An outbreak of multidrug-resistant pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents

BACKGROUND: Outbreaks of pneumococcal disease are uncommon and have occurred mainly in institutional settings. Epidemic, invasive, drug-resistant pneumococcal disease has not been seen among adults in the United States. In February 1996, there was an outbreak of multidrug-resistant pneumococcal pneumonia among the residents of a nursing home in rural Oklahoma. METHODS: We obtained nasopharyngeal swabs for culture from residents and employees. Streptococcus pneumoniae isolates were serotyped and compared by pulsed-field gel electrophoresis. A retrospective cohort study was conducted to identify factors associated with colonization and disease. RESULTS: Pneumonia developed in 11 of 84 residents (13 percent), 3 of whom died. Multidrug-resistant S. pneumoniae, serotype 23F, was isolated from blood and sputum from 7 of the 11 residents with pneumonia (64 percent) and from nasopharygeal specimens from 17 of the 74 residents tested (23 percent) and 2 of the 69 employees tested (3 percent). All the serotype 23F isolates were identical according to pulsed-field gel electrophoresis. Recent use of antibiotics was associated with both colonization (relative risk, 2.3; 95 percent confidence interval, 1.3 to 4.2) and disease (relative risk, 3.6; 95 percent confidence interval, 1.2 to 10.8). Only three residents (4 percent) had undergone pneumococcal vaccination. After residents received pneumococcal vaccine and prophylactic antibiotics, there were no additional cases of pneumonia, and the rates of carriage decreased substantially. CONCLUSIONS: In this outbreak a single pneumococcal strain was disseminated among the residents and employees of a nursing home. The high prevalence of colonization with a virulent organism in an unvaccinated population contributed to the high attack rate. Clusters of pneumococcal disease may be underrecognized in nursing homes, and wider use of pneumococcal vaccine is important to prevent institutional outbreaks of drug-resistant S. pneumoniae infection.     

Cerebral abscess with special reference to the angiographic changes

From 1961 to 1973 forty patients with surgically confirmed intracranial abscesses had preoperative cerebral angiography. The findings were abnormal in all cases but one. In 20 patients (50%) the primary diagnosis was a space-occupying lesion. In 19 patients (47.5%) an abscess was suggested by the presence of a capsule, the only finding definitely diagnostic of an abscess. Subtraction technique provided essential information in detecting the capsule. Angiography proved indispensable in suggesting the nature of the lesion.     

Clinical implications of penicillin and ceftriaxone resistance among children with pneumococcal bacteremia

BACKGROUND: The influence of non-ionic osmols on thermoregulation is unclear. HYPOTHESIS: Hyperglycemia will attenuate the rise in exercise core temperature. METHODS: Dehydrated by 4-h of water immersion (34.5 degrees C) to the neck, 6 men, (35+/-SD 7 yr) participated in each of three trials where 2.0 g x kg(-1) body wt of oral glucose (33.8% weight per volume) was consumed followed by 80 min supine rest (Glu/Rest), or 70 min supine cycle exercise at 62.8%+/-SE 0.5% (1.97+/-0.02 L x min(-1)) peak O2 uptake, followed by 10 min supine recovery with prior (Glu/Ex) or without glucose (No Glu/Ex) ingestion. Blood samples were taken periodically for measurement of Hb, Hct, Na+, K+, Osm, and glucose; mean skin (Tsk) and rectal (Tre) temperatures, and sweating rate (resistance hygrometry) and skin blood velocity (laser Doppler) were measured intermittently. RESULTS: Mean percent changes in plasma volume (p<0.05) for the exercise trials were not different: -12.3+/-2.2% (No Glu/Ex) and -12.1+/-2.1% (Glu/Ex). Mean (+/-SE) pre-exercise plasma [glucose] for Glu/Ex was higher than that of No Glu/Ex (108.4+/-3.9 vs. 85.6+/-1.6 mg x dL(-1), respectively, p<0.05). Glu/Ex vs. No Glu/Ex data, respectively, at the end of exercise indicated that: Tre was lower by 0.4 degrees C (38.2+/-0.2 vs. 38.6+/-0.1 degrees C, p<0.05), Tsk was lower (32.0+/-0.3 vs. 32.4+/-0.2 degrees C, p<0.05), forearm sweating rate was lower (0.94+/-0.09 vs. 1.05+/-0.07 mg x cm(-2) x min(-1), p<0.05); and head (temporal) skin blood velocity was not different (1.67+/-0.21 vs. 1.51+/-0.24 Hz x 10(3), NS). CONCLUSIONS: Elevation of plasma [glucose] prior to supine submaximal exercise in dehydrated men attenuates the increase of Tre without alteration of heat production, total body sweating, serum electrolytes and osmolality, or exercise-induced hypoglycemia: the mechanism may be enhanced peripheral blood flow that could enhance body heat loss.     

The fine structure of the digital corpuscle of the mouse toe pad, with special reference to nerve fibers

Digital corpuscles in the dermal papillae of the mouse toe pad have been studied using light and electron microscopy of serial thick and thin sections, and silver impregnations of frozen sections. These corpuscles are ellipsoid in shape and approximately 10-30 mum in diameter. They consist of one to three lamellar cells, nerve fibers and a capsule. These digital corpuscles are regarded as small Meissner corpuscles. The capsule is perineural epithelium. One or two myelinated nerve fibers and occasionally an unmyelinated nerve fiber enter the corpuscle. The axon terminals contain many mitochondria and a variable population of vesicular profiles. These terminals are ellipsoid or discoid in shape with the long axis parallel to the skin surface. The cytoplasmic plates (or lamellae) of the lamellar cells are arranged parallel to the skin surface, as is the cleft between the bilaterally symmetrical stacks of lamellae. Small processes extend from the expanded terminal of the neurite into the cleft between the lamellae. The relationship of the neurite terminal and associated lamellar cells resembles in some respects the organization of the inner core of Pacinian corpuscles. Intraepidermal fibers derived from myelinated neurites of the corpuscle may extend to the superficial epidermis. Intraepidermal fibers derived from unmyelinated neurites usually terminate in the basal regions of the epidermis.     

Ambiguous role of interleukin-12 in Yersinia enterocolitica infection in susceptible and resistant mouse strains

Endogenous interleukin-12 (IL-12) mediates protection against Yersinia enterocolitica in C57BL/6 mice by triggering gamma interferon (IFN-gamma) production in NK and CD4+ T cells. Administration of exogenous IL-12 confers protection against yersiniae in Yersinia-susceptible BALB/c mice but exacerbates yersiniosis in resistant C57BL/6 mice. Therefore, we wanted to dissect the different mechanisms exerted by IL-12 during Yersinia infections by using different models of Yersinia-resistant and -susceptible mice, including resistant C57BL/6 mice, susceptible BALB/c mice, intermediate-susceptible wild-type 129/Sv mice, 129/Sv IFN-gamma-receptor-deficient (IFN-gamma R-/-) mice and C57BL/6 tumor necrosis factor (TNF) receptor p55 chain-deficient (TNFR p55-/-) mice. IFN-gamma R-/- mice turned out to be highly susceptible to infection by Y. enterocolitica compared with IFN-gamma R+/+ mice. Administration of IL-12 was protective in IFN-gamma R+/+ mice but not in IFN-gamma R-/- mice, suggesting that IFN-gamma R-induced mechanisms are essential for IL-12-induced resistance against yersiniae. BALB/c mice could be rendered Yersinia resistant by administration of anti-CD4 antibodies or by administration of IL-12. In contrast, C57BL/6 mice could be rendered more resistant by administration of transforming growth factor beta (TGF-beta). Furthermore, IL-12-triggered toxic effects in C57BL/6 mice were abrogated by coadministration of TGF-beta. While administration of IL-12 alone increased TNF-alpha levels, administration of TGF-beta or TGF-beta plus IL-12 decreased both TNF-alpha and IFN-gamma levels in Yersinia-infected C57BL/6 mice. Moreover, IL-12 did not induce toxicity in Yersinia-infected TNFR p55-/- mice, suggesting that TNF-alpha accounts for IL-12-induced toxicity. Taken together, IL-12 may induce different effector mechanisms in BALB/c and C57BL/6 mice resulting either in protection or exacerbation. These results are important for understanding the critical balance of proinflammatory and regulatory cytokines in bacterial infections which is decisive for beneficial effects of cytokine therapy.     

Severe pneumococcal pneumonia with acute respiratory failure and neutropenia

A biological bank has been developed to extend the biochemical and molecular research base for a prospective study on diet and cancer in the city of Malmo, Sweden. The study entered individuals 45-69 years of age, of which 30,382 individuals (45%) participated. Each individual entering the bank has stored samples of viable mononuclear leukocytes (MNLs; -140 degrees C) and granulocytes (GRANs; -80 degrees C) or buffy coats (-140 degrees C), erythrocytes (-80 degrees C), and plasma/serum (-80 degrees C). The bioassays developed to monitor the quality of storage conditions were: (a) viability and growth response to phytohemagglutinin for MNLs; (b) DNA strand breakage for GRANs; (c) NAD content for erythrocytes; and (d) thiol status for plasma/serum. The yield, purity, and storage conditions were all quality controlled, and the samples were determined to be of high standard after 137-190 weeks of storage. No differences in yield and purity were found in samples banked by different laboratory technicians. Growth responses of MNLs were severely reduced (90%) after 40 weeks of storage, which justified switching from the storage of purified MNLs and GRANs to the more cost-effective banking of buffy coats. We conclude that the quality of the banked material, based on the biochemical analysis done, indicate that the storage conditions are optimal at least up to 3.5 years, except for the growth response of MNLs.     

Atherosclerosis, with special reference to vitamin E

The relationship between atherosclerosis and fat soluble vitamin, especially vitamin E is reviewed on the basis of oxidised modification of low density lipoprotein (LDL). Data now support the notion that the oxidised LDL is present in the blood and arterial wall and antioxidant drugs such as probucol and vitamin E, beta-carotene, may prevent the progression of atherosclerosis. LDL alpha-tocopherol levels are generally correlated to the plasma concentrations and supplementation with alpha-tocopherol increases its content in LDL. There is a significant correlation between the LDL alpha-tocopherol level and the resistance to oxidative modification. Epidemiological data also shows the relation between low levels of plasma vitamin E and the increased incidence of coronary heart disease. Clinical application of vitamin E should be clarified in detail to inhibit the progression of atherosclerosis.     

Immune response to the filaria Litomosoides sigmodontis in susceptible and resistant mice

Comparisons were made between the immune responses evoked during the course of chronic and patient infections of Litomosoides sigmodontis in susceptible BALB/c mice and non-patent infections in resistant B10.D2 mice. Early antigen specific responses of spleen cells were weak in both mouse strains. However, by day 58 post infection a strong Th2 response, as determined by production of IL-4, IL-5 and IL-10, was observed in BALB/c mice but not in B10.D2 mice. Antibody responses seemed to appear sooner in B10.D2 than in BALB/c mice, and these differentially recognised two antigens of 15 kD and 80 kD.     

Detection of intracranial tumours with special reference to immunodiagnosis

Approximately 60% of cerebral infarcts between 1 and 4 weeks old may be enhanced by contrast material. A recent infarct can be missed if contrast material is not used; however, recent infarcts can also be partially obscured by the contrast medium, so that a precontrast scan is necessary. Infarcts, arteriovenous malformations, and gliomas may appear similar on the CT scan. Recent infarcts can have a significant mass effect (seen in 22% of cases), and their anatomical location and morphology may or may not be helpful in the differential diagnosis. Ipsilateral ventricular dilatation, homogeneous low-density areas, and sharp margins are usually found in older infarcts.     

Growth of the cervical spine with special reference to its lordosis and mobility

STUDY DESIGN: The cervical spine of the healthy Japanese children aged between 1 year and 18 years was radiographically examined. OBJECTIVES: To examine the correlation between growth of the cervical vertebral body and the facet joint and the development of the cervical lordosis and intervertebral motion. SUMMARY OF BACKGROUND DATA: Although the growth of body height and facet angle have been well documented, their correlation with curvature or mobility has not been elucidated. METHODS: We evaluated plain lateral radiographs of 180 boys and 180 girls regarding diameters and central heights of the cervical vertebra, the anterior and posterior vertebral height ratio, body height index, the facet joint angles, and tilting and sliding motions. Cervical length as the summation of the central height from C3 to C7 and the cervical lordosis angle (C3-C7 angle) were also measured. RESULTS: The mean C3-C7 angle and body height index gradually decreased until 9 years of age and then increased. The C3-C7 angle showed a significant correlation with cervical length, body height index, and facet joint angles before 9 years of age, and with cervical length and body height index after 9 years of age but not with facet joint angles. Facet joint angle decreased until 10 years of age and remained almost unchanged thereafter. Total sliding showed a significant age-related decrease and showed a significant correlation with facet joint angle. CONCLUSION: Although the lordosis angle showed a significant correlation with the other values, cervical length, body height index, and facet joint angle, the determinants of the lordosis could not be elucidate in the present study. As for the mobility of the cervical spine, changes of tilting motion were small, whereas changes of sliding motion were restricted by the change of orientation of the facet joints.