Multidrug and Mupirocin Resistance in Environmental Methicillin-Resistant Staphylococcus aureus (MRSA) Isolates from Homes of People Diagnosed with Community-Onset MRSA Infection.

Patients with community-onset (CO) methicillin-resistant Staphylococcus aureus (MRSA) infections contribute to MRSA contamination of the home environment and may be reexposed to MRSA strains from this reservoir. This study evaluates One Health risk factors, which focus on the relationship between humans, animals, and the environment, for the increased prevalence of multiple antimicrobial-resistant MRSA isolates in the home environment. During a trial of patients with CO-MRSA infection, MRSA was isolated from the household environment at the baseline and 3 months later, following randomization of patients and household members to mupirocin-based decolonization therapy or an education control group. Up to two environmental MRSA isolates collected at each visit were tested. MRSA isolates were identified in 68% (65/95) of homes at the baseline (n = 104 isolates) and 51% (33/65) of homes 3 months later (n = 56 isolates). The rates of multidrug resistance (MDR) were 61% among isolates collected at the baseline and 55% among isolates collected at the visit 3 months later. At the baseline, 100% (14/14) of MRSA isolates from rural homes were MDR. While antimicrobial use by humans or pets was associated with an increased risk for the isolation of MDR MRSA from the environment, clindamycin use was not associated with an increased risk for the isolation of MDR MRSA. Incident low-level mupirocin-resistant MRSA strains were isolated at 3 months from 2 (5%) of 39 homes that were randomized to mupirocin treatment but none of the control homes. Among patients recently treated for a CO-MRSA infection, MRSA and MDR MRSA were common contaminants in the home environment. This study contributes to evidence that occupant use of antimicrobial drugs, except for clindamycin, is associated with MDR MRSA in the home environmental reservoir. (This study has been registered at ClinicalTrials.gov under registration no. NCT00966446.)IMPORTANCE MRSA is a common bacterial agent implicated in skin and soft tissue infections (SSTIs) in both community and health care settings. Patients with CO-MRSA infections contribute to environmental MRSA contamination in these settings and may be reexposed to MRSA strains from these reservoirs. People interact with natural and built environments; therefore, understanding the relationships between humans and animals as well as the characteristics of environmental reservoirs is important to advance strategies to combat antimicrobial resistance. Household interactions may influence the frequency and duration of exposure, which in turn may impact the duration of MRSA colonization or the probability for recurrent colonization and infection. Therefore, MRSA contamination of the home environment may contribute to human and animal recolonization and decolonization treatment failure. The aim of this study was to evaluate One Health risk factors that may be amenable to intervention and may influence the recovery of MDR and mupirocin resistance in CO-MRSA isolates.

Weight assessment in cardiac patients: implications for prescription of low molecular weight heparin.

BACKGROUND: Many drugs such as low molecular weight heparin (LMWH) are administered at "patient weight adjusted" doses. Obtaining an accurate measurement of a patient's weight may not always be possible. The aim of this study was to assess patterns and accuracy of weight estimation and implications for drug dosing. METHODS: The study comprised three parts: (1) inpatient weight documentation was reviewed over a 4 week period (January 2008); (2) a questionnaire was distributed to healthcare staff; (3) healthcare staff were asked to estimate the weight of patients. These estimates took place in three locations: the coronary care unit, cardiac catheterisation laboratory, and the cardiac outpatient department. RESULTS: (1) In 385 patient notes, only 192 (49.9%) had a record of the patient's weight. The dose of LMWH was correct only 51% of the time. (2) Doctors were more likely to estimate a patient's weight than nurses (85 vs 51%, p = 0.003). (3) 50 healthcare staff made 533 weight estimations on 182 patients. There was a tendency to overestimate the weight of lighter patients and underestimate the weight of heavier patients (p<0.001). Patients were more accurate than healthcare staff at estimating their weight (80% vs 39%, p<0.001) and female patients were more likely to be accurate than men (62% vs 44%, p = 0.035). CONCLUSIONS: In our institution weight estimation occurs and may result in inaccurate prescription of LMWH. Estimating a patient's weight should be discouraged but if necessary the patient reported weight is likely to be most accurate. Unless there is significant investment in improved technology to allow obese or acutely unwell patients to be weighed, the dangerous practice of weight estimation is likely to continue.

Whole-tumor perfusion CT parameters and glucose metabolism measurements in head and neck squamous cell carcinomas: a pilot study using combined positron-emission tomography/CT imaging.

BACKGROUND AND PURPOSE: Previous (separately performed) perfusion CT (PCT) and PET studies have been inconclusive regarding the correlation of functional tumor characteristics. The purpose of this study was to perform dual assessment of head and neck squamous cell carcinomas (SCCAs) to examine the relationship between perfusion measurements derived from PCT and glucose standardized uptake values (SUV). MATERIALS AND METHODS: We prospectively evaluated 15 primary and recurrent SCCAs using combined positron-emission tomography (PET) and CT of the head and neck. SUV(mean), SUV(max), blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability (PS) values were calculated with use of manually drawn regions of interest (ROIs) over the lesions and the healthy muscle tissue. Parametric comparison test, correlation coefficients, and regression analysis were performed. RESULTS: The mean (+/- SD) SUV(mean), SUV(max), BF, BV, MTT, and PS values in the tumor tissue were 6.26 (+/- 1.48), 15.25 (+/- 3.81), 91.50 (+/- 24.69), 5.08 (+/- 1.17), 7.51 (+/- 2.24), and 23.08 (+/- 8.77), respectively. All PET/CT and PCT parameters of muscle versus tumor tissue were statistically different (.0001 < P < .001). There were significant correlations between BF and SUV(max) as well as SUV(mean) (r = 0.57; P = .02 and r = 0.63; P = .011, respectively) in the tumors. Significant correlation was also found between PS and SUV(mean) (r = 0.53; P = .04) in the tumors. Regression analysis showed: SUV(max) = 0.09 x BF + 7.2 (R(2) = 0.33; P = .02), SUV(mean) = 0.05 x BF + 2.22 (R(2) = 0.45; P = .011), and SUV(mean) = 0.05 x PS + 5.36 (R(2) = 0.35; P = .04). The tumor to nontumor (muscle) SUV(mean) and SUV(max) ratio was 9.45 (+/- 3.55) and 17.58 (+/- 4.32), respectively. BF-ratio SUV(mean) and BF-ratio SUV(max) showed significant correlations (r = 0.64; P = .01 and r = 0.53; P = .04, respectively). Regression analysis showed ratio SUV(mean) = 0.14 x BF-3.48 (R(2) = 0.42; P = .01) and ratio SUV(max) = 0.14 x BF + 4.51 (R(2) = 0.29; P = .04). CONCLUSION: Tissue perfusion-metabolic coupling is evident in head and neck SCCAs and may provide additional diagnostic information in patients undergoing PET/CT studies.

Brain effects of TMS delivered over prefrontal cortex in depressed adults: role of stimulation frequency and coil-cortex distance.

Relative regional brain blood flow was measured in 23 clinically depressed adults by using ECD SPECT at baseline and again during actual prefrontal transcranial magnetic stimulation (TMS) following 5 daily sessions of TMS. TMS over prefrontal cortex caused increased activity in cortex directly under the stimulation (inversely correlated with distance from scalp to cortex) and decreased activity in remote regions (anterior cingulate and anterior temporal poles). High-frequency rTMS (20 Hz) caused more relative flow immediately below the TMS coil than did low-frequency rTMS (5 Hz). Confirming the hypotheses tested, repeated daily TMS over the prefrontal cortex in medication-free depressed adults appears to change both local and remote blood flow in a manner that may also depend on the frequency of stimulation and coil to outer cortex distance.

Cholecystokinin-Stimulated mebrofenin (99mTc-Choletec) hepatobiliary scintigraphy in asymptomatic postcholecystectomy individuals: assessment of specificity, interobserver reliability, and reproducibility.

OBJECTIVES: Cholecystokinin-stimulated hepatobiliary scintigraphy (CCK-HBS) is a noninvasive method reported to be highly accurate in the diagnosis of sphincter of Oddi dysfunction. Our primary aim was to assess the specificity of CCK-HBS by evaluating its ability to exclude disease in 20 asymptomatic postcholecystectomy individuals. Secondary aims were to assess the interobserver reliability in scoring the CCK-HBS examinations between three blinded observers and to assess reproducibility of CCK-HBS repeated in the same individuals. METHODS: Twenty asymptomatic postcholecystectomy individuals with normal liver serum chemistries underwent CCK-HBS on two separate occasions. Three nuclear medicine specialists read each CCK-HBS study in a blinded fashion. RESULTS: There was good agreement between the three observers reading the same scans for both the first scan (kappa = 0.554) and the second scan (kappa = 0.507). There was poor agreement between the first and second scans on the same patient, read by the same nuclear medicine specialist (kappa = 0.062-0.385). The overall specificity of the CCK-HBS score was 77.5%; however, the specificity was only 60% when a true negative was defined as two negative CCK-HBS examinations. CONCLUSIONS: Quantitative CCK-HBS is of poor specificity in asymptomatic postcholecystectomy individuals. Hence, it is of questionable value in excluding sphincter of Oddi dysfunction in patients suspected to suffer from this disorder.

Driving and dementia: a review of the literature.

In North American society driving is closely linked with independence. Unfortunately, the freedom to operate a motor vehicle may be lost when an individual develops a specific medical diagnosis. The complex issue of dementia and driving safety is frequently encountered by health care professionals. Physicians are required, by law, to report any medical diagnosis such as dementia, that may affect driving safety. Physicians often refer to occupational therapists to assist them in determining if an individual's impairment significantly impacts driving safety. Unfortunately many health care professionals are not using reliable, valid and sensitive tests to determine the point at which an individual with dementia will become an unsafe driver. Through a review of the literature, the authors explore the effects of normal aging and cognitive impairment on driving safety. Specific assessment tools used to assess driving ability are examined and the role of health professionals in driver assessment is discussed. Some suggestions to improve the overall approach to evaluating driving safety are offered in the conclusion.

What every nurse needs to know about breast pumping: instructing and supporting mothers of premature infants in the NICU.

Research has established that breast milk is the best source of nutrition for the premature infant. Because the infant is born prematurely, the mother will need support in expressing breast milk for her infant's use. The clinical nurse has the opportunity to educate the mother on the importance of breast milk for the premature infant and to support the mother through the course of pumping. However, many nurses are not sufficiently educated in the physiology of lactation to adequately support the mother. The purpose of this article is to educate the bedside nurse in the physiology of lactation so that the mother is adequately assisted in expressing breast milk for her vulnerable infant.

Health physics consequences of out-patient treatment of non-Hodgkin's lymphoma with 131I-radiolabeled anti-B1 antibody.

The Medical University of South Carolina is currently participating in clinical trials of 131I radiolabeled Anti-B1 antibody for treatment of Non-Hodgkin's lymphoma. Under current South Carolina Department of Health and Environmental Control regulatory guidelines,; these patients are required to be admitted to the hospital and to remain as inpatients until the whole body burden is <30 mCi or the exposure rate measured 1 m from the patient is <5 mR h(-1). We demonstrate that these patients can be released in accordance with the new recommended guidelines of the Nuclear Regulatory Commission for the release of patients containing radioactive materials in compliance with all radioactive material and public dose standards. This benefits these patients by reducing their risk of infection and other hospital insults and by reducing the length of hospitalizations. Further, unnecessary hospital admissions are decreased, and the overall cost of healthcare delivery for these patients is significantly reduced.

The filmless radiology reading room: a survey of established picture archiving and communication system sites.

The purpose of this study was to survey radiologists experienced in soft-copy diagnosis using computer workstations about their current reading room environment, their impressions of the efficacy of their reading room design, and their recommendations based on their experience for improvement of the soft-copy reading environment. Surveys were obtained from radiologists at seven sites representing three major picture archiving and communication system (PACS) vendors throughout the world that have had extensive experience with soft-copy interpretation of radiology studies. The radiologists filled out a detailed survey, which was designed to assess their current reading room environment and to provide them with the opportunity to make suggestions about improvement of the PACS reading rooms. The survey data were entered into a database and results were correlated with multiple parameters, including experience with PACS, types of modalities interpreted on the system, and number of years of experience in radiology. The factors judged to be most important in promoting radiologist productivity were room lighting, monitor number, and monitor brightness. Almost all of the radiologists indicated that their lighting source was from overhead rather than indirect or portable light sources. Approximately half indicated they had the capability of dimming the brightness of the overhead lighting. Most radiologists indicated that they were able to adjust room temperature but that they did not have individual temperature controls at their workstations. The radiologists indicated that the most troublesome sources of noise included background noise, other radiologists, and clinicians much more than noise from computer monitors, technologists, or patients. Most radiologists did not have chairs that could recline or arm rests. Most did have wheels and the capability to swivel, both of which were judged important. The majority of chairs also had lumbar support, which was also seen to be important. Radiologists commonly adjusted room lighting and their reading chair, but rarely adjusted room temperature or monitor brightness. The median number of hours spent at the workstation before taken a "break" was 1.5. Common recommendations to improve the room layout included compartmentalization of the reading room and availability of the hospital/radiology information system at each workstation. The survey data suggest several areas of potential improvement based on radiologists' experience. Optimization of soft-copy reading room design is likely to result in decreased fatigue and increased productivity.

Changes in prefrontal cortex and paralimbic activity in depression following two weeks of daily left prefrontal TMS.

Twenty-two depressed adults were scanned with perfusion single-photon computed emission tomography before and after 2 weeks of left perfrontal transcranial magnetic stimulation (TMS) in a parallel design, double-blind treatment study. At medication-free baseline, across all subjects, blood flow in the bilateral medial temporal lobes, left prefrontal cortex, and caudate significantly declined with increased depression severity. Also at baseline, depressed adults who responded to TMS, compared with nonresponders, showed increased inferior frontal lobe activity. Following treatment, there was an even greater difference in inferior frontal blood flow in responders compared with nonresponders, and the negative baseline correlations between depression severity and limbic and prefrontal blood flow disappeared. These results suggest that in depressed adults, 10 days of prefrontal TMS affects prefrontal and paralimbic activity, which may explain its antidepressant effects.

Lexical priming on Neely's (1977) paradigm in Parkinson's disease: where do we stand?

In two published studies, we used a variant of Neely's (1977) lexical decision paradigm to study shifts of attention and automatic lexical activation in nondemented individuals with Parkinson's disease (McDonald, Brown, & Gorell, 1996; Spicer, Brown, & Gorell, 1994). Arnott and Chenery (in press) noticed differences between Neely's results and the results we observed in our control group that raise questions about some of the conclusions presented in the McDonald et al. (1996) and Spicer et al. (1994) papers. Even when considering the important differences between Neely's (1977) results and those in our control groups, we argue that our results support the conclusions of normal automatic semantic activation and deficient set-shifting in Parkinson's disease. We also introduce the notion of generalized priming to account for some of the priming effects observed in our studies.

Multiple previous alcohol detoxifications are associated with decreased medial temporal and paralimbic function in the postwithdrawal period.

BACKGROUND: Functional neuroimaging studies after alcohol cessation have demonstrated that chronic alcohol use globally reduces neuronal activity for several weeks. Less is known about the effects of previous alcohol use patterns on regional brain activity. Multiple previous alcohol detoxifications are associated with a worse clinical course and increased risk of seizures, perhaps due to sensitization of key brain structures. We performed the following imaging study in alcoholics in the postwithdrawal period to determine if blood flow in medial temporal structures would differ as a function of previous alcohol use (i.e., whether regions were kindled or sensitized due to multiple detoxifications). METHODS: Fourteen adults meeting DSM-IV criteria for alcohol dependence (mean age 35, 8 SD; 10 men) and participating in a double-blind detoxification medication study underwent a brain perfusion Tc99 m-ECD (Neurolite) single photon emission computed tomography scan on days 7 through 9 (mean 7.6, .5 SD) after their last drink and 2 to 3 days since their last detoxification medication. Seven nonpsychiatrically ill, nonalcohol-dependent healthy adults were scanned as control subjects. RESULTS: Alcoholics compared with controls had widely reduced relative activity in cortical secondary association areas and relatively increased activity in the medial temporal lobes (p < 0.01). Five alcoholic patients with > or = 2 previous detoxifications were compared with five patients in their first detoxification (age and detoxification medication matched). Multiple detoxification patients had significantly lower relative activity in bilateral anterior temporal poles and medial temporal lobes and in visual cortex (p < 0.01) compared with first episode patients. CONCLUSIONS: These studies are consistent with other studies comparing alcoholics and controls. They also suggest that on day 7 of detoxification, alcoholic subjects with multiple previous detoxifications have decreased visual cortex, medial temporal lobes, and anterior paralimbic blood flow, compared with those in their first detoxification. Further studies seem warranted to confirm these initial exploratory results.

Teleradiology: technology and practice.

Teleradiology increases the ability of radiologists to provide service to remote and underserved locations as well as coverage at times when direct reading of images is not possible. Good practices for teleradiology are described in the American College of Radiology (ACR) teleradiology standard. Teleradiology equipment is converging with picture archiving and communications systems (PACS) equipment so that diagnostic interpretation from remote locations is possible. Image capture can be directly from digital modalities or by film scanner. Transmission speed is still an issue. High transmission speeds were difficult to achieve but recent improvements may increase speeds and decrease costs.

The usefulness of iodine-123 whole-body scans in evaluating thyroid carcinoma and metastases.

OBJECTIVE: It is recognized that diagnostic doses of (131)I larger than 3 mCi will cause some cell injury to the tissue in which it concentrates and reduce subsequent uptake of (131)I administered therapeutically. Iodine-123 has been suggested as an alternate radiopharmaceutical to perform whole-body scans since its primary emissions are photons with minimal particulate radiation and it does not cause thyroid stunning and cell injury. The purpose of this study was to assess the effectiveness of (123)I for whole-body scans. METHODS: We examined 12 patients who had (123)I whole-body scans for known papillary/follicular thyroid cancer and 1 patient with Hurthle cell carcinoma, all with suspected metastases. All patients had undergone neck surgery and were given 0.81-0 mCi (123)I. Twenty-four hours later a whole-body image and static views of relevant areas were obtained. If abnormal uptake was noted, patients were treated with large doses of (131)I and then had whole-body (131)I scans 7-10 d post-therapy. These images were compared to (123)I whole-body scans. RESULTS: All 13 patients had abnormal (123)I scans and were treated with therapeutic doses of (123)I, followed by whole-body scans 7-10 d later. In 11 patients the activity seen on the 123I scans correlated well with that seen on (131)I scans. In 1 patient, additional lesions were noted on the (131)I images. In another patient, neck activity was seen on the (123)I scan but not on the subsequent (131)I post-therapy scan. The (123)I activity was felt to represent esophageal lumen activity. CONCLUSION: We found (123)1 effective in demonstrating residual thyroid tissue, thyroid carcinoma and metastases, and recommend its use for whole-body iodine scans since it does not cause thyroid stunning.

Magnetic resonance chemical shift microimaging of aging human skin in vivo: initial findings.

BACKGROUND/AIMS: In recent decades, interest has increased in the chronological and environmental factors governing the aging of skin. Various methods have been used for determining water and lipid content of human skin as a function of subject age. Magnetic resonance chemical shift imaging (CSI) offers a noninvasive technique for observing detailed distributions of water, lipids and other chemicals in the skin, and thus may be useful in dermatogerontology. METHODS: Human skin was examined in vivo on nine healthy volunteers, both male and female. Localized (1) H spectra of the skin were obtained from voxels 78 µm thick and parallel to the skin surface. Unique water and lipid profiles were observed for different individuals, showing the composition and microstructure of epidermis, dermis and hypodermis in each subject. These allowed the quantification of skin thickness in vivo by the first appearance of triacylglyceride olefinic protons at the dermal-hy-podermal junction, or alternatively by the degree of lipid infiltration into dermis. RESULTS: The relative concentration of free water in the skin, normalized to skin thickness, was observed to be slightly greater in older subjects and also in tanned subjects. More significantly, a microstructural feature common to every subject, i.e., the position of a possible capillary plexus in the dermis, showed migration toward the skin surface with advancing age. CONCLUSIONS: Such observations are consistent with previous studies of skin aging by other techniques and show promise for CSI in dermatogerontology as a non-invasive means for determination of skin water in vivo.

Magnetic resonance coil for (31) P spectroscopy of skin over curved body surfaces.

BACKGROUND/AIMS: Increasing signal-to-noise ratio for skin spectroscopy means increasing area, but increased area usually means resorting to Fourier window techniques to prevent overwhelming muscle contamination. The aim of this work was to develop a simple coil that would allow large areas of skin to be sampled while limiting muscle contamination simply by the coil's geometry. METHODS: The coil design was arrived at by using simulations that were calibrated by phantom tests with prototype units. It was then fabricated by using an etched circuitboard technique and tested on three volunteers for comparison with predicted performance. RESULTS: The new coil acquires magnetic resonance signals from a 140 cm(2) contoured layer of surface tissue with sufficient selectivity that 81% of the signal comes from tissue less than 1.9 mm deep. For skin and fat thicknesses of 1.1 and 3.1 mm, respectively, tending toward a worst case in-vivo situation, muscle contamination is only 3.3%. With the new coil, in 1 h, it was possible to directly acquire (31) P skin spectra comparable to those formerly obtained in 4 h in two separate acquistions that then had to be subtracted to obtain the desired skin spectra. CONCLUSION: Increasing the area of skin sampled while maintaining selectivity to limit muscle contamination, relying simply on coil geometry, is practical using a parallel configuration of long narrow strip coils.

Ultratag RBC kit for combined cardiac first-pass and multigated acquisition studies.

UNLABELLED: The authors developed a procedure to use the in vitro Ultratag (Mallinckrodt, St. Louis, MO) red blood cell (RBC) labeling kit for both first-pass (FP) and multigated acquisition (MUGA) studies with a high specific activity in a reduced volume (50 mCi/0.5 ml) and a high labeling efficiency that can be used with a single-crystal camera to yield a quality study. METHODS: A packed red blood cell (PRBC) bolus was created by two methods: (a) reducing the volume of the components of the Ultratag kit and (b) centrifuging the final dose volume. The labeling efficiency of each bolus was evaluated, each PRBC bolus was visually inspected for clots and percent hemolysis was assessed using a hemocytometer at 30 min, 1 hr and 2 hr postcentrifugation. RESULTS: Use of the first method, the 50% kit, provided the best results. However, the resulting volume from this kit only approached 1 ml, which is not clinically adequate for a first-pass study. In the second method, the total volume was centrifuged to form a PRBC bolus, which appeared to be stable in the syringe for at least 2 hr. A combined FP/MUGA study from a centrifuged 50% reduced kit was performed in one normal subject as a preliminary assessment of the clinical utility of this procedure. The image quality of the scan is diagnostically adequate. CONCLUSION: By using the in vitro Ultratag kit, a compact PRBC bolus was created that was stable in the syringe and could be reinjected safely into the patient for combined cardiac FP/MUGA studies.