Treatment of infections in the patient with acquired immunodeficiency syndrome

Modern technology has led to a contemporary medical practice that must be able to manage a variety of opportunistic infections in the immunocompromised host. The most common causes of immune suppression are immunosuppressive therapy after organ transplantation, granulocytopenia secondary to cancer chemotherapy, and the human immunodeficiency virus (HIV). All of these forms of immunosuppression predispose patients to a wide variety of opportunistic infections caused by reduction in T- and B-cell lymphocyte function as well as depression of neutrophils. However, the acquired immunodeficiency syndrome (AIDS) has presented the clinician with the greatest challenge in this area. Therefore, it is imperative that physicians and other health care professionals have a comprehensive understanding of the recommended therapy as well as the epidemiology, pathogenesis, and diagnosis of the various infections in these patients.     

9 reflexions on health and medical education in Mexico

In Mexico's case, the fields of healthcare and medical education are closely vinculated. On the other hand, contemporary society lives in a deep transformation process. In the present article, some paradoxes and contrasts in relation to health and medical education characterize the reality in Mexico. Particular emphasis is made on the analysis of the profound differences which exist between the two federative entities which present the extreme figures on life expectancy at birth. The thesis which supports the document, recognizes the need for integral analysis of the organizational and administrative processes of healthcare and medical education in Mexico.     

Spiral CT vs incremental CT: is spiral CT superior in imaging of the brain?

Historically, staphylococci, pseudomonads, and Escherichia coli have been the nosocomial infection troika; nosocomial pneumonia, surgical wound infections, and vascular access-related bacteremia have caused the most illness and death in hospitalized patients; and intensive care units have been the epicenters of antibiotic resistance. Acquired antimicrobial resistance is the major problem, and vancomycin-resistant Staphylococcus aureus is the pathogen of greatest concern. The shift to outpatient care is leaving the most vulnerable patients in hospitals. Aging of our population and increasingly aggressive medical and surgical interventions, including implanted foreign bodies, organ transplantations, and xenotransplantation, create a cohort of particularly susceptible persons. Renovation of aging hospitals increases risk of airborne fungal and other infections. To prevent and control these emerging nosocomial infections, we need to increase national surveillance, "risk adjust" infection rates so that interhospital comparisons are valid, develop more noninvasive infection-resistant devices, and work with health-care workers on better implementation of existing control measures such as hand washing.     

Nosocomial infections in hand surgery

The active and experienced hand surgeon should have enough knowledge to recognize both common and uncommon hand infections. Control of hospital-acquired infections, including surgical site infections, requires a knowledge of potential personal risk factors and ongoing surveillance systems to aid in prevention and early detection. Current national trends may soon require that surgical-site infections be diagnosed by specific criteria that will allow comparisons of data from various locations. Although most hand surgery procedures are now performed on an ambulatory basis, it is important for the hand surgeon to be aware of current methodologies for the prevention, control, surveillance, and treatment of hospital-acquired infections. These intriguing aspects of hospital-acquired infections are reviewed in this article.     

Diagnosis and management of chronic neutropenia during childhood

The approach to the diagnostic evaluation of a patient with neutropenia can be guided largely by clinical history and physical examination and does not always require an extensive laboratory evaluation. Based on the history and bone marrow morphology, most children with chronic neutropenia can be classified and managed. Most patients with chronic neutropenia are free of infections and are able to maintain a normal lifestyle with no or minimal medical intervention. On the other hand, for patients with recurrent or severe infections, careful follow-up and institution of treatment are mandatory. The Food and Drug Administration has approved the use of rhG-CSF in patients with chronic neutropenia. As mentioned previously, the use of colony-stimulating factors has dramatically improved the outcome for many patients with the more severe neutropenia; however, this cytokine is expensive, so treatment should be reserved for more severely affected patients and not given just because the ANC is low. Although concerns exist regarding leukemogenic effects or eventual loss of the progenitor cell compartment driven by the continuous stimulation of rhG-CSF, at this moment, the long-term data available suggest that the chronic administration of rhG-CSF is safe.     

Record-keeping and routine nursing practice: the view from the wards

This paper examines general nurses' views of the nursing record and its routine usage in contemporary hospital practice. It draws on ethnographic data generated on a surgical ward and a medical ward in a single District General Hospital in the United Kingdom (UK). A key research finding was ward nurses' equivocal attitudes to the nursing record. On the one hand, because of its links with the nursing process, the nursing record was highly valued as a symbol of professionalism and ward staff were loathe to criticise it directly. On the other hand, however, the nurses in this study clearly found it difficult to reconcile their professional ideals with the ways in which the nursing record was routinely employed on the wards. In this paper it is suggested that at one level, nurses' ambivalence towards the nursing record reflected the distortion of its founding philosophy by the new managerialism in the contemporary UK health care context. At another level, however, there are also difficulties which arise from the tension between the assumptions about the nature of nursing work which underpin the nursing record and the workplace reality on hospital wards.     

Polymer materials for the prevention of catheter-related infections

Catheter-related infections are major problems in medicine because of severe consequences for the patient, prolongation of hospitalization, and increasing therapy costs. Beside progress in hygienic measures, development of catheters with antiinfective properties seems to be a promising approach to the prevention of such infections. Two approaches for infection-resistant catheter materials have been developed: materials with antiadhesive properties and materials with antimicrobial properties. Antiadhesive polymers shall prevent the adhesion of microorganisms to the medical device. However, up to now there has been no material which would lead to a complete inhibition of adherence ("zero adherence"). Materials with antimicrobial properties contain antimicrobial substances which are incorporated into the biomaterial or bound to the polymer surface. These devices seem to be effective in the prevention of "early onset infections". In this paper, an overview of the development and efficiency of antiadhesive or antimicrobial polymers is given.     

Fatal hand sepsis in Tanzanian diabetic patients

Hand infections are common presentations among diabetic patients admitted to hospital in Tanzania. The morbidity and mortality are high and patients' hospital inpatient stay tend to be prolonged because of suboptimal therapy. We describe four diabetic patients with hand infections and fatal outcomes. In contrast to patients with foot infections, none of our patients had clinical evidence of peripheral neuropathy or vascular disease. All four patients eventually died in hospital after acquiring hand sepsis and diabetic ketoacidosis which did not respond to prolonged courses of intravenous insulin and antimicrobials. Literature review suggests such infections are at least as likely to include Gram-negative organisms as Staphylococcus aureus. Primary management should have included aggressive surgery with limb amputation if necessary with adjunctive antimicrobial therapy.     

Congenital toxoplasmosis and seroconversion at the end of pregnancy: clinical observations

OBJECTIVE: To determine the knowledge of HIV-disease management and the adherence to contemporary guidelines among British Columbia physicians whose practices focused on HIV/AIDS. DESIGN: Self-administered mail survey. PARTICIPANTS: All 659 physicians registered in a province-wide HIV/AIDS drug treatment program. OUTCOME MEASURES: Data on demographic and personal characteristics of respondents, level of HIV-related experience, use of preventive vaccinations and tests, and preferred approaches to the prophylaxis and treatment of common opportunistic infections. Knowledge scores in 4 areas of patient care, as well as an overall score, were computed by comparing respondents' answers with the therapeutic strategies recommended at the time of the survey. Associations between physician characteristics and knowledge scores were identified by linear regression analysis. RESULTS: Of the 659 physicians surveyed, 65% returned responses: only 38% returned completed surveys while a further 27% returned a follow-up survey that asked nonrespondents about their demographic characteristics and HIV-related experience. Scores for specific areas of patient management ranged from 29% for the treatment of opportunistic infections to 62% for preventive measures, with a mean overall score of 47%. Physician knowledge in all areas of patient care was associated with the number of HIV-positive patients in the practice (p = 0.003 to p < 0.001). Physicians who were younger were more knowledgeable regarding preventive measures (p = 0.001); those whose practice location was in Vancouver had a greater knowledge of prophylaxis (p = 0.047); and those who had medical specialty training were more knowledgeable about the treatment of opportunistic infections (p = 0.009). CONCLUSIONS: There is substantial disparity in how physicians approach the management of HIV and related conditions. Deviations from therapeutic guidelines are common and may be associated with physician characteristics, particularly lack of experience in managing HIV.     

Health psychology and the public health perspective: In search of the pump handle.

Health psychology and public health share many common interests and goals, but frequently define and approach problems differently. Drawing from historical and contemporary examples, this paper examines key elements of the public health approach: identification of a health problem in a population, empirically derived understanding of problems, and use of preventive interventions, often of a regulatory nature. Justification for this approach is based on explication of the public health model, described in comparison to the traditional medical model and several psychological approaches. The example of health promotion is used to explore both challenges and potential pitfalls of collaboration between health psychology and public health. (21 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of cancer diagnosis and treatment on hand function

Cancer diagnosis and treatment can have a profound effect upon hand function, presenting a challenge to the occupational therapist. The therapist who specializes in oncology or hand therapy must have knowledge of the medical treatment model in regard to cancer conditions and must be able to set realistic goals that consider the patient's medical prognosis as well as the effect the disease or medical treatment has on the patient's physical and emotional functioning. The challenge to therapists in this area of practice will be to conduct research to verify or validate the effectiveness of the occupational therapy interventions currently provided. As cancer is diagnosed at earlier stages of the disease and survival improves after cancer treatment, hand therapy may improve the functional outcomes of persons with cancer. This judgment of rehabilitation oncology practice will need to be confirmed by research.     

Adenovirus CNS infections

Adenovirus infections are very common diseases, especially upper respiratory infections and diarrhea in infants. Moreover, adenoviruses can occasionally produce CNS infections. The common causative adenovirus is type 7 for them, and they have been associated with pneumonia and epidemics of adenovirus in family outbreaks. Reye-like syndrome has rarely been reported. As AIDS and other immunocompromised patients have increased, new reports of adenovirus CNS infections have also increased. Of course the immunosuppressed conditions have included lymphoma, transplant etc. In the near future, long term care for immunocompromised patients will have a crisis of adenovirus CNS infection. On the other hand, adenovirus CNS infections are difficult to diagnose precisely without special facilities, due to the need for adenovirus cultivation from CSF. In addition, the diagnosis may have limitations due to the many subtypes of adenovirus. Despite the benefits of PCR methods, standard laboratory testing procedures are still not established for diagnosis.     

Hand infections in patients with diabetes mellitus

In a study of diabetic patients with hand infections reviewed at Jackson Memorial Hospital, University of Miami School of Medicine, 20 such diabetic patients with hand infections were found. The most outstanding result was that seven of the 20 had amputation either to control infection or because the function of the extremity was impaired by the remaining ravaged part. Pathologic examination of tissue removed showed the same changes commonly seen in diabetic gangrene of the lower extremity. Electromyographic studies, when done, have been confirmatory of a peripheral neuropathy with delayed nerve conduction studies. The bacterial organisms of the infections were variable, but a predominance of Gram-negative organisms were cultured in twelve of the 20 patients. Early aggressive management, including surgical debridement and intravenous antibiotics, is recommended to prevent unnecessary amputations and improve residual function.     

Christian social policy and homosexuality in The Netherlands, 1900-1970

This essay explores the historical process in which homosexuality became an object for pastoral, medical, and mental health care in the Dutch Catholic community during the twentieth century. The confrontation between a moral-religious approach and the professional (medical and psychological) treatment of homosexuality is the central issue. In a continuing dialogue and a process of changing power relations between clergymen, physicians, psychiatrist, psychologists, and pedagogues as well as Catholic homosexuals themselves, homosexuality was transformed from sin and pathology into a psychological and social problem that could be treated in pastoral and mental health care. The changing attitudes of Catholics towards homosexuality can be explained in the context of the changing relations between religion on the one hand and health care on the other hand. Current viewpoints resulting from sociohistorical studies on the development of the medical and welfare professions have concluded that religion lost importance in modern society because physicians, psychiatrists, psycho-therapists, and social workers not only created new areas of intervention in people's private lives, but also took over the traditional tasks of the church in the field of charity and pastoral care. Medical anamnesis, psychoanalysis, and psychotherapy took the place of confession and pastoral care, thus the argument runs, and remission of sins and redemption were replaced by health and welfare. However, especially in the case of the development of the Dutch welfare state, there was a more complicated interplay between changing religious values and professional strategies. In the Netherlands professional health care and welfare institutions often were organized in a religious context and it is difficult to make a clear differentiation between religious and moral discourses on the one hand and medical and psychological ones on the other hand. Moreover, professional interventions did not take the place of pastoral care; it appears that pastoral care for homosexuals gained ground and was intensified after medical and psychological definitions of homosexuality had found acceptance in the Catholic community. Professional strategies did not supersede religion, but rather contributed to a moral re-orientation and a new pattern of Christian values and appreciations in the field of sexuality.     

Biopsy of lesions of the female genital tract

Surgical biopsies are often the bedrock of contemporary medical care--the foundation upon which many subsequent and important medical decisions are based. The methods described herein have been found to be very reliable and to produce diagnostic material of high quality. Although some clinics have been reluctant to rely on FNA cytopathologic diagnoses, always insisting on traditional biopsies for histopathologic study, we have relied on both biopsy methods for more than 15 years. The diagnostic accuracy of both methods is greatly improved by attention to technical detail and adherence to an established protocol. Neither method is exclusively applicable in all clinical settings.     

Medical risk report: improving patient management and record keeping through a problem-oriented approach

The problem-oriented record satisfies the needs of the contemporary practitioner by addressing the transition from diagnosis to treatment. The technique organizes collected data, identifies all patient problems (medical and dental), defines solutions and/or management of those problems, and documents treatment rendered. Predictably, the problem-oriented record will avoid problems associated with malpractice litigation, conform to regulations of third-party payers, and facilitate practice analyses and quality assessment, i.e., through computer-assisted tracking of patient care based on problems and not just treatment rendered. As many practices today focus on a "patient-centered" approach to practice, the problem-oriented record clearly supports such a philosophy in its completeness of managing patient care information. The dentist, in consultation with other health care providers, can and should feel confident treating patients from the growing population of patients with medical risk. By integrating the problem-oriented approach into patient management and record keeping, dentists can more easily develop a plan for the complexities that accompany patients. Whether these complexities are of a medical, dental, or combined nature, the problem-oriented record helps the practitioner organize information, plan for treatment, and document patient care in a complete and concise manner.     

Atypical hand infections

The diagnosis and treatment of an atypical hand infection present a distinctive challenge for the hand surgeon. Infections caused by these uncommon organisms occur more often in immunocompromised patients. This article emphasizes the salient features of mycobacterial, nocardial, and fungal infections of the hand. With an accurate and timely diagnosis, appropriate surgical and pharmacologic treatment may eradicate these unusual infections.     

Clenched fist injuries from teeth: not to be disregarded

During the delivery of a blow to the jaw, two men, 33 and 34 years of age, suffered an injury at the level of the right metacarpophalangeal joint in, respectively, the 4th and 3rd digit. In both cases, purulent arthritis and destruction of the MCP-joint developed. Clenched-fist injuries are known for their severe complications such as septic arthritis, osteomyelitis and persistent infection leading to amputation. These complications are due to the easy perforation of the MCP-joint capsule and the fact that the patients do not seek medical treatment until a significant inflammatory process has developed. Exploration of the wound on a flexed hand is crucial to exclude perforation of tendon, joint and bone. The wound should be left open to avoid infections. In case of infections, which can be caused by a variety of aerobic and anaerobic bacteria, the recommended treatment is immediate debridement and administration of broad-spectrum antibiotics.     

Differences in psychosocial and health correlates of major and minor depression in medically ill older adults

OBJECTIVES: To compare the differences in correlates of different levels of depression in medically ill hospitalized older adults. DESIGN, SETTING, AND PARTICIPANTS: A consecutive series of 542 patients aged 60 or older admitted to the medical inpatient services of Duke Hospital underwent a structured psychiatric evaluation administered by a psychiatrist. MEASUREMENT: A wide range of demographic, social, psychiatric, and physical health data were collected, and associations with major and minor depression were assessed. RESULTS: Compared with patients without depression, those with major depression were more likely to have a history of prior episodes of depression, higher dysfunctional attitude scores, greater overall severity of medical illness, cognitive impairment, and symptoms of pain or other somatic complaints. Specific medical diagnosis was less important a predictor of major depression than overall severity of medical illness. Compared with patients without depression, those with minor depression were more likely to report non-health-related stressors during the year before hospital admission, have a diagnosis of immune system disorder, and have greater severity of medical illness. When major and minor depression were compared directly, on the other hand, no significant differences were observed except for history of depression, and that relationship was weak and present only when the etiologic approach to diagnosis was used. CONCLUSION: During hospital admission, certain psychosocial, psychiatric, and physical health characteristics of older medical patients place them at high risk for different levels of depression. Patients with major and minor depression resemble each other more than they do patients without depression. These findings may help clinicians better understand the causes of different types of depression in this setting and lead to improved diagnosis and treatment.