Genital ulcer infections in the female patient and the vaginitides

This article discusses genital ulcers caused by sexually transmitted diseases in female patients, and the etiology, morphology of the ulcerations, diagnostic work-up, and current treatment. The article also discusses patients with a vaginal discharge, laboratory work-up, diagnoses, and treatment.     

Hospital infections and their control in neurology departments

Further studies have been carried out on blood of the 15-year-old Negro male from Baltimore who was the first reported case of the homozygous state for hereditary persistence of fetal haemoglobin. His red cells contain only Hb F; Hbs A and A2 have never been detected. Over a 15-year period of follow up the red cells of this individual have shown persistent microcytosis with reduced MCH and MCV values. His whole-blood p50 value is decreased, probably because of lack of interaction between Hb F and 2,3-diphosphoglycerate. However, his haemoglobin level at the age of 15 years is lower than would be predicted from the degree of increased oxygen affinity. Globin-chain synthesis studies suggest that this is because he has a mild thalassaemia disorder with an alpha/gamma-chain production ratio of about 1.5, similar to that found in beta-thalassemia heterozygotes. Thus Negro HPFH appears to be a well-compensated form of delta beta thalassaemia.     

Hospital infections and their prevention in dental clinics

The normal flora is typified by the yeast-like fungi Malassezia (Pityrosporum). Successful attempts at treating patients with atopic and seborreic dermatitis, pityriasis versicolor, and psoriasis with antifungicides confirm the involvement of these fungi in the etiology and development of these diseases. In patients with various skin diseases, an immune response to M. furfur is specific. In those with psoriasis, it is characterized by the higher chemoatractant activity of polymorphonuclear leukocytes stimulated by a M. furfur extract and by the immune response of IgG antibodies with immunoreactive proteins having a molecular weight of 100-120 kD. Patients with atopic dermatitis show a hyperimmune IgE-mediated response to M. furfur, with its specific Th2-lymphocytes inducing the atopic cytokines (IL-4, IL-10) that stimulate allergic reactions to other allergens. Those with pityriasis versicolor had impaired keratinocytic pigment exchange due to azelainic acid produced by M. furfur. The cause of transformation of the yeast phase of M. furfur to the mycelial one is presumably to be changes in the composition of fatty acids of the sebaceous glands due to increased androgen concentrations.     

Genital herpes

As well as being painful and distressing to women who contract the virus, genital herpes can pose danger to a fetus. Women with this condition require prompt and sensitive care.     

Nosocomial infections in a neurosurgical intensive care unit

The occurrence of nosocomial infections in 1017 consecutive patients seen in a neurosurgical intensive care unit (ICU), over a period of 18 months is reported. The frequency of infections is low, which may possibly be due partly to the short stay in the ICU. Close interdisciplinary cooperation is stressed as an important factor in limiting infections. BACKGROUND. The aim of this study was to analyse the nosocomial infections in a neurosurgical intensive care unit over a period of 18 months, emphasizing localization and cause of infection, in order to adapt treatment and to take preventive measures. From 15% to 27% of patients treated in ICUs acquire nosocomial infections. In Germany this means 500,000-800,000 patients a year, and the annual costs related to nosocomial infections are estimated at 1.7 billion Deutschmarks. PATIENTS AND METHODS. In all, 1017 consecutive patients were evaluated. The patients were divided into two groups, depending on the duration of treatment in the ICU: Patients who remained for less than 48 h (1017 patients) Patients who were treated for a period exceeding 48 h (314 patients) The evaluation was performed retrospectively from the medical documentation. Criteria for registration are those of the Centers for Disease Control (Atlanta 1988). When more than one infection was diagnosed, each was considered as a new infection, regardless of the bacteria involved. Among the 314 patients who were in the ICU for more than 48 h a total of 114 nosocomial infections were recorded. The frequency of infection referred to all patients treated during that time (n = 1017) was 11.2%, while the frequency among those who were treated for longer than 48 h was 36.3%. Most infections (38.6%) affected the respiratory tract, followed by infections of the urinary tract. Of the bacteria determined 56.7% were gram-negative. In this group E. coli was the most frequently found (29.8%). In the group of gram-positive bacteria, S. aureus was diagnosed in 56.3% of cases. Twelve (16%) of the infected patients died and lethality referred to all patients was 8.6%. DISCUSSION. Compared with other studies, this study revealed a low the infection rate, at 11.2%. This can be explained partly by the short stay in this ICU (mean 3.7 days) and partly by the retrospective method of registration and the particular medical characteristics of neurosurgical patients. The well-known general risk factors for infection, such as age, mechanical ventilation, continuous catheterization of the bladder, and long duration of stay, are also found in neurosurgical ICUs. It is quite difficult to determine to what extent nosocomial infections prolong the treatment necessitated by the primary neurosurgical disease. We were not able to extrapolate the influence of immunosuppressant treatment on the appearance of nosocomial infections, as almost all patients in this study were receiving steroids. This study underlines the necessity of interdisciplinary cooperation between neurosurgeons, anaesthesiologists, microbiologists and nurses in neurosurgical ICUs, where most patients staying longer than 48 h are immunosuppressed and ventilated and thereby particularly at risk of nosocomial infections.     

Nosocomial infections in an oncology intensive care unit

INTRODUCTION: Treatment of cancer has contributed to a growing number of immunocompromised patients with life-threatening nosocomial infections (NI). High mortality with considerable cost is observed when they are admitted to the intensive care unit (ICU). Few studies on infection control and surveillance have been undertaken in this population group. METHODS: All patients treated at a six-bed medical-surgical oncology ICU for > 48 hours were prospectively observed for the development of an NI and the influence of device utilization on infection rates. The analysis used the standard definitions of the National Nosocomial Infection Surveillance System Intensive Care Unit surveillance component. RESULTS: From September 1993 through November 1995, 370 infections occurred in 623 patients during 4034 patient-days, for an overall rate of 50.0 per 100 patients or 91.7 per 1000 patient-days. Pneumonia (28.9%), urinary tract infections (25.6%), and bloodstream infections (24.1%) were the main types of infection. The most common microorganisms isolated were Enterobacteriaceae (29.7%), fungi (22.2%), and Pseudomonas aeruginosa (13.2%). The median device utilization ratios were 0.63, 0.83, and 0.86 for ventilator, indwelling urinary catheter, and central venous catheter, respectively. The highest median device-specific associated infection rate was 41.7 for ventilator. The median for the average length of stay was 8.8 days, and the average severity of illness score was 4.0. There was a strong positive correlation between the overall NI patient rate and device utilization (r = 0.56, p < 0.01), average severity of illness score (r = 0.54, p < 0.01), and average length of stay (r = 0.67, p < 0.01). No correlations were statistically significant when patient-days were used in the denominator. Among the devices only the number of central venous catheter days was significantly correlated with infections (r = 0.51, p = 0.01). The NI patient-day rates were progressively higher the longer the patients stayed in the ICU. CONCLUSIONS: The high rates reported in this study may reflect a combination of several factors related to the underlying illness, neutrophil count, and exposure to invasive procedures. The adjusted infection rates described here provide specific surveillance data for further interhospital comparisons and also to assess the influence of invasive medical interventions, allowing the implementation of preventable measures to control infections.     

Hospital infections and their consequences in patients of advanced age

On the basis of a representative survey of more than 66,000 patients in German acute hospitals from 1978 to 1989 the incidence and consequences of nosocomial infections on length of hospital stay and mortality for patients above age 60 are discussed. Infection rates are higher for female patients and increase with age for both sexes. Surprisingly the length of stay differences due to nosocomial infections are smaller in absolute and relative terms for older patients. The consequences on mortality, however, strongly concentrate on older patients. Using realistic assumptions on incidence and mortality and on possible degrees of infection the number of "preventable deaths" due to nosocomial infections are calculated. For 1990 the results sum up to more than 6000 deaths at ages above 60 alone for the Federal Republic of Germany within its former borders.     

Magnitude and prevention of nosocomial infections in the intensive care unit

Nosocomial infections among intensive care unit (ICU) patients usually are related to the use of invasive devices (e.g., mechanical ventilators, urinary catheters, or central venous catheters). This article discusses the impact of these devices and other risk factors for nosocomial infection in ICU patients. Data on etiologic pathogens and device-related infection rates from the National Nosocomial Infection Surveillance System are presented, general infection control guidelines for ICUs are reviewed, and special infection control problems encountered in ICUs are discussed.     

Nurses and physicians evaluate their intensive care experiences

PURPOSE: To evaluate quantitative analysis of dynamic breast MRI studies using a dedicated PC based diagnosis system (DS) providing parametric images and automatic ROI definition as compared to the standard subtraction image, manual-ROI based procedure. METHODS: We compared the diagnostic usefulness of parametric versus subtraction images in terms of visualisation of enhancement inhomogeneities and enhancement velocities. Quantitative analysis of enhancing lesions of 15 breast MRI studies was performed using both the DS and the system's console software (SC). We assessed the time needed for complete quantitative analysis and number of lesions evaluated. This was followed by assessment of within-reader and between-reader variability or within-case reproducibility of results of quantitative analysis. RESULTS: Parametric images are superior to subtraction images in visualizing enhancement inhomogeneities or ring enhancement in breast cancers. Mean time needed for analysis at DS and SC was 4 (3-5) min. and 23 (8-39) min., respectively. During this time period, significantly more lesions were evaluated per case using the DS as compared to the SC (2-14 vs. 1-6). Mean within-reader variability of enhancement velocities of the same lesions was 0% and 25% (DS and SC); between-reader variability of enhancement values obtained in the same lesions was 11% (DS) versus 41% (SC). CONCLUSION: The DS significantly cuts down the time needed for quantitative analysis. It significantly improves reproducibility of quantitative enhancement values due to standardization of ROI analysis.     

Genital ulcers. Evaluation and treatment

Ulcerations may appear on the genitalia in a variety of both infectious and noninfectious conditions. The vast diversity of etiologies, coupled with the often overlapping morphological features, make the diagnosis of genital ulcerations a challenging endeavor. This article highlights the most important clinical manifestations and laboratory findings which aid in the proper diagnosis of genital ulcerations.     

Genital manifestation of filariasis

'Natural' antibodies are generally believed to possess solely 2H-2L immunoglobulin structure. They have many disulphide bonds, the structural importance of which is not yet understood. However, some natural heterohaemagglutinins in the sera of some lower vertebrates (eel, shark, perhaps also trout and toad) are subunit proteins; the subunits are held together not by disulphide bonds but solely by non-covalent interactions like animal lectins. The relevance of these findings for immunophylogeny is discussed.     

Genital herpes complicating pregnancy

The seroprevalence of herpes simplex virus type 2 (HSV-2) infections among reproductive-aged women in the United States in prevalent. This article discusses HSV and how it effects the pregnant women and neonates. Management of the disease is reviewed, and recommendations for management of HSV during pregnancy are given.     

Genital prolapse during pregnancy

A case is presented of genital prolapse occurring during pregnancy in a patient with multiple congenital urogenital defects. The etiologies are hypothesized to be a congenitally defective pelvis and hormonally mediated connective tissue changes in pregnancy. The procidentia was treated with a vaginal hysterectomy, anterior and posterior colporrhaphy and sarcrospinous fixation. Pudendal nerve injury as a rare complication of sacrospinous fixation is discussed.     

Preferences of physicians and their patients for end-of-life care

OBJECTIVE: Both physicians and patients view advance directives as important, yet discussions occur infrequently. We assessed differences and correlations between physicians' and their patients' desires for end-of-life care for themselves. MEASUREMENTS AND MAIN RESULTS: Study physicians (n = 78) were residents and faculty practicing in an inner-city, academic primary care general internal medicine practice. Patients (n = 831) received primary care from these physicians and were either at least 75 or between 50 and 74 years of age, with selected morbid conditions. Physicians and patients completed identical questionnaires that included an assessment of their preferences for six specific treatments if they were terminally ill. There were significant differences between physicians' and patients' preferences for all six treatments (p < .0001), with physicians wanting less treatment than their patients for five of them. Patients desiring more care (p < .01) were more often male (odds ratio [OR] 1.7). African-American (OR 1.6), and older (OR 1.02 per year). There were no such correlates with physicians' preferences. A treatment preference score was calculated from respondents' desires to receive or refuse the six treatments. Physicians' scores were highly correlated with those of their enrolled primary care patients (r = .51, p < .0001). CONCLUSIONS: Although patients and physicians as groups differ substantially in their preferences for end-of-life care, there was significant correlation between individual academic physicians' preferences and those of their primary care patients. Reasons for this correlation are unknown.     

Beliefs of foster parents regarding the children in their care and their natural parents

The propagation of pluripotential mouse embryonic stem (ES) cells is sustained by leukemia inhibitory factor (LIF) or related cytokines that act through a common receptor complex comprising the LIF receptor subunit (LIF-R) and the signal transducer gp130. However, the findings that embryos lacking LIF-R or gp130 can develop beyond gastrulation argue for the existence of an alternative pathway(s) governing the maintenance of pluripotency in vivo. In order to define those factors that contribute to self-renewal in ES cell cultures, we have generated ES cells in which both copies of the lif gene are deleted. These cells showed a significantly reduced capacity for regeneration of stem cell colonies when induced to differentiate, confirming that LIF is the major endogenous regulatory cytokine in ES cell cultures. However, self-renewal was not abolished and undifferentiated ES cell colonies were still obtained in the complete absence of LIF. A differentiated, LIF-deficient, parietal endoderm-like cell line was derived and shown to support ES cell propagation via production of a soluble, macromolecular, trypsin-sensitive activity. This activity, which we name ES cell renewal factor (ESRF), is distinct from members of the IL-6/LIF family because (i) it is effective on ES cells lacking LIF-R; (ii) it is not blocked by anti-gp130 neutralizing antibodies; and (iii) it acts without activation of STAT3. ES cells propagated clonally using ESRF alone can contribute fully to chimaeras and engender germline transmission. These findings establish that ES cell pluripotency can be sustained via a LIF-R/gp130-independent, STAT-3 independent, signaling pathway. Operation of this pathway in vivo could play an important role in the regulation of pluripotency in the epiblast and account for the viability of lifr -/- and gp130 -/- embryos.