A prospective observational prevalence study of elevated HbA1c among elective surgical patients.

Type 2 Diabetes Mellitus (DM) is a chronic disease with high prevalence worldwide. Using glycated haemoglobin (HbA1c) as a surrogate for potential pre-DM and DM conditions, our primary objective was to determine the HbA1c epidemiology in non-cardiac elective surgical patients in Singapore. Our secondary aim was to identify risk factors associated with elevated HbA1c. We conducted a prospective, observational single-centre study in adult patients. HbA1c screening was performed. Patient demographics and comorbidities were recorded. Patients were divided into those with HbA1C ≤ 6.0% and HbA1C ≥ 6.1%. Regression analyses were performed to identify associated factors. Subgroup analysis was performed comparing patients with HbA1C ≥ 6.1% and HbA1C ≥ 8.0%. Of the 875 patients recruited, 182 (20.8%) had HbA1c ≥ 6.1%, of which 32 (3.7%) had HbA1c ≥ 8%. HbA1C ≥ 6.1% was associated with Indian ethnicity [1.07 (1.01-1.13), p = 0.023], BMI > 27.5 [1.07 (1.02-1.11), p = 0.002], higher preoperative random serum glucose [1.03 (1.02-1.04), p < 0.001], pre-existing diagnosis of DM [1.85 (1.75-1.96), p < 0.001] and prediabetes [1.44 (1.24-1.67), p < 0.001], and peripheral vascular disease [1.30 (1.10-1.54), p = 0.002]. HbA1c ≥ 8% had an additional association with age > 60 years [0.96 (0.93-0.99), p = 0.017]. The prevalence of elevated HbA1c is high among the surgical population. Targeted preoperative HbA1c screening for at-risk elective surgical patients reduces cost, allowing focused use of healthcare resources.

Hyoid and laryngeal excursion kinematics - magnitude, duration and velocity - changes following successful exercise-based dysphagia rehabilitation: MDTP.

Variability in magnitude of deglutitional hyolaryngeal excursion in patients with dysphagia suggests that it does not adequately represent the kinematics of swallowing difficulties or recovery following rehabilitation. On the other hand, reduced hyolaryngeal excursion velocity has been reported in patients with dysphagia. While increased movement velocity often accompanies clinical and functional recovery in many diseases, velocity changes in swallowing-related movement following dysphagia therapy have not been well studied. This study evaluated changes in hyoid and laryngeal excursion (magnitude, duration and velocity) before and following successful dysphagia therapy to provide a more comprehensive representation of improvement to swallowing kinematics in patients who have experienced successful rehabilitation. A secondary analysis of case series data was completed. Eight patients with severe, chronic dysphagia completed a standard course of an exercise-based dysphagia treatment programme (McNeill dysphagia therapy program, MDTP). Pre- and post-treatment, kinematic aspects of swallowing were evaluated for thin liquid, thick liquid and pudding swallows. Maximum hyoid and laryngeal excursion magnitude and excursion duration were measured. Excursion velocities were calculated from excursion magnitude and duration measures. Successful treatment for dysphagia facilitated increased hyolaryngeal excursion magnitude, duration and velocity. These changes were most prominent for the hyoid and most often observed with thin liquids. By examining hyoid and laryngeal excursion velocity in patients who have experienced successful dysphagia rehabilitation, this study demonstrated the value of evaluating spatial and temporal aspects of swallowing kinematics in a single measure for a more comprehensive representation of positive changes underlying functional recovery.

Capacity building through focus group training in community-based participatory research.

BACKGROUND: Community-based participatory research (CBPR) emphasizes collaborative efforts among communities and academics where all members are equitable contributors. Capacity building through training in research methodology is a potentially important outcome for CBPR partnerships. OBJECTIVES: To describe the logistics and lessons learned from building community research capacity for focus group moderation in the context of a CBPR partnership. METHODS: After orientation to CBPR principles, members of a US suburban community underwent twelve hours of interactive learning in focus group moderation by a national focus group expert. An additional eight-hour workshop promoted advanced proficiency and built on identified strengths and weaknesses. Ten focus groups were conducted at an adult education center addressing a health concern previously identified by the center's largely immigrant and refugee population. Program evaluation was achieved through multiple observations by community and academic-based observers. RESULTS: Twenty-seven community and academic members were recruited through established relationships for training in focus group moderation, note-taking, and report compilation. Focus group training led to increased trust among community and research partners while empowering individual community members and increasing research capacity for CBPR. CONCLUSIONS: Community members were trained in focus group moderation and successfully applied these skills to a CBPR project addressing a health concern in the community. This approach of equipping community members with skills in a qualitative research method promoted capacity building within a socio-culturally diverse community, while strengthening community-academic partnership. In this setting, capacity building efforts may help to ensure the success and sustainability for continued health interventions through CBPR.

Efficacy and safety of rifampin containing regimen for staphylococcal prosthetic joint infections treated with debridement and retention.

The aim of this study was to evaluate the efficacy and safety of rifampin for Staphylococcus aureus (SA) or coagulase negative staphylococci (CNS) prosthetic joint infection (PJI) treated with debridement and retention (D/R). We calculated the treatment failure cumulative incidence (TF) of a cohort of 101 patients with SA or CNS PJI treated with D/R and antimicrobial therapy. The effect of the use of a rifampin-based regimen was evaluated. Cox proportional hazards regression evaluated the association between treatment and time-to-TF controlling for the propensity to treat with rifampin and temporal confounders. Seven percent (1/14) of the prospective rifampin-treated patients, 32% (10/31) of the historical rifampin-treated patients and 38% (21/56) of the historical non-rifampin treated patients developed TF. After controlling for the propensity to treat with rifampin and American Society of Anesthesia scores, patients in the prospective cohort had a lower risk of TF compared to patients in the historical cohort not treated with rifampin (HR 0.11; 95%CI 0.01-0.84). None (0/14) of the patients in the prospective study developed hepatotoxicity. The outcome of staphylococcal PJI treated with D/R and rifampin-based regimens was better when compared with a historical cohort treated without rifampin.

Tuberculosis attributed to household contacts in the Philippines.

Data on the burden of disease from tuberculosis (TB) in Filipino households are limited. To determine the magnitude of undiagnosed TB in TB households, and the demographic and socio-economic factors associated with TB in the Philippines, household contacts of adult smear-positive TB patients seen from July 2001 to June 2003 were assessed based on interview, chest X-ray, tuberculin skin test and sputum examination. History of TB and older age were independently associated with TB disease, and age and duration of cohabitation with TB infection. TB and TB infection are highly prevalent in TB households in the Philippines.

Tuberculosis infection and disease in children living in households of Filipino patients with tuberculosis: a preliminary report.

SETTING: DOTS Clinic with a DOTS-Plus pilot project for the management of multidrug-resistant tuberculosis (MDR-TB) in a high burden country. OBJECTIVE: To determine the prevalence of tuberculosis (TB) infection and disease among pediatric household contacts of patients with pulmonary TB (PTB). DESIGN: Cross-sectional study. METHODOLOGY: One hundred and fifty-three children aged 0-15 years in the households of 62 bacteriologically confirmed PTB patients, including 44 with MDR-TB, were studied. BCG scars were noted, and tuberculin skin test (TST), screening chest radiography, and sputum or gastric aspirate smear and culture for Mycobacterium tuberculosis in those with radiographic findings suggestive of PTB were done. RESULTS: For children in this study, the prevalences of latent TB infection (LTBI), radiographically diagnosed pulmonary TB, and bacillary pulmonary TB were 69.2%, 3.3%, and 0.65%, respectively. Only age > or = 5 years was found to be a significant predictor of LTBI (OR 3.17, 95%CI 1.43-7.01). CONCLUSION: Contact investigation for active case-finding and early treatment of TB in children from households of patients with active PTB is essential for TB control. Further study on a more precise definition of TB infection and strategies for control in this population will be pursued.

A trial of proguanil-dapsone in comparison with sulfadoxine-pyrimethamine for the clearance of Plasmodium falciparum infections in Tanzania.

Considerable levels of resistance to sulfadoxine-pyrimethamine (SP) have been reported in Plasmodium falciparum in north-eastern Tanzania, and the identification of a suitable antimalarial to replace SP is now a high priority. We conducted a trial in July 2000 to determine the efficacy of proguanil (PG) plus dapsone (DS), compared with that of SP, for the treatment of asymptomatic falciparum infection. A total of 220 children with parasitaemia > or = 2000 per microL completed the study; 112 had received a single dose of SP (dosage calculated for pyrimethamine 1.25 mg/kg and sulfadoxine 25 mg/kg) and 108 had taken PG 10 mg/kg with DS 2.5 mg/kg each day for 3 days. Clearance of asexual parasites at day 7 was 14.3% with SP, but 93.5% with PG-DS. The remarkably high failure rate with SP was not associated with occurrence of leucine substitution at position 164 of the dhfr gene. Both treatment regimens were well tolerated. Compared with available data on another antifolate combination, chlorproguanil-dapsone ('Lapdap'), PG-DS was slightly but significantly inferior in achieving parasite clearance (99.5% versus 93.5%). The estimated cost of a 3-day course of PG-DS treatment for a child weighing 18 kg is US $0.15. With the rising incidence of SP-resistant P. falciparum infection, PG-DS could provide an effective, affordable and already available therapeutic alternative for malaria in East Africa at least until chlorproguanil-dapsone is registered.

Evaluation of the COBAS AMPLICOR CMV MONITOR test for detection of viral DNA in specimens taken from patients after liver transplantation.

Detection of cytomegalovirus (CMV) DNA in blood by PCR is a sensitive method for the detection of infection in patients posttransplantation. The test, however, has low specificity for the identification of overt CMV disease. Quantitative CMV PCR has been shown to overcome this shortcoming. The COBAS AMPLICOR CMV MONITOR test was evaluated by using consecutive serum and peripheral blood mononuclear cell (PBMN) samples from liver transplant patients. Twenty-five patients had CMV viremia (by shell vial cell culture assay) and/or tissue-invasive disease (by biopsy); 20 had no active infection. A total of 262 serum and 62 PBMN specimens were tested. Of 159 serum specimens from patients with overt CMV infection, the COBAS assay detected CMV DNA in 21 patients (sensitivity, 84%). Only 1 of 103 samples from patients with no evidence of active infection had detectable CMV DNA (341 copies/ml). By comparison of 62 matching serum and PBMN samples by the same assay, 12 PBMN samples were exclusively positive, whereas only 2 serum samples were exclusively positive (P < 0.05). At the time of clinical CMV infection, viral copy numbers were higher in PBMNs than serum from four of five patients. The COBAS AMPLICOR CMV MONITOR test is a sensitive and specific test for the quantitative detection of CMV DNA in blood. Clinical applications of the assay will require further validation with samples from a larger population of transplant patients.

Cytomegalovirus (CMV) DNA load predicts relapsing CMV infection after solid organ transplantation.

Cytomegalovirus (CMV) DNA load was analyzed as a marker for relapse of CMV infection in 24 solid organ transplant patients with CMV infection or disease who received a fixed 14-day course of intravenous ganciclovir. Viral load was measured in blood samples obtained before and at the completion of treatment. Eight (33%) of 24 patients developed relapsing CMV infection. Median pretreatment viral loads were higher in the relapsing group (80,150 copies/106 leukocytes) than in the nonrelapsing group (5500 copies/106 leukocytes; P=.007). The relapsing group also had persistent detectable viral DNA (median, 5810 copies/106 leukocytes) after treatment, whereas it was undetectable in the nonrelapsing group (P<. 0001). Primary CMV infection (seronegative recipients of seropositive organs, D+R-) was an independent marker for CMV relapse (P=.03), and these patients had higher pre- and posttreatment viral loads than did non-D+/R- patients (P<.0001 and P=.0014, respectively). CMV DNA load is a useful marker for individualizing antiviral treatment of CMV infection in solid organ transplant recipients.

New strategies for prevention and therapy of cytomegalovirus infection and disease in solid-organ transplant recipients.

In the past three decades since the inception of human organ transplantation, cytomegalovirus (CMV) has gained increasing clinical import because it is a common pathogen in the immunocompromised transplant recipient. Patients may suffer from severe manifestations of this infection along with the threat of potential fatality. Additionally, the dynamic evolution of immunosuppressive and antiviral agents has brought forth changes in the natural history of CMV infection and disease. Transplant physicians now face the daunting task of recognizing and managing the changing spectrum of CMV infection and its consequences in the organ recipient. For the microbiology laboratory, the emphasis has been geared toward the development of more sophisticated detection assays, including methods to detect emerging antiviral resistance. The discovery of novel antiviral chemotherapy is an important theme of clinical research. Investigations have also focused on preventative measures for CMV disease in the solid-organ transplant population. In all, while much has been achieved in the overall management of CMV infection, the current understanding of CMV pathogenesis and therapy still leaves much to be learned before success can be claimed.

Novel mutation in the CMV UL97 gene associated with resistance to ganciclovir therapy.

Cytomegalovirus (CMV) strains resistant to ganciclovir have been associated with specific mutations in the UL97 and UL54 genes. The UL97 gene of a CMV strain isolated from a renal transplant recipient before and after 438 days of ganciclovir treatment was amplified by polymerase chain reaction and sequenced. A novel mutation resulting in deletion of codons 595 to 603 was identified in the viral DNA from specimens obtained after, but not before, prolonged ganciclovir therapy. Clinical and virological resolution of CMV disease occurred after switching to foscarnet therapy. Although many ganciclovir resistance mutations have been mapped to the UL97 codon range 591-607, this one is unusual in that it involves deletion of half these codons. Because UL97 seems to be necessary for effective CMV replication, this deletion suggests that much of codons 591-607 can be removed without destroying the biological function of UL97, and that this codon range can be altered in various ways to affect ganciclovir susceptibility. Rapid, flexible genotypic assays directed at this part of UL97 may facilitate the early recognition of ganciclovir resistance.

Infectious complications following renal transplantation.

Despite significant advancements in renal transplantation, infectious disease complications remain an important cause of morbidity and mortality in the transplant recipient. The prevention and treatment of these infections remain a major challenge.

[Clinical studies on sultamicillin fine granules in the urological field].

Clinical studies of sultamicillin (SBTPC) fine granules, an oral antibiotic with ester linked ampicillin and beta-lactamase inhibitor, sulbactam, were performed in acute uncomplicated cystitis and complicated urinary tract infections. 1. SBTPC fine granules were administrated at a dose of 187.5 mg 2-3 times daily for 5-7 days to 6 patients with acute uncomplicated cystitis. Clinical efficacies as judged according to the criteria of the UTI Committee were excellent in 5 cases and moderate in 1 case with an effectiveness rate of 100%. All of 7 identified bacteria were eradicated by the treatment. 2. SBTPC fine granules were administrated at a dose of 187.5 mg or 375 mg 3 times daily for 5-7 days to 17 patients with complicated urinary tract infections. Clinical efficacies as judged according to the criteria of the UTI Committee were excellent in 8 cases, moderate in 4 cases and poor in 5 cases with an effectiveness rate of 70.6%. Out of 17 identified bacteria, 14 (82.4%) were eradicated by the treatment. 3. As adverse reactions, glossitis, diarrhea and pharyngeal redness were observed in 1 case out of 31 cases treated with the drug. These symptoms, however, were mild and transient. No abnormal laboratory test values were observed. From the above results, it appears that SBTPC fine granules are useful in the treatment of urinary tract infections.