Interpersonal psychotherapy for late-life depression: past, present, and future.

Interpersonal psychotherapy (IPT) has demonstrated efficacy in protecting against a recurrence of major depression in elderly subjects when used alone on a monthly basis and when combined with antidepressant medication. The authors summarize their experience using IPT over the past 10 years and discuss a variety of treatment correlates. In addition, preliminary results using IPT combined with paroxetine in depressed elders reveals no difference in remission rates between cognitively intact and cognitively impaired depressed elders.

Genetic relatedness among nontypeable pneumococci implicated in sporadic cases of conjunctivitis.

Nontypeable Streptococcus pneumoniae is a common cause of epidemic conjunctivitis. A previous molecular fingerprinting study identified a clone of nontypeable pneumococcus that was responsible for a recent outbreak of conjunctivitis. In the present study, we examined the extent to which pneumococci that cause sporadic cases of conjunctivitis are related to this epidemic strain. Using arbitrarily primed BOX-PCR, we have determined that, of 10 nontypeable pneumococci causing sporadic conjunctivitis, 5 were clonal and closely related to a previous outbreak strain, whereas 5 others were genetically diverse.

A multicenter study of the prevalence and susceptibility patterns of isolates of Streptococcus pneumoniae with reduced susceptibility to penicillin G in Louisiana.

Because of increasing reports of multiple-antibiotic-resistant strains of Streptococcus pneumoniae and associated clinical failures, this study was performed to determine the prevalence of multiresistance among strains from nine Louisiana medical centers. Using a National Committee for Laboratory Standards broth microdilution method, 481 strains were tested. Of these, 70% were penicillin-susceptible (PS), 23% had intermediate minimum inhibitory concentration values to penicillin (I), and 7% were fully resistant to penicillin (PR). The isolation rates (15% to 40% for I strains and 0% to 33% for PR strains) at the various medical centers varied appreciably. The prevalence of penicillin resistance was highest among upper respiratory isolates, while cross-resistance to other antimicrobials varied. The least cross-resistance was noted among PS strains. However, strains with reduced penicillin susceptibility had high levels of cross-resistance. Among I strains, the prevalence of cross-resistance (%) was noted for amoxicillin/clavulanate (6%), cefuroxime (71%), cefaclor (91%), ceftriaxone (13%), cefotaxime (34%), erythromycin (67%), azithromycin (32%), and clarithromycin (32%). For PR strains, the prevalence of cross-resistance was 97% for amoxicillin/clavulanate, cefuroxime, and cefaclor; 67% for ceftriaxone and erythromycin; 89% for cefotaxime; and 69% for azithromycin and clarithromycin. These data emphasize the high prevalence of multiple-antimicrobial-resistance among strains of S pneumoniae with reduced penicillin susceptibility in this geographic area.

Drug-resistant Streptococcus pneumoniae.

Streptococcus pneumoniae remains a major cause of infection in both children and adults, annually resulting in significant morbidity and mortality. The past two decades have seen an alarming worldwide increase in the incidence of drug-resistant S. pneumoniae (DRSP). DRSP is now common throughout the United States, and physicians are questioning how best to approach this epidemic. With the introduction of a number of newer antimicrobial agents, the potential for improved preventive measures, and a better understanding of DRSP, the approach to the management of DRSP infections may change greatly in the next few years. In this article we will review the development of DRSP, identify populations at increased risk of exposure to DRSP, address what approaches might be used to limit its spread, and suggest initial empirical therapy when treating patients with pneumonia due to DRSP.

Acalculous cholecystitis and septicemia caused by non-O1 Vibrio cholerae: first reported case and review of biliary infections with Vibrio cholerae.

The first case of septicemic acute acalculous cholecystitis caused by non-O1 Vibrio cholerae is described in a healthy traveler, and biliary tract infections from V. cholerae are reviewed. Immediately after a vacation in Cancun, Mexico, a 55-year-old man developed acute cholecystitis. Blood and bile cultures grew non-O1 V. cholerae. At surgery, the gallbladder was acalculous, inflamed, distended, and nearly ruptured. Pathogenetic factors may have included diarrhea prophylaxis with bismuth subsalicylate, distension of the gallbladder from illness-induced fasting, and bacterial toxins in the gallbladder. The patient received i.v. cephapirin, followed by oral cephradine for a total of 10 days, and he made a quick and complete recovery. V. cholerae should be considered in the differential diagnosis of persons from endemic areas who present with cholecystitis or acute jaundice.

Prospective evaluation of a microprocessor-assisted cardiac rhythm algorithm: results from one clinical center.

A new microprocessor-assisted cardiac rhythm algorithm (MAC-RHYTHM), based on median QRST subtraction from 10-second electrocardiographic (ECG) data, was prospectively tested on 10,761 ECGs acquired at one of three clinical centers. Atrial waves (P waves, atrial fibrillatory waves, and flutter waves) were detected from the median QRST-subtracted residual signals. Rhythm criteria were applied to the detected atrial waves and their temporal relation to QRS complexes for generating rhythm interpretations. Rhythm statements generated by MAC-RHYTHM were compared against the true rhythm of the ECGs as read by an experienced cardiologist. The results of prospective testing were compared with the results of an earlier retrospective testing using MAC-RHYTHM and a released commercial ECG analysis program on stored ECGs. The prospective results were very similar to the results of MAC-RHYTHM on retrospective data for all the rhythms examined (sinus rhythms, atrial fibrillation, atrial flutter, junctional rhythms, second degree atrioventricular blocks). For three of the abnormal rhythms, namely, atrial fibrillation, junctional rhythms, and second degree atrioventricular blocks, MAC-RHYTHM gave significantly higher sensitivity in both prospective (87.5%, 92.2%, and 80.8%, respectively) and retrospective (82.0%, 81.2%, and 79.6% respectively) testing than the released commercial ECG analysis program (65.0%, 39.6%, and 12.0% respectively). Similarly, for sinus rhythms, MAC-RHYTHM had significantly higher specificity (prospective, 91.0% and retrospective, 91.7%) than the released commercial program (86.5%). The specificity for the abnormal rhythms remained very high with MAC-RHYTHM (prospective, 99.4% to 99.7% and retrospective, 99.1% to 99.7%) compared to the released commercial program (99.0% to 99.9%). This prospective study also indicated that further work is needed to improve the detection of pacemaker spikes and the interpretation of paced rhythms in 10-second resting ECGs.

Using interpersonal psychotherapy (IPT) in a combined psychotherapy/medication research protocol with depressed elders. A descriptive report with case vignettes.

One hundred eighty subjects at least 60 years of age with recurrent unipolar major depression were recruited to participate in a depression treatment protocol. All patients received drug therapy with nortriptyline (NT) and interpersonal psychotherapy (IPT) with an experienced clinician. Acutely, 81% of subjects showed a full response to combined treatment. In the initial 127 subjects, the most common problem areas in therapy were role transition (41%), interpersonal disputes (34.5%), and grief (23%). Case vignettes are presented and discussed. The combination of IPT and NT showed a powerful antidepressant effect. IPT was readily adaptable to the needs of depressed elders.

Candida parapsilosis bloodstream infections in neonatal intensive care unit patients: epidemiologic and laboratory confirmation of a common source outbreak.

BACKGROUND: Candida parapsilosis is a common cause of sporadic and epidemic infections in neonatal intensive care units (NICUs). When a cluster of C. parapsilosis bloodstream infections occurred in NICU patients in a hospital in Louisiana, it provided us with the opportunity to conduct an epidemiologic investigation and to apply newly developed molecular typing techniques. METHODS: A case-patient was defined as any NICU patient at Louisiana State University Medical Center, University Hospital, with a blood culture positive for C. parapsilosis during July 20 to 27, 1991. To identify risk factors for C. parapsilosis bloodstream infection, a cohort study of all NICU infants admitted during July 17 to 27, 1991, was performed. Electrophoretic karyotyping was used to assess the relatedness of C. parapsilosis isolates. RESULTS: The receipt of liquid glycerin given as a suppository was identified as a risk factor (relative risk, 31.2; 95% confidence intervals, 4.3 to 226.8). Glycerin was supplied to the NICU in a 16-oz multidose bottle. Bottles used at the time of the outbreak were not available for culture. All six available isolates from four case-patients had identical chromosomal banding patterns; six University Hospital non-outbreak isolates had different banding patterns. CONCLUSIONS: This study demonstrates the utility of combined epidemiologic and laboratory techniques in identifying a novel common source for a C. parapsilosis bloodstream infection outbreak and illustrates that extreme caution should be exercised when using multidose medications in more than one patient.

Plasmid-mediated induction of recombination in yeast.

Diploid yeast cells heteroallelic at the HIS3 locus were transformed with a minichromosome (centromeric plasmid) carrying homology to the HIS3 region and containing the same two mutations as were present in the chromosomes. When a double-strand break (DSB) was introduced in the region of homology, an increase in the recombination frequency between heteroalleles (leading to His+ cells) was observed, although the plasmid was unable to donate wild-type information. This induction of recombination was dependent on the presence of homology between the plasmid sequences and the chromosomes. We show evidence for the physical involvement of the plasmid in tripartite recombination events, and we propose models that can explain the interactions between the plasmid-borne and chromosomal-borne alleles. Our results suggest that the mitotic induction of recombination by DNA damage is due to localized initiation of recombination events, and not to a general induction of recombination enzymes in the cell.

Nosocomial Malassezia pachydermatis bloodstream infections in a neonatal intensive care unit.

Malassezia pachydermatis, a lipophilic yeast, has been described to cause sporadic nosocomial bloodstream infections (BSI). Nosocomial outbreaks of M. pachydermatis BSI have never been described. A cluster of M. pachydermatis BSIs in the neonatal intensive care unit at Louisiana State University Medical Center, University Hospital provided the opportunity to investigate the epidemiology of this organism and apply molecular epidemiologic typing techniques. A case-patient was defined as any neonatal intensive care unit patient in University Hospital with a blood culture positive for M. pachydermatis from January 1, 1989, through August 15, 1991. Five patients met the case definition. Case-patients were premature as estimated by gestational age and required prolonged hospitalization. Case-patients received parenteral nutrition and intravenous lipids for twice as many days as randomly selected controls. No environmental source of M. pachydermatis was identified; however, infants on each side of a previously identified M. pachydermatis-colonized infant became colonized with M. pachydermatis during a 20-day period. Chromosomal analysis of five M. pachydermatis blood isolates from two case-patients had identical banding patterns. These data show that M. pachydermatis can cause nosocomial BSI outbreaks, that premature infants receiving parenteral nutrition and/or lipids may be at greatest risk and that transmission is most likely from person to person, probably via the hands of medical personnel.

Applying interpersonal psychotherapy to bereavement-related depression following loss of a spouse in late life.

The efficacy of interpersonal psychotherapy (IPT) as a treatment for outpatients with major depression has been documented in several controlled trials. Recently, IPT has been adapted specifically for depression in late life. The authors report on their experience in applying IPT to geriatric patients whose depression is temporally linked to the loss of their spouses. Detailed treatment techniques are illustrated with case vignettes. Preliminary treatment outcomes are presented for 6 subjects who showed a mean change on the 17-item Hamilton Rating Scale for Depression from 18.5 ± 2.3 SD to 7.2 ± 4.6 after an average of 17 weekly IPT sessions. IPT appears to be an effective short-term treatment for bereavement-related depression in elderly subjects.

Therapy of recurrent high grade gliomas with surgery, and autologous mitogen activated IL-2 stimulated killer (MAK) lymphocytes: I. Enhancement of MAK lytic activity and cytokine production by PHA and clinical use of PHA.

Nineteen patients with recurrent high grade gliomas were treated in a phase I/II trial with aggressive debulking of the tumor, mitogen activated IL-2 stimulated peripheral blood lymphocytes (MAK cells), and rIL-2. Phytohemagglutin (PHA) was introduced into the tumor site in 16 patients prior to implanting MAK cells and IL-2 in an attempt to trigger more effective lysis of the tumor in vivo. In vitro both TNF bioactivity and cytolytic activity of long term cultured MAK (LMAK) cells were dramatically enhanced by adding PHA to the cultures of these activated PBL. Three of eleven patients (27%) had a decrease in size of the enhancing lesion on CT and/or MRI. Seven (37%) patients clinically improved. Median survival after therapy was 30 weeks. PHA was shown to be safe in vivo and more effective than IL-2 triggering enhanced effector function in vitro.

Evaluation of an intervention program in the control of an urban outbreak of shigellosis.

Community-wide outbreaks of shigellosis are a persistent public health problem. We evaluated the effect of a household-based intervention program on the control of an urban outbreak of S. sonnei gastroenteritis. During the intervention we attempted to contact all households with culture-confirmed S. sonnei and provide education in methods to prevent spread of Shigella. Subsequently we conducted a survey of intervention (n = 43) and nonintervention (n = 33) households. We also conducted a serosurvey of children three to five years of age. The number of new cases of S. sonnei infection declined steadily over several months after the intervention began. Members of the intervention households were more knowledgeable about handwashing (rate ratio [RR] 4.7, 95% confidence interval [CI] = 2.1-10.8) and others methods of S. sonnei transmission and control than members of nonintervention households. However, intervention households had higher attack rates of Shigella-associated diarrhea in susceptible household members (RR 1.4, 95% CI = 1.0-2.0). During the intervention we were able to contact only 25% of households by the eighth day after onset of diarrhea in the index case, when 90% of intrahousehold transmission of Shigella had already occurred. Two months after the outbreak ended, 42% of children in the outbreak community had elevated antibody titers against S. sonnei; an additional 19% had borderline elevated titers. The intervention program improved knowledge but may have occurred too late to prevent intrahousehold transmission of Shigella. Exhaustion of susceptible hosts, rather than the education program, likely accounted for the decline in shigellosis cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Cross-modal exercise prescription at absolute and relative oxygen uptake using perceived exertion.

Cross-modal exercise prescription at absolute and relative oxygen uptake using perceived exertion. Med. Sci. Sports Exerc., Vol. 22, No. 5, pp. 653-659, 1990. The validity of cross-modal prescription of exercise intensity based on rated perceived exertion (RPE) was determined for eight men (26 +/- SE 1.9 yr) at absolute and relative VO2. Exercise modes were treadmill (TM), cycle ergometer (C), and bench stepping while pumping 0.91 kg handweights (HB). Relative (Rel) constant load sessions were performed for each mode at 70% of mode-specific VO2 peak. Absolute (Absol) constant load sessions were performed for C and HB at the VO2 equivalent to 70% of TM VO2 peak. The five 12 min sessions were presented on separate days in random order. RPE-Overall during TM-Rel (11.1) was a) lower (P less than 0.05) than C-Absol (12.6) and HB-Absol (12.5) and b) the same as C-Rel (11.3) and HB-Rel (10.7). RPE-Legs during TM-Rel was a) lower (P less than 0.05) than C-Absol and HB-Absol and b) the same as C-Rel and HB-Rel. RPE-Chest a) did not differ between TM-Rel and C-Absol or HB-Absol and b) was lower (P less than 0.05) for C-Rel and HB-Rel than TM-Rel. RPE-Arms was higher (P less than 0.05) for C-Absol, HB-Absol, and HB-Rel than TM-Rel but did not differ between TM-Rel and C-Rel. Oxygen uptake, heart rate, and ventilation during TM-Rel were a) the same as C-Absol and HB-Absol and b) higher (P less than 0.05) than C-Rel and HB-Rel. Perceptually based cross-modal prescription of exercise intensity using a psychophysical estimation method is valid provided that the physiological reference is the relative, not the absolute, VO2.

Tissue distribution of avidin and streptavidin injected to mice. Effect of avidin carbohydrate, streptavidin truncation and exogenous biotin.

Radioionated avidin and streptavidin were characterized for their biodistribution and tissue association in Balb/c mice, in comparison to their interaction with cells in vitro. Binding of avidin to spleen and bone-marrow cells in vitro was up to 20-fold higher than that of streptavidin, but when tested in vivo avidin clearance from blood and tissues was considerably faster than that of streptavidin. Levels of avidin at 24 h after an intravenous injection were below 1% (of the injected dose/mass tissue) in most organs. Non-glycosylated avidin was similar in its biodistribution to native avidin. Native streptavidin exhibited higher and prolonged tissue association with 5-10% levels in lung, liver, spleen, kidney and blood, whereas its truncated form showed low tissue levels (1-3%) but a remarkably high affinity to the kidney (80%). Exogenous biotin did not affect streptavidin distribution in vivo but caused a 2-7-fold increase in the retention of avidin (but not non-glycodylated avidin) in some of the organs.

Energy cost of bench stepping and pumping light handweights in trained subjects.

Rhythmic pumping of light hand-held weights while walking or running has become a popular approach to total body aerobic exercise. The use of handweights (HW) in conjunction with walking and running significantly increases the energy requirement of a given locomotor speed and adds variety to the choice of modes when prescribing exercise regimens (Auble, Schwartz, & Robertson, 1987; Francis & Hoobler, 1986; Graves, Pollock, Montain, Jackson, & O'Keefe, 1987). Handweighted exercise can also be conveniently and accurately prescribed for use with other exercise modalities such as bench stepping (Goss, et al., 1987). Stepping up and down on a bench at varying frequencies while pumping handweights is a low-impact, space efficient form of total body aerobic exercise. However, little is known about the energy cost of this unique exercise modality. Such information is important if handweighted exercise is to be used in conjunction with bench stepping when prescribing both therapeutic and recreational training regimens. The purpose of this investigation, therefore, was to evaluate the energy cost associated with combined bench stepping and rhythmic pumping of light handheld weights.

Aerobic metabolic requirements of simulated cross-country skiing.

This study evaluated the aerobic metabolic requirements of simulated cross-country skiing. Five male subjects exercised on a cross-country skiing machine at 12 different arm and leg resistances and movement frequencies. Oxygen consumption (VO2) ranged from 21.6 to 44.4 ml kg(-1) min(-1). The VO2 increased significantly (p less than 0.05) as the frequency of limb movement was increased. These data suggest that simulated cross-country skiing places a significant demand on the aerobic metabolic system and as such is a viable alternative to conventional cardiovascular exercise modalities.

Mycobacterium chelonae causing otitis media in an ear-nose-and-throat practice.

Seventeen cases of otitis media caused by Mycobacterium chelonae were detected among patients seen at a single ear-nose-and-throat (ENT) office (Office A) in Louisiana between May 5 and September 15, 1987. All the patients had a tympanotomy tube or tubes in place or had one or more tympanic-membrane perforations, with chronic otorrhea that was unresponsive to standard therapy with antimicrobial agents. Middle-ear exploration in six patients revealed abundant granulation tissue; multiple granulomas and acid-fast bacilli were demonstrated on a section of tissue from one patient with a nonhealing mastoidectomy incision. Thirteen of the 14 ear isolates obtained from patients seen in Office A had the same unusual pattern of high-level resistance to aminoglycosides. M. chelonae and other nontuberculous mycobacteria were recovered from several sources of water in Office A, as well as in another ENT office (Office B) in a neighboring city that was visited by the index patient. Only one additional case was detected in Office B during the same period. Otologic instruments in Office A were cleaned in an ultrasonic bath with tap water and a liquid detergent; the contents of the bath were changed only once weekly. Instruments in Office B were placed in boiling water between patient examinations. This outbreak establishes M. chelonae as an agent of otitis media and underscores the need for high-level disinfection or sterilization of ENT instruments between examinations to prevent the transmission of this organism to patients in the office setting.

Comparison of two selective media developed to isolate Pseudomonas cepacia from patients with cystic fibrosis.

Two media selective for Pseudomonas cepacia have been described recently: OF-polymyxinbacitracin-lactose agar (OFPBL) and P. cepacia agar (PCA). We compared these by culturing sputum from 27 patients with cystic fibrosis. Sputum from each patient was studied using streak-plate (SP) and quantitative (Q) culture methods. Five strains of P. cepacia were isolated from four patients (15%). P. cepacia was not found on routine media by SP or Q methods in three of the four patients. All five isolates grew on both OFPBL and PCA and all were recovered by SP and Q culture methods. Colony counts of P. cepacia obtained by Q cultures were similar on both selective media. Each of the selective media allowed the growth of other organisms; nineteen of 27 specimens cultured on OFPBL yielded non-P. cepacia spp. and six of 27 specimens cultured on PCA yielded non-P. cepacia spp. species (p less than 0.005). Pseudomonas aeruginosa was isolated from 26 of 27 patients on routine media (96%). This organism was recovered from four specimens cultured on OFPBL but from none on PCA (p less than 0.05). OFPBL and PCA are both selective for P. cepacia and enhance the ability to recover this organism from patients with cystic fibrosis using either SP or Q cultures of sputum; however, PCA is significantly more inhibitory for non-P. cepacia spp. than OFPBL.