An epidemic of Malassezia pachydermatis in an intensive care nursery associated with colonization of health care workers' pet dogs

BACKGROUND: Malassezia species are lipophilic yeasts that are emerging as nosocomial pathogens, particularly in low-birth-weight neonates who receive lipid emulsions. When a cluster of patients with Malassezia pachydermatis infection was identified in an intensive care nursery, we initiated an investigation. METHODS: A case patient was defined as any infant in the intensive care nursery who had a positive culture for M. pachydermatis between October 17, 1993, and January 18, 1995. We conducted a cohort study to identify risk factors for colonization and infection with M. pachydermatis. We collected cultures from the infants and the health care workers and from the health care workers' pets, since this organism has been associated with otitis externa in dogs. RESULTS: Fifteen infants met the case definition: eight with bloodstream infections, two with urinary tract infections, one with meningitis, and four with asymptomatic colonization. The case patients were significantly more likely than the other infants to weigh 1300 g or less (15 of 65 vs. 0 of 419, P<0.001). In a multivariate analysis of infants weighing 1300 g or less, the independent risk factors for colonization or infection with M. pachydermatis were a greater severity of concomitant illness (odds ratio, 19.7; P=0.001), arterial catheterization for nine or more days (odds ratio, 29.5; P=0.027), and exposure to Nurse A (odds ratio, 74.7; P=0.004). In a point-prevalence survey, 9 additional infants, 1 health care worker, and 12 of the health care workers' pet dogs had positive cultures for M. pachydermatis. The isolates from all 15 case patients, the 9 additional colonized infants, 1 health care worker, and 3 of the 12 dogs had identical patterns of restriction-fragment-length polymorphisms. CONCLUSIONS: In this outbreak, it is likely that M. pachydermatis was introduced into the intensive care nursery on health care workers' hands after being colonized from pet dogs at home. The organism persisted in the nursery through patient-to-patient transmission.     

Permitting maternal contact through vision alone: Films of mothers for promoting play and locomotion.

Studied the effectiveness of visually presented maternal stimuli for promoting adaptive behaviors. 40 36–54 mo old children in a standardized playroom were accompanied by either their mother; a silent, color, life-sized motion picture of her; a film of an unfamiliar woman; or a gray light. Ss with their mother, whether physically present or filmed, played longer than Ss with the filmed stranger or light. Thus, visual reception alone was sufficient to promote play duration. Other measures yielded similar but at times statistically nonsignificant patterns. Postexperimental interviews revealed that 40% of the Ss shown the filmed stranger mistook her for their mother. A reanalysis demonstrated that children misidentifying the stranger engaged in more play and locomotor activity than those correctly identifying her. This implied that any visual display perceived as the mother may suffice to promote adaptive responding in novel situations. (16 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevalence and toxigenicity of Clostridium difficile isolates in fecal microflora of preterm infants in the intensive care nursery

Fecal isolates of Clostridium difficile and its toxin B were followed prospectively in 50 preterm intensive care nursery (ICN) patients. The first stool specimen was obtained after 1 week of enteral feeding, at 15 +/- 1 days of life, and 2 more specimens were collected at 2-week intervals, 24 +/- 1 and 32 +/- 2 days of life. The stools were cultured for C. difficile, and tested for C. difficile toxin B. In the first specimen 15% of stools grew C. difficile. In the second specimen C. difficile isolation rates increased to 33% and plateaued. Toxin B was detected in 71, 93 and 100% of culture-positive stools in the first, second, and third specimens, respectively. C. difficile colonization was not associated with a higher incidence of necrotizing enterocolitis or diarrhea, and using precollected, frozen human milk did not protect from C. difficile colonization.     

Comparison of self, nurse, and physician assessment of residents rotating through an intensive care unit

OBJECTIVE: Compare resident evaluations by self, nurses, and attending physicians. DESIGN: Prospective cohort. SETTING: University intensive care unit. SUBJECTS: Sixty residents. INTERVENTIONS: End-rotational evaluation using a standardized, multiple-choice examination and one of two subjective instruments, Global Rating Scale and Behaviorally Anchored Rating Scale. MEASUREMENTS AND MAIN RESULTS: Means for overall competence, using both the Behaviorally Anchored Rating Scale and the Global Rating Scale clustered between 3 to 4 on a 5-point scale. Physicians' evaluations correlated with the multiple-choice test scores (Spearman's rho 0.3082, p = .005, n = 82), whereas neither self-evaluation (Spearman's rho 0.1124, p = .65, n = 42) nor nurses' evaluations (Spearman's rho 0.2060, p = .069, n = 79) had a significant correlation with test scores. Spearman's correlations were not significant for either overall competence or specific medical knowledge by any category of evaluator using the Global Rating Scale. Spearman's rho correlations and kappa statistic between the three types of evaluators (physicians, nurses, and self) for each criterion of the Behaviorally Anchored Rating Scale demonstrated significant correlations between the ratings of physicians and nurses, except for the assessment of humanistic qualities. Pooled clinical skills-history taking (b = 0.277, p <.009), humanistic qualities (b = 0.607, p <.000), and professional attitudes and behavior (b = 0.488, p < .000) systematically differed in ratings comparing self with nurse and physician (by analysis of variance). The explanatory power of the model of ratings (independent variables of year of residency, category of evaluator, evaluation criteria, and interaction terms) was 47.3% (r2adj). CONCLUSIONS: Self-rating by residents did not correlate to multiple-choice test scores and differed in some criteria with physicians' or nurses' evaluations. We found many similarities and some differences between physicians' and nurses' evaluations of residents. We speculate that different categories of evaluators assess different aspects of performance. Assessment by a varied group of evaluators should be used when attempts to predict future practice are made.     

Use of bladder thermistor catheters in an intensive care unit. Comparative study of core temperature measurements with bladder thermometers and rectal thermometers in an intensive care unit

Bladder temperature measured by a thermistor tipped urinary catheter was compared to rectal temperature in 14 ICU patients. During a period of five days 2 x 232 measurements were recorded, and good correlation was found between rectal and bladder temperatures (R = 0.97). There did not seem to be any drift in the bladder thermistor. Measurement was accurate during periods of oliguria. We find that bladder temperature measurement is reliable, safe, convenient and accurate for routine use in the ICU.     

Skin-to-skin contact beginning in the delivery room for Colombian mothers and their preterm infants

To determine if the transition to extrauterine life is facilitated by skin-to-skin contact, six relatively low risk preterm infants experienced six continuous hours of skin-to-skin contact on their mothers' chests beginning within 30 minutes of birth. Heart and respiratory rates and oxygen saturation remained within normal limits and all infant temperatures rose rapidly to thermoneutral range. Two infants developed grunting respirations by the time skin-to-skin contact began, but the grunting disappeared with warm, humidified oxygen and continuous skin-to-skin contact. All infants were fully breastfeeding and ready for discharge by 24-48 hours postbirth. Early skin-to-skin contact was safe and seemed beneficial for these relatively low risk preterm infants.     

Myocardial infarction in an intensive care unit for blacks. A review over 6 years

Ischaemic heart disease seems to be on the increase in South African Blacks, and medical staff should be more conscious of this. Fifty-four Black patients with acute myocardial infarction are presented and their complications and management while in an intensive care unit reviewed. Epidemiological aspects of ischaemic heart disease in South Africa are discussed.     

Asthma severity and psychopathology in a tertiary care department for children and adolescent

OBJECTIVES: To find what self-perception of their health (SPH) and of their morbidity by school-children; and to analyse possible differences, in function of their social and demographic characteristics and life-styles. DESIGN: An observational crossover study, using a health questionnaire. SETTING: Community. PARTICIPANTS: 548 6th and 8th grade (EGB) children in the Occidente Health Area, Córdoba. INTERVENTIONS: Self-filled health questionnaire. MEASUREMENTS AND MAIN RESULTS: 43.7% of students felt very healthy. Bad SPH was independently associated with being a girl, poor state of physical fitness and feeling unhappy. Tiredness and nervousness were the most frequent disorders suffered by school-children. CONCLUSIONS: Although the SPH of the school-children was acceptable, we found high perceived morbidity and prevalence of accidents, along with a striking consumption of medication.     

Obstetric and gynaecological patients in an intensive care unit: a 1 year review

BACKGROUND: Pathophysiologic events in biological tissue are characterized by a shift of the electrical impedance spectra of the tissue under study. OBJECTIVE: To discuss studies on experimental skin reactions with an improved impedance spectrometer. The instrumentation is related to noninvasive techniques based on other physical principles. METHODS: The results from studies on patients with allergic contact reactions (n = 8), prick tests (n = 10), and irritant contact reactions (benzalkonium chloride [n = 14], sodium lauryl sulfate [n = 12], and nonanoic acid [n = 14]), and an appropriate number of controls are reviewed. RESULTS: Results show statistically significant changes of the impedance parameters when compared with relevant controls, at different types of experimental cutaneous reactions, both allergic and irritant type. Each reaction type had a specific impedance index pattern. CONCLUSIONS: Current data indicate that the improved impedance technique offers a possible noninvasive alternative for characterization and perhaps differentiation, not only between the skin responses induced by either an allergen or an irritant, but also a capability to distinguish responses induced by chemically different irritants. The assumption that the impedance method is capable to distinguish allergic from irritant contact reactions has not been proven yet in direct comparative studies.     

Indications for the use of magnesium in anesthesia and intensive care

Magnesium (Mg), a cofactor in numerous enzymatic reactions, is often ignored by clinicians, as the symptomatology of Mg depletion is not specific and usually associated with that of the cause of the depletion. Furthermore, the plasma Mg concentration (0.8 to 1.1 mmol.L-1) is only equivalent to one percent of the total body content. A Mg deficit may exist while plasma Mg concentration is normal. Therefore other techniques for Mg assessment, such as the repletion test, as well as red blood cell and lymphocyte concentrations have been used. A renewed interest for Mg occurred as numerous studies have shown the therapeutic efficiency of Mg and as the mechanisms of its haemodynamic effects have been recognized. Mg regulates Na-K-ATPase activity, K channels activity and, most of all, it is a natural calcium channel blocking agent. These properties explain its important place in electrophysiology of myocardial cells and the effects on the tension of smooth muscles, resulting in a vasodilation and a bronchodilation respectively. The antagonistic effect of Mg on calcium decreases the presynaptic release of acetylcholine at the neuromuscular junction and the release of epinephrine at the peripheral sympathetic nerves and the adrenals. Mg potentiates the effect of non-depolarizing muscle relaxants. A Mg deficiency occurs often in ICU patients, in alcoholics and during use of diuretics. Simultaneous administration of Mg is often required for treatment of potassium deficiency. Mg has an anti-arrhythmic effect towards digoxin-mediated dysrhythmias and torsades de pointes, and can be efficient in other arrhythmias. Systematic use of Mg seems to decrease mortality of acute myocardial infarction and is justified during cardiac surgery, often associated with hypomagnesemia, because of vasodilation of coronary arteries and in order to prevent occurrence of arrhythmias. Mg, because of its calcium channel blocking properties and as it lowers the release of epinephrine, is indicated for surgery of pheochromocytoma. In eclamptic and pre-eclamptic patients, the use of Mg is valuable, but not as an anti-epileptic agent. Other clinical uses of Mg have been proposed, but they are either anecdotal or of uncertain efficiency.     

Breast carcinoma survival analysis for African American and white women in an equal-access health care system

BACKGROUND: This retrospective review of breast carcinoma cases in the Department of Defense (DoD) Central Tumor Registry evaluated differences in survival patterns between African American and white women treated in U.S. military health care facilities. The study examined the effects of age, stage of cancer, tumor size, grade, lymph node involvement, waiting time between diagnosis and first treatment, marital status, military dependent status, alcohol usage, tobacco usage, and family history of cancer. METHODS: Researchers reviewed the tumor registry records of 6577 women (5879 whites and 698 African Americans) diagnosed with breast carcinoma. The patients, ages 19-97 years, were diagnosed between 1975 and 1994. A hazard ratio (relative risk of mortality) model compared African American and white patients, adjusting for various combinations of covariates; impact of independent variables on the risk of death; prognostic factors significantly associated with survival; disease free and overall survival times; effects of ethnicity, stage, and age on survival; and trends in stage at diagnosis. A P value (2-sided) of less than 0.05 was considered statistically significant. RESULTS: After adjustment for age, the risk of death was 1.45 (95% confidence interval [CI], 1.20-1.76) times greater for African American women than for white women. Adjustment for stage reduced the risk to 1.41 (95% CI, 1.16-1.70); further adjustment for demographic variables and most clinical variables had no effect. Still, African American women treated in the military health care facilities had a better survival rate than African American women represented in the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. In our study, the 5-year risk of death, from any cause, was 1.37 for African American women with breast carcinoma; in other words, the mortality rate for African American women was 24.77% compared with 18.08% for white women. In the latest SEER data, the 5-year relative risk of death for African American women compared with white women is 1.86. The mortality rate in SEER is 34.2% for African American women and 18.4% for white women. The survival rate for white DoD beneficiaries is comparable to that for white women in SEER. CONCLUSIONS: These observations suggest that ready access to medical facilities and the full complement of treatment options that are standard for all DoD patients improve survival rates for African American women. However, a significant unexplained difference in survival still exists between African American and white military beneficiaries.     

Reflecting on the knowledge used when caring for an intensive care patient and his/her family

Carper's four ways of knowing are used to structure a reflection on the knowledge used by an associate nurse in intensive care when caring for her patient, his wife and son. John, the patient, had previously undergone a sex change operation as well as cardiac surgery. His current period in intensive care was due to pancreatitis and involved numerous returns to theatre. He eventually died following multi-organ failure. The reflection focuses on the associate nurse's feelings when trying to act as an advocate for both John and his wife at the time of the patient's pending death.     

Prognostic factors for neutropenic patients in an intensive care unit: respective roles of underlying malignancies and acute organ failures

The response of caprine macrophages to exposure to caprine arthritis-encephalitis virus (CAEV) and lipopolysaccharide (LPS) was investigated in female Nubian and Nubian crossbreed of goats. Macrophages were matured in vitro from monocytes isolated from blood of control and CAEV-infected goats and the concentrations of tumor necrosis factor (TNF-alpha) and interleukin-6 (IL-6) in culture supernatant after exposure of cells to LPS and virus were assayed. Though barely detectable in unstimulated cells, TNF-alpha and IL-6 levels showed peak values of 420 +/- 28 to 530 +/- 32 and 70 +/- 27 to 93 +/- 29, respectively, in supernatants of control goat cells [corrected], remaining high through 24 hrs. post treatment with LPS stimulation. Exposure of these control goat cells [corrected] to virus induced lower secretions (p<0.05) of the cytokines. The peak values occurred between 6 and 12 hrs. post treatment with LPS or virus. Cells prepared from virus-infected goats and treated with the mitogen or virus showed significantly (p<0.05) lower response than those from control goats. The present results suggest a dysregulation, possibly downregulation of the production of both cytokines in macrophages of goats chronically diseased by lentivirus infection.     

Use and effectiveness of hypothermia blankets for febrile patients in the intensive care unit

We performed a prospective observational (noninterventional) study of hypothermia blanket use in a population of adult intensive care unit patients with body temperatures of > or = 102.5 degrees F. Thirty-nine of ninety-four febrile episodes (in 83 patients) were treated with hypothermia blankets. Logistic regression revealed that the strongest independent predictors of hypothermia blanket use were a temperature of > or = 103.5 degrees F (odds ratio [OR] = 17), mechanical ventilation (OR = 25), and acute central nervous system illness (OR = 7.5). Hospitalization in the medical intensive care unit was strongly associated with avoidance of this therapy (OR = 0.023). Treatment with a hypothermia blanket was ordered by a physician in only 15% of cases. The mean cooling rate was the same (0.028 degree F/h) for blanket-treated and control patients. Multivariate Cox regression and factorial and repeated measures of analysis of variance revealed that blanket treatment was not more effective than other cooling methods. However, this treatment was associated with more "zigzag" temperature fluctuations of > or = 3 degrees F (56% of blanket-treated patients vs. 18% of control patients; P < .001) and rebound hypothermia (18% vs. 0; P = .001). Hypothermia blanket therapy is primarily a nursing decision. We conclude that in addition to being no more effective than other cooling measures, hypothermia blanket therapy was associated with more temperature fluctuations and with more episodes of rebound hypothermia.     

The use of TCD in intensive care and for identification of complications in subarachnoid hemorrhage ]

OBJECTIVE: An autoimmunological approach to the pathogenesis of post-pericardiotomy syndrome. METHODS: In 100 consecutive patients, after open heart surgery, postpericardiotomy syndrome (PPS) was diagnosed in 15 patients according to clinical and laboratory criteria. These patients were prospectively followed up. Levels of serum autoantibodies against cardiac muscle antigen were studied on the 14th, 21st and 33rd day postoperatively. In order to evaluate the cardiac muscle antibody (CMA), antigenic tissue sections from primate heart tissue in solid phase with intermyofibrillar and sarcolemmal-subsarcolemmal fluorescent staining, were taken as substrate. PPS occurrence was determined according to strongly positive antibody titers on the 14th and 21st day postoperatively. RESULTS: CMA were positive in 18 patients, and 14 of them showed clinical signs of PPS. In one case PPS was apparent clinically although CMA were not detected. There was a significant difference between CMA positive and CMA negative patients on the occurrence of PPS. With the use of monoclonal antihuman IgG in the conjugate of indirect fluorescent antibody test the specificity was enhanced. Also, in our experience, the length of cardiopulmonary bypass (CPB) time was an important factor affecting the development of PPS. CONCLUSION: In this study, we found a positive correlation between the presence of CMA and PPS, which is a practical, secure and cheap criterion for the diagnosis.