Epidemiology and incidence of Clostridium difficile-associated diarrhoea diagnosed upon admission to a university hospital.

Patients with Clostridium difficile-associated diarrhoea (CDAD) may initially develop symptoms in the community and be subsequently diagnosed at hospital admission. At the present time there is no national surveillance system and no standardized case definition of CDAD in the USA, and baseline data on the incidence and epidemiology of CDAD are scarce. The objective of this study was to report the incidence of CDAD at a tertiary care hospital, and to determine the epidemiology of cases diagnosed within 48h of hospital admission, compared with cases of nosocomial CDAD diagnosed 48h or more after hospitalization. The average incidence was 4.0 cases/10 000 patient-days for CDAD on admission and 7.0 cases/10 000 patient-days for nosocomial CDAD. A significant difference was observed in CDAD rates on admission compared with nosocomial CDAD rates (P=0.017), but no differences were observed over time for either rate. Overall, 44% of cases had CDAD on admission and 56% of cases had nosocomial CDAD. Fifty-six (62%) patients with CDAD on admission had been admitted to the same hospital and 24 (27%) had been admitted to another hospital within the previous 90 days. Only eight (9%) patients had not been exposed to any healthcare services in the 90 days preceding hospital admission. A standardized case definition of healthcare-associated CDAD should include previous hospitalizations. Admitting physicians should consider C. difficile in the differential diagnosis of patients admitted with diarrhoea, with or without a history of admission to healthcare facilities.

Liposuction as an adjunct procedure in reduction mammaplasty.

Liposuction has been recognized as a useful adjunct to breast reduction surgery for fine contouring of adjacent areas to achieve aesthetic balance and preservation of nipple sensation. In particular, the liposuction technique has provided an acceptable way of treating the "fat roll" of the lateral portion of the breast, which extends to the axilla and lateral chest. The purpose of this study was to review the authors' approach to adjunctive lipoplasty with breast reduction surgery and to review their experience. Examination of their own results in 70 consecutive women who underwent reduction mammaplasty in 1998 by the senior surgeon did not reveal any substantial difference in the complication rate of those women who had adjunctive liposuction with their breast reduction surgery vs. those who did not. All complications such as fat necrosis, cellulitis, and seromas were confined to the breast and were not related to the liposuction. Furthermore, there was no additional morbidity associated with ultrasonic liposuction compared with traditional suction-assisted lipectomy. Their experience indicates that patients undergoing reduction mammaplasty may benefit aesthetically from adjunct lateral chest wall liposuction without additional morbidity.

Prevalence of nasal colonization with methicillin-resistant Staphylococcus aureus in selected patient populations.

Methicillin-resistant Staphylococcus aureus nasal colonization was investigated in patients arriving for elective cardiovascular surgery, renal patients admitted for arteriovenous graft surgery, and patients transferred to our hospital from other institutions. Renal patients were significantly more likely to be colonized and represent a potential source of MRSA to our institution.

Granular cell tumor in a child's finger.

Granular cell tumor is an uncommon tumor found in the hand. It is probably of Schwann cell origin and may be associated with a peripheral nerve. Although it is often described as a painless tumor of the oral cavity and skin, its presentation in the fingers or hand is often painful--a characteristic not well recognized.

Prevalence of methicillin-resistant Staphylococcus aureus in a dermatology outpatient population.

BACKGROUND: The number of methicillin-resistant STaphylococcus aureus (MRSA) infections in the hospital setting is increasing but little is known of its prevalence in the community. In a 1986-1987 study, the prevalence in dermatology outpatient clinics was <0.9%. This study reports changes in the same facilities from 1988 through 1996. METHODS: Culture results and antimicrobial susceptibility patterns were reviewed for the population for the period 1988 through 1996. RESULTS: We report a gradual increase of MRSA from 1.5% of all strains of Staphylococcus aureus in 1988 to 11.9% in 1996 in these outpatient facilities. Susceptibility data indicate that the MRSA strains isolated in 1996 are more resistant to oral agents such as ciprofloxacin and tetracycline, while all strains remain susceptible to the intravenous agent vancomycin. CONCLUSION: The prevalence of MRSA in the community is increasing and should be considered when selecting a treatment regimen for staphylococcal infections.

The effects of pressure-reducing mattresses in CPR.

In this article, the author summarises a small study examining the effects that support surface mattresses might have on perfusion in cardiopulmonary resuscitation.

Fluconazole susceptibilities of Candida species and distribution of species recovered from blood cultures over a 5-year period.

The distribution and fluconazole susceptibilities of Candida species isolated over a 5-year period were investigated. Susceptibilities were determined by using a new microtiter procedure and the National Committee for Clinical Laboratory Standards (NCCLS) proposed standard. The new method correlated well with the NCCLS proposed standard and gave very clear end points. Results indicate that there are species-related differences in MICs as reflected in the MICs for 90% of species tested. Candida albicans is most susceptible to fluconazole, while Candida glabrata is among the least susceptible. These findings coincided with the observation of a shift in distribution of yeast species recovered from blood cultures from 1987 to 1992. C. albicans was the predominant species (87%) in the pre- or early fluconazole years but decreased to only 31% of the isolates in 1992. Thus, Candida species for which MICs of fluconazole were higher have become more prominent in recent years. Significantly, throughout this period, MICs for each species did not change appreciably.

Suction lipoplasty: biohazardous aerosols and exhaust mist--the clouded issue.

With the increased popularity of suction lipoplasty procedures, attention has been focused on their safety. One significant concern involves the rotary vane aspirators used to provide the suction required for the procedure. A series of experiments was carried out to determine whether aerosols are produced during the use of a rotary vane aspirator, since aerosols are known to be hazardous under appropriate conditions. Using a viable strain of Pseudomonas aeruginosa, we challenged the system through the suction port, and the exhaust from the aspirator was then cultured in a particle sampler. Results indicate that viable pathogens are released from the exhaust in physiologically significant particles capable of penetrating to the level of the alveolus in the normal human lung. These infectious particles were produced for 3 hours after the initial challenge. When an appropriate filtration device was attached to the aspirator outflow, the aspirator pump and environment were protected. In the absence of an appropriate filtration device, the aerosolized particles may constitute a hazard to patients or medical workers in the vicinity of the aspirator.

A new synthetic route to nucleotide adducts derived from N-acetylated and unacetylated 4-aminobiphenyl.

The carcinogen N-acetoxy-N-2-acetylaminofluorene reacts with dG and dG-containing nucleotides to give good yields of the C-8 adducts, but the analogous 4-aminobiphenyl derivative does not. Replacement of the N-acetoxy group by 2,6-dichlorobenzoyloxy circumvents this difficulty. This reaction is shown to be generally applicable, and biphenylamido adducts with dG, d(CpG), d(GpC) and d(ApG) have been prepared. A new, useful deacetylation procedure employing the heterogeneous system sodium carbonate/methanol which leads to the corresponding biphenylamino derivative without appreciable imidazole ring opening is also reported.

Carbocyclic glycinamide ribonucleotide is a substrate for glycinamide ribonucleotide transformylase.

The carbocyclic analog of glycinamide ribonucleotide has been synthesized from the racemic parent trihydroxy cyclopentyl amine (B.L. Kam and N.J. Oppenheimer (1981) J. Org. Chem. 46, 3268-3272). This analog was accepted as a substrate (Km = 18 microM, Vmax = 0.23 mM/min) by mammalian glycinamide ribonucleotide transformylase (EC 2.1.2.2) with an efficiency comparable to that of the natural substrate glycinamide ribonucleotide (Km = 10 microM, Vmax = 0.27 mM/min). For each molecule of 10-formyl-5,8-dideazafolate cosubstrate consumed, 0.92 molecule of N-formyl carbocyclic glycinamide ribonucleotide was produced in the enzymatic reaction, indicating a 1:1 stoichiometry. These studies afford the first alternate nucleotide substrate for glycinamide ribonucleotide transformylase and suggest that the ribose ring oxygen of glycinamide ribonucleotide is not critical for enzyme recognition and binding.

Incidence and significance of candida antigen in low-risk and high-risk patient populations.

A latex agglutination test which detects candida antigen in patients with disseminated infection was used to screen 328 patients. Of these patients 100 had renal failure but no signs or symptoms of candida infection, and 100 had high rheumatoid factor titers but also no signs or symptoms of candida infection. The remaining 128 patients were considered at high risk of developing systemic candida infection. Sequential titers were also determined in a number of these patients. The incidence of candida antigen titers greater than or equal to 1:4 in the low-risk population was 3% as compared to 53% in the high-risk group. None of the patients with positive rheumatoid factor titers had candida antigen titers greater than or equal to 1:2, however 13% had nonspecific agglutination at titers greater than 1:2. The incidence of nonspecific agglutination increased with increasing rheumatoid factor titers. In general the candida antigen titers correlated well with clinical findings and with the course of infection in those patients in whom sequential candida antigen titers were determined. This latex test thus appears to be a useful adjunct procedure for the diagnosis of serious candida infections.

Inhibition of povidone-iodine's bactericidal activity by common organic substances: an experimental study.

An in vitro study demonstrated that some organic substances commonly present in the surgical field inhibit the bactericidal activity of dilute povidone-iodine solutions. The degree of inhibition was inversely proportional to the concentration of the povidone-iodine solutions and it was greatest by blood, followed by pus, fat, and glove powder. The pattern of bacterial kill was virtually identical for all the strains tested. The most likely explanation for this phenomenon is that iodine is bound by the organic substances, decreasing the iodine available for bacterial kill. To obtain an optimal benefit, we suggest eliminating these substances from the operative site or wound when possible before the use of povidone-iodine solution.

Latex agglutination test for detection of Candida antigen in patients with disseminated disease.

A latex agglutination test has been devised which allows detection of a circulating antigen in patients with systemic infection due to Candida albicans, Candida tropicalis and Candida parapsilosis. Latex is sensitized with serum from rabbits immunized with whole heat killed Candida albicans blastoconidia. The active component of this serum is IgG. Control latex, used to differentiate non-specific agglutination, is sensitized with the same dilution of serum from a rabbit without antibody to Candida species. Sera from a number of patient groups were tested. While none of the hundred normal controls had an antigen titer of greater than or equal to 1:4, 30 of 33 patients with documented disseminated candida infection had antigen titers of 1:4 to 1:32. Two of the 33 gave false negative results, and one caused nonspecific agglutination. In all patients who recovered after antifungal therapy antigen levels returned to within the range found in normal controls.

Plate method for detection of phospholipase activity in Candida albicans.

Intracellular phospholipase activity has previously been detected in Candida albicans. A plate method is described which allows rapid detection and measurement of the extracellular activity in a number of clinical isolates. The ratio of colony diameter to diameter of the dense white zone of precipitation around phospholipase positive colonies, (Pz value), correlates with hydrolysis of [14C]phosphatidylcholine by concentrated culture filtrates of selected test isolates. A large variation in phospholipase activity is found between different isolates of C. albicans, however the Pz value is constant for any one isolate regardless of the site from which it is recovered in the patient. Fifty five % of fresh blood isolates are positive and these are also the most potent phospholipase producers. Fifth % of wound isolates and 30% of urine isolates are also positive. A larger sample group must be studied, however, before it can be determined whether these differences are highly significant.

Phospholipase activity in Candida albicans.

Phospholipase A and lysophospholipase have been identified as the enzymes responsible for phospholipid hydrolysis by Candida albicans. The method used to identify and measure the activity of these enzymes is described, and the probable significance of phospholipase in the invasion of the epithelium by Candida albicans discussed.

Macromolecular syntheses during the cell cycles of yeast and hyphal phases of Candida albicans.

Synchronous cultures of yeast and hyphal phases of Candida albicans showed exponential increases in RNA content and stepwise exponential increases in DNA content. The periods of DNA synthesis in the two phases coincided with one another and with the budding peaks of the yeast phase. Hyphae grown in synchronous cultures also showed an exponential increase in length. The hyphal phase was therefore normal. Hyphal nuclear division occurred after hyphal DNA synthesis. Germination was a unique event for a hypha and unlike yeast bud formation, preceded the first period of DNA synthesis. The exponential increase in RNA and DNA in asynchronous cultures of hyphae in serum paralleled the exponential increase in the numbers of cells in asynchronous cultures of yeasts in defined media. Thus there are no factors in serum which inhibit the normal exponential growth of C. albicans.

Factors affecting plaque formation by Candida albicans infecting the chick chorio-allantoic membrane.

The numbers of plaques formed by Candida albicans in replicate inocula on the chick chorio--allantoic membrane (CAM) was not related to the size of the inocula. Washing the CAM with saline 1 h after inoculation recovered only 10% of the inoculum. After 5 h cells could not be recovered by washing. By contrast, counts on serial dilutions of homofenised eggs after inoculation showed that the organisms had retained their viability within the egg. Failure of the inoculum to recover in spite of survival of the organisms appears to be due to adhesion of the inoculum to the CAM and cohesion of the inoculum to form clumps. We suggest that clumps of a least 20 organism are needed to stimulate the CAM to proliferate and produce visible plaques. The clumping is random and this accounts for the variation in the number of plaques. The production of plaques by the CAM may depend on the clumping of a sufficient number of organisms to produce a critical concentration of extra-cellular enzymes which aid penetration of the CAM by the invading hyphae. The relevance of this to the lesions of mucocutaneous candidiasis has been considered.

A re-evaluation of the effect of cysteine or Candida albicans.

The effect of cysteine on Candida albicans has been re-examined. Concentrations between 0-1 and 10-0 mM were tested on 12 isolates in yeast and hyphal form. The growth of both forms was inhibited by 10 mM cysteine. Though the rate of hyphal elongation was decreased there was no suppression of initiation of hyphal formation. All isolates showed a random variation in their general inhibitory response to cysteine. We found no support for the concept of cysteine-mediated from determination in rapidly growing C. albicans in submerged culture. High concentrations of cystiene cause a general inhibition of growth of C. albicans.