Enterococcal bacteremia in children: a review of seventy-five episodes in a pediatric hospital

BACKGROUND: Enterococcal bacteremia is being increasingly reported. Although there have been a number of recent studies of enterococcal bacteremia in adults, there are few studies involving children. We carried out a prospective study to determine the epidemiologic, clinical and laboratory characteristics of such bacteremia in children. METHODS: Clinical and microbiologic data were recorded prospectively for all episodes of enterococcal bacteremia occurring during a 3-year period between January 1, 1995, and December 31, 1997. RESULTS: Seventy-five episodes of enterococcal bacteremia occurring in children at our institution during a 3-year period were prospectively analyzed. Serious underlying disease was present in 67 (89.3%) episodes, and in 48 (64.%) episodes patients had received antibiotics during the 2 weeks preceding enterococcal bacteremia. Forty-seven (62.7%) episodes were nosocomial in origin and 26 (34.7%) were polymicrobial. Fifty (66.7%) episodes occurred in children 1 year old or less. A source of bacteremia was identified in 33 (44%) episodes, intravascular device being the most common identifiable source. Of the 73 isolates identified to species level, there were 36 Enterococcus faecium, 36 Enterococcus faecalis and one Enterococcus avium. In 60 (80%) episodes appropriate anti-enterococcal therapy was given. The overall mortality rate was 7.5%. Four clinical patterns of infection were identified: self-limited bacteremia, 16.0%; low grade sepsis with a favorable outcome after specific therapy, 65.3%; severe and prolonged infection associated with a high mortality rate, 14.7%; and fulminant neonatal sepsis in previously healthy babies, 4.0%. CONCLUSION: Enterococcal bacteremia in children comprises a heterogeneous group. Bacteremias that are mild and self-limited and respond promptly to antibiotic therapy appear to be more common in children.     

Partnership between a Veterans Affairs medical center and a podiatric medical college

The health care academic delivery system is dramatically changing in today's economy. In order to survive, the delivery system must decrease its costs and increase productivity. Integration of academic affiliates and community health care facilities has produced a more efficient health care system and improved medical education. The formation and methodology of the mutual benefits and responsibilities between a health care system and a college of podiatric medicine are examined in detail. Developing unique sharing partnerships can mutually improve medical student experiences, reduce financial burdens, combine joint research projects, and ultimately improve patient care.     

Use of adenosine in patients hospitalized in a university medical center

A 54-year old woman was scheduled for thoracotomy for excision of a tumor of the left upper lobe. Reduced thyromental distance and thyroid enlargement were identified by the preoperative physical examination and inability to visualize the larynx was encountered during direct laryngoscopy. A 37-Fr left sided double lumen tube was inserted in trachea with great difficulty after three failed attempts. One lung anesthesia underwent uneventfully and postoperatively it was decided to exchange the double lumen tube to a single lumen tracheal tube. After the extubation, five failed attempts of reintubation were performed. A laryngeal mask airway (LMA) size 3 was passed easily achieving an airtight airway. The patient underwent an uneventful prolonged (105 min) weaning via the LMA which was left in place until the patient regained full consciousness. Peripheral oxygen saturation remained greater than 95% throughout the airway manipulation. LMA insertion is an easy non-invasive technique and should be considered whenever airway management proves difficult.     

Dynamics and administrative behavior of a multi-disciplinary medical center

Fifteen-second exposure of rabbit kidneys to 2 MHz focused ultrasound with approximately 900 w/sq cm acoustic power consistently produced localized parenchymal destruction. Evolution of the lesions was followed histologically over a one-year period. The lesions were sharply delineated from outlying renal tissue and had a concentric multizonal structure. Resorption of the damaged tissue with scarring was completed in 6 to 12 months following intermediate phases characterized by cellular infiltration. The lesions are compared to other models of renal injury, particularly with respect to cellular infiltration. A combination of mechanical, thermal, and ischemic factors seem to be responsible for development of ultrasonic lesions. The sharply circumscribed nature and ultimate complete scarring of the lesions suggest the feasibility of ultrasound in achieving selective complete destruction of renal parenchyma.     

Noxious fumes in a medical center: chemical and psychological aspects

Due to spine-loading activities nursing professionals have a relatively high incidence/prevalence of low back pain. As lumbar disc disorders can be regarded as occupational diseases (since January 1993, occupational disease BK 2108, normally more than 10 years of exposition, lumbar disc disorders with pain and reduced motility) international literature is reviewed. Own results of different prevalence-, case-control- and incidence studies (relative risk for lumbago sciatica/odds ratio for disc prolaps appr. 3-6 depending on age and occupational age) are presented. Finally the question of compensation and prevention of disc disorders is discussed.     

Reinventing the academic medical center

In this study we have demonstrated that the native rabbit sperm protein, Sp17, is a 22- to 24-kDa triplet of proteins in washed ejaculated rabbit spermatozoa and is unaffected by capacitation. However, during the acrosome reaction, Sp17 is processed from a 22- to 24-kDa triplet of proteins to a triplet of proteins at 17-19 kDa by the removal of amino acids from the C-terminal. Recombinant rabbit Sp17 (rRSp17) can also be proteolytically processed by acrosome-reacted spermatozoa in a similar manner. Protease inhibitors prevent the proteolytic processing of Sp17. Both forms of native Sp17 remain associated with acrosome-reacted spermatozoa and are solubilized by ionic detergents. Previously, sequence analysis of Sp17 revealed that Sp17 amino acids 108-137 were 52% identical to the calmodulin binding domain of neuromodulin and contained an IQ motif found in other calmodulin binding proteins. In this study, a truncated recombinant Sp17, rRSp17CB, which lacks amino acids 118-146, including the potential calmodulin binding site, was made. Recombinant rabbit Sp17, but not rRSp17CB, binds to calmodulin in the presence of Ca2+ or EDTA, under reduced or nonreduced conditions in biotinylated-calmodulin overlay assays. In DSS crosslinker experiments, calmodulin bound to rRSp17 in a 1:1 ratio but not to rRSp17CB. Additionally, biotinylated rRSp17 interacts with native sperm calmodulin. We propose that the processing of native Sp17, by removing a C-terminal fragment during the acrosome reaction, might be a mechanism to regulate the calmodulin binding activity of Sp17 and provide calmodulin at specific sites after the acrosome reaction.     

Survey-guided process consultation in a Veterans Administration medical center psychology service.

During an assessment of an organizational effectiveness intervention in a psychology service in a Veterans Administration hospital, 13 psychologists assigned to the psychology service provided survey, Work Environment Scale (WES), and structured interview data. A written evaluation report was provided to all Ss, and a feedback session was scheduled involving the chief, the consultants, and the staff. Three subsequent group consultations involving all Ss were conducted, with consultants serving as process commentators, not content experts. To assess the impact, the WES was readministered following consultation. Four scales showed significant differences in a positive-change direction. 24 mo later, a 2nd administration of the WES was completed. On 7 of 10 scales, the reported increase in job satisfaction between August 1982 and July 1984 was significant. (8 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Breast conservation surgery for breast cancer at a regional medical center

Physical exercise is recommended for the prevention and treatment of osteoporosis. However, its exact role and effectiveness in adulthood is unclear. While vigorous exercise of long duration enhances bone density, few adult individuals comply with such training programs. The present study evaluates the influence of nonphysiological mechanical stimulation, in the form of low intensity vibration (frequency: 50 Hz, acceleration: 2 g, 30 min/day for 5 days/week), on the prevention of bone loss in an animal model of postmenopausal osteoporosis. In the ovariectomised groups of rats a statistically significant (p < 0.05) decrease of bone density (femur and tibia) was recorded at 5 weeks postovariectomy. This effect was maintained for the 12 week duration of the study. Vibration prevented early bone loss after ovariectomy. Vibrated ovariectomised rats showed statistically significantly higher (p < 0.05) BMD values compared to those of their ovariectomised controls at 5 weeks. Vibration did not influence the bone density of the SHAM-operated rats. Although vibration increased ultimate strength (fracture load of the rat femur) in the ovariectomised rats, this finding was not statistically significant. Our data indicate that this method of safe and easily applicable vibration, in the form of a vibrating platform, is effective in preventing early postovariectomy bone loss in an animal model.     

Pursuing clinical and operational improvement in an academic medical center

BACKGROUND: An academic medical center in an increasingly competitive market, the University of California-Davis Medical Center in Sacramento started working with a consulting firm in 1995 to reduce overall operational costs and costs for the clinical processes involved in treating patients with specific conditions. ESTABLISHING THE TEAMS: Twelve operational efficiency (OE) teams and five clinical teams were commissioned, with a combined total of nearly one-half of the target cost reduction. The second wave of six clinical teams was simultaneously initiated in late spring 1996. THE IMPROVEMENT METHOD: The quality improvement process for clinical improvement teams included the review and inquiry method, which enables many pilot experiments to be conducted in parallel by work groups and coordinated by the main task team. RESULTS AND CASE STUDIES: Within six weeks of launching, the 12 OE teams achieved their goals and identified savings opportunities of more than $27 million. One OE team, medical records, had set a goal of $514,000 in cost reduction for a three-year period and achieved the first-year goal of $190,000. For a clinical team on interventional cardiology, the clinical benchmark data revealed that the cost per case of providing cardiac catheterization was greater than for all three benchmark groups. These patients, including 270 patients per year, showed a possible savings through process improvement of nearly $1.4 million. From January 1996 through March 1997, the rate of occurrence of complications decreased from 5.5% to 3%. EPILOGUE: Physicians gradually accepted more responsibility and accountability for controlling and reducing costs, while maintaining their traditional role as advocates for improved patient care.     

A cryptologic based trust center for medical images

OBJECTIVE: To investigate practical solutions that can integrate cryptographic techniques and picture archiving and communication systems (PACS) to improve the security of medical images. DESIGN: The PACS at the University of California San Francisco Medical Center consolidate images and associated data from various scanners into a centralized data archive and transmit them to remote display stations for review and consultation purposes. The purpose of this study is to investigate the model of a digital trust center that integrates cryptographic algorithms and protocols seamlessly into such a digital radiology environment to improve the security of medical images. MEASUREMENTS: The timing performance of encryption, decryption, and transmission of the cryptographic protocols over 81 volumetric PACS datasets has been measured. Lossless data compression is also applied before the encryption. The transmission performance is measured against three types of networks of different bandwidths: narrow-band Integrated Services Digital Network, Ethernet, and OC-3c Asynchronous Transfer Mode. RESULTS: The proposed digital trust center provides a cryptosystem solution to protect the confidentiality and to determine the authenticity of digital images in hospitals. The results of this study indicate that diagnostic images such as x-rays and magnetic resonance images could be routinely encrypted in PACS. However, applying encryption in teleradiology and PACS is a tradeoff between communications performance and security measures. CONCLUSION: Many people are uncertain about how to integrate cryptographic algorithms coherently into existing operations of the clinical enterprise. This paper describes a centralized cryptosystem architecture to ensure image data authenticity in a digital radiology department. The system performance has been evaluated in a hospital-integrated PACS environment.     

Analysis of patients referred to the gastroenterology service of a VA medical center

We recorded clinical information over a 12-month period on consecutive consultations to the gastroenterology service of the Durham VA Medical Center. Of 902 consultations, 789 were prospectively collected. Eighty-five percent of the patients were between 40 and 70 years old. Seventy-five percent of the referrals were from the internal medicine service. The most frequent reasons for consultation were abdominal pain (19%), GI bleeding (active, 16%; occult, 9%), abnormal results of liver tests (18%), and request for a procedure (11%). Diseases of the liver (32%) and "peptic diseases" (30%) were the most common diagnoses. One or more procedures were done in 71% of consultations. When these data are compared with those of a practicing gastroenterologist, using an identical instrument, it is apparent that trainees' experience with structurally identifiable gastroenterologic disease and with a variety of procedures was similar in scope. There were, however, differences in that the physicians at the VA saw substantially fewer patients with so-called "functional" illness. If these data are applicable to other VA Medical Centers, then the training of physicians in gastroenterology at a VA Medical Center should probably be broadened.     

Enterococcal infective endocarditis on native aortic valve

Enterococcal endocarditis accounts for 10% of all bacterial endocardits. The infection progresses in a subacute way and when localized on the aortic valve it has a very poor prognosis since the valve is usually destroyed being death the fatal outcome. We report a case of a patient with infective endocarditis resulting from the implantion of the Enterococcus on the native aortic valve. Nor visk factors or an apparent main gate could be found. The patient was hospitalized after several months of a non especific febrile syndrome. The literature is reviewed. Diagnostic tests and clinical signs are discussed making emphasis on the refractoriness to chemotherapy.     

The SAFE Program: A family psychoeducational curriculum developed in a Veterans Affairs medical center.

One of the unintended positive consequences of deinstitutionalization and managed care restrictions has been an increased awareness of the impact of serious mental illness on the family. The Support and Family Education (SAFE) Program: Mental Health Facts for Families is a 14-session curriculum of monthly workshops for caregivers. In contrast to similar programs, the SAFE Program is facilitated by mental health professionals, is not diagnostic specific, and includes attention to posttraumatic stress disorder. Three years of outcome data reveal that program attendance is related to increased understanding of mental illness and enhanced awareness of Veterans Affairs resources. Workshop attendance is positively correlated with improvements in participants' self-care. The entire SAFE Program manual is available free of charge on the Internet (http://w3.ouhsc.edu/safeprogram). (PsycINFO Database Record (c) 2010 APA, all rights reserved)