), pleuritic chest pain (OR = 0.5; 95% CI, 0.3 to 0.8), hypothermia (OR = 5.0; 95% CI, 2.4 to 10.4), systolic hypotension (OR = 4.8; 95% CI, 2.8 to 8.3), tachypnea (OR = 2.9; 95% CI, 1.7 to 4.9), diabetes mellitus (OR = 1.3; 95% CI, 1.1 to 1.5), neoplastic disease (OR = 2.8; 95% CI, 2.4 to 3.1), neurologic disease (OR = 4.6; 95% CI, 2.3 to 8.9), bacteremia (OR = 2.8; 95% CI, 2.3 to 3.6), leukopenia (OR = 2.5, 95% CI, 1.6 to 3.7), and multilobar radiographic pulmonary infiltrate (OR = 3.1; 95% CI, 1.9 to 5.1). Assessments of other clinically relevant medical outcomes such as morbid complications (41 cohorts), symptoms resolution (seven cohorts), return to work or usual activities (five cohorts), or functional status (one cohort) were infrequently performed. CONCLUSIONS: Mortality for patients hospitalized with CAP was high and was associated with characteristics of the study cohort, pneumonia etiology, and a variety of prognostic factors. Generalization of these findings to all patients with CAP should be made with caution because of insufficient published information on medical outcomes other than mortality in ambulatory patients.

Admission, recruitment, and retention: finding and keeping the generalist-oriented student. SGIM Task Force on Career Choice in Primary Care and Internal Medicine.

As the country strives to produce larger numbers of generalist physicians, considerable controversy has arisen over whether or not generalist applicants can be identified, recruited, and influenced to keep a generalist-oriented commitment throughout medical training. The authors present new and existing data to show that: 1) preadmission (BA/MD or post-baccalaureate) programs can help to identify generalist-oriented students; 2) characteristics determined at admission to medical school are predictive of future generalist career choice; 3) current inpatient-oriented training programs strongly push students away from a primary care career; 4) women are more likely than men to choose generalist careers, primarily because of those careers' interpersonal orientation; and 5) residency training programs are able to select applicants likely to become generalists. Therefore, to produce more generalists, attempts should be made to encourage generalist-oriented students to enter medical schools and to revise curricula to focus on outpatient settings in which students can establish effective and satisfying relationships with patients. These strategies are most likely to be successful if enacted within the context of governmental and medical school-based changes that allow for more reimbursement and respect for the generalist disciplines.

Biochemical identification of alpha-fodrin and protein 4.1 in human keratinocytes.

The mature erythrocyte has a cytoskeleton of less complexity than that of nucleated cells and has been elucidated in greater detail. Two of its major components are the heterodimeric protein spectrin and protein 4.1. We report here our isolation from human keratinocytes of immunoreactive forms of both protein 4.1 and of alpha-fodrin, the extra-erythrocytic form of alpha-spectrin. These keratinocyte proteins are approximately 125 kD and 240 kD in size, respectively. We also have isolated clones containing alpha-fodrin and protein 4.1 sequences from a human keratinocyte cDNA library. These sequences confirm the active transcription in keratinocytes of the alpha-fodrin and protein 4.1 genes. Both alpha-fodrin and protein 4.1 mRNA are detectable by Northern blot analysis in human keratinocytes, where their abundance appears not to be regulated by calcium concentration in the medium.

Production of interferon gamma, interleukin 2, interleukin 4, and interleukin 10 by CD4+ lymphocytes in vivo during healing and progressive murine leishmaniasis.

The expression of interleukin (IL) 2, IL-4, IL-10, and interferon gamma (IFN-gamma) by lymphocyte subsets was examined during infection of resistant C57BL/6 and susceptible BALB/c mice with the protozoan parasite Leishmania major. CD4+ and CD8+ T lymphocytes and B lymphocytes were isolated from the lymph nodes draining infectious lesions, and their RNA was examined for lymphokine transcripts. Distinct patterns of CD4+ cell cytokine expression were apparent: C57BL/6 CD4+ cells contained IFN-gamma and IL-2 mRNA, whereas BALB/c CD4+ cells expressed IL-4 and IL-10 message. CD8+ cells contributed little lymphokine expression during disease, but B cells were a major source of IL-2 mRNA in both strains of mice. BALB/c mice made resistant by treatment with anti-CD4 antibody at the time of infection repopulated lymph nodes with CD4+ cells that expressed IL-2 and IFN-gamma. Protective treatment with anti-IL-4 antibody in vivo also resulted in the appearance of CD4+ cells with increased IFN-gamma and diminished IL-4 and IL-10 expression. These data establish CD4+ cells as the primary source of IFN-gamma in healing mice and of IL-4 and IL-10 during progressive infection and confirm that the spectral extremes of this disease are characterized by the presence of CD4+ cells expressing Th1 or Th2 phenotypes in vivo.