Geographic clustering of Pneumocystis carinii pneumonia in patients with HIV infection.

To detect whether there was geographic clustering of Pneumocystis carinii pneumonia cases among patients with human immunodeficiency virus (HIV) infection, we performed a retrospective analysis of a clinical database. The rates of pneumocystosis were analyzed by zip code zones for evidence of geographical clustering. During the study period, 118 patients at our AIDS Treatment Center had a first episode of P. carinii pneumonia. An analysis of the 24 zip code zones for which a P. carinii pneumonia rate was calculated (requiring a denominator of at least 10 known HIV- infected individuals residing in that zone) showed a trend toward geographic clustering (p = 0.07); when all 45 Cincinnati zip code zones were included in the analysis, clustering of cases was observed (p = 0. 02). By contrast, no clustering was observed for 52 HIV-infected control subjects with respiratory disease or for 960 HIV-infected patients treated at our center during the same time period. These data raise intriguing questions about exposure to exogenous sources of P. carinii and suggest the need for prospective studies.

Equal survival rates for first, second, and third episodes of Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome.

BACKGROUND: Second and subsequent episodes of acute Pneumocystis carinii pneumonia (PCP) are reported to have a worse prognosis than initial episodes in patients with the acquired immunodeficiency syndrome. We tested the hypothesis that survival rates of first, second, and subsequent episodes of acute PCP in patients with the acquired immunodeficiency syndrome are equal. METHODS: Analysis of the outcomes in prospective series of patients with the acquired immunodeficiency syndrome treated for acute PCP over 5 years. RESULTS: Survival rates of 222 PCP occurrences by episode number were: first, 86%; second, 84%; third, 88%; and fourth, 67%. Survival rates for the first, second, and third episodes were not significantly different. Second and third episodes had a larger proportion of patients with mild disease than initial episodes. CONCLUSIONS: Survival rates for first, second, and third episodes of PCP in patients with the acquired immunodeficiency syndrome are not different. In contrast to earlier articles, treatment for second and third episodes of acute PCP may be as successful as in initial episodes.

Absorption of bupivacaine after topical application to the oropharynx.

Bupivacaine in dosages of 20, 40, 60, or 80 mg was applied by spray to the oropharynx of 24 volunteers. Blood levels of bupivacaine were detectable at 10 minutes, peaked at 60-90 minutes, and were still measurable at 150 minutes after administration. The maximum bupivacaine plasma level recorded in any volunteer was 0.96 -g/mL (after 80 mg). Increase in pulse rate and decrease in systolic blood pressure were significantly correlated with increasing bupivacaine dosage. No clinical signs or symptoms of drug toxicity were observed in any subject.

Comparison of continuous epidural infusion of a local anesthetic and administration of systemic narcotics in the management of pain after total knee replacement surgery.

Continuous bupivacaine epidural analgesia was compared with conventional methods of systemic analgesic administration in the management of postoperative pain in 30 patients for 3 days following total knee replacement surgery. Patients given continuous epidural analgesia had significantly better pain relief (visual analogue scale, global evaluation), needed significantly fewer supplementary analgesics, and had significantly fewer side effects. In the epidural group, sensory block averaged six dermatomes on day 1 and four dermatomes on day 3. The number of patients with complete (or almost complete) motor block of the lower limbs decreased from eight on day 1 to five on day 3. The mean dosage of bupivacaine decreased from 21.0 +/- 5.7 (SD) mg/hr on day 1 to 15.1 +/- 8.5 mg/hr on day 3. No signs of accumulation of or toxic reactions to bupivacaine were seen.

Antibody responses to toxic-shock-syndrome (TSS) toxin by patients with TSS and by healthy staphylococcal carriers.

Serum samples taken from women with toxic-shock syndrome (TSS) and from women without a history of TSS were examined for the presence of antibodies to toxic-shock-syndrome toxin (TST). Serum samples from 38 women with TSS and from 70 women with no history of TSS were analyzed by radioimmunoassay (RIA) and by an enzyme-linked immunoadsorbent assay (ELISA). Antitoxin titers obtained by the assays were highly correlated. Antibody levels in sera of women with TSS, or a history of TSS, were significantly lower than levels in sera of women with no prior evidence of TSS. The mean level of antitoxin titers in the total sample of acute, convalescent, and recovered TSS groups was significantly lower than that of the control groups, which consisted of 31 carriers of genital Staphylococcus aureus and a similar number of age- and race-matched noncarriers. Although a trend toward elevated antitoxin titers was apparent after recovery, no vigorous immunologic response to TST was noted. In contrast, the majority of healthy women demonstrated measurable antitoxin titers, a finding indicative of current or prior colonization with TST-producing strains of S. aureus. The data suggest that absence of antibodies to the TSS toxin may be a predisposing factor in the development of clinical disease.