Biomedical subjects
Publications and source records attributed to G L Goodhart.
A 54-year-old man deliberately drank a potassium-gold cyanide solution that contained approximately 1,650 mg of potassium cyanide. He survived after treatment with the Lilly antidote kit and hyperbaric oxygen.
Gallium imaging offers many practical advantages over indium-111-labeled leukocyte imaging, and calculating quantitative ratios in addition to performing the routine bone-gallium images allows accurate and easy evaluation of patients with suspected osteomyelitis. To add objectivity and improve the accuracy and confidence in diagnosis of osteomyelitis, quantitative comparison of abnormalities seen on bone scans and gallium scans was performed. One hundred and ten adult patients with 126 sites of suspected osteomyelitis were evaluated and categorized by gallium-to-bone ratios, gallium-to-background ratios, and spatial incongruency of gallium and bone activity. Combined evaluation using these criteria gave a 70% sensitivity and 93% specificity for the diagnosis of osteomyelitis.
Consequent to a high-speed motor-vehicle accident, a patient developed Mycobacterium fortuitum osteomyelitis of an open fracture of his proximal humerus. The patient was treated with a single debridement, oral ciprofloxacin, and hyperbaric oxygen and is free of disease at 2 years.
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Two patients with uncomplicated enterococcal urinary tract infections were treated with trimethoprim-sulfamethoxazole based on in vitro susceptibilities. Bacteremia developed in both patients and they recovered only after the cessation of trimethoprim-sulfamethoxazole administration and institution of therapy with penicillin G potassium or vancomycin hydrochloride plus streptomycin sulfate. Although the enterococcus may appear susceptible to trimethoprim-sulfamethoxazole in vitro, it escapes the antifolate activity of the drug in vivo by its unique ability to incorporate preformed exogenous folates. The practice by clinical microbiology laboratories of reporting the susceptibilities of the enterococcus to drugs other than the penicillins or vancomycin is misleading and potentially dangerous.
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Syphilis has become a disease of low prevalence in the general population of the United States. In addition, serologic tests for syphilis are not as specific as commonly believed. These two facts cast doubt on a diagnosis of syphilis based solely on serologic evidence. However, ordering tests selectively on the basis of clinical evidence and reserving treponemal tests for reagin-reactive specimens is an effective strategy for dealing with these diagnostic uncertainties.
In 1976 and 1977, 28 state laboratories participated in a blinded proficiency testing study of syphilis serologic tests. The test considered of a battery of 50 duplicate reagin-positive sera; 12 specimens were obtained from syphilitic patients. The median reproducibility scores for the VDRL and FTA-ABS tests were the same, 92%, and the scores for the two tests were correlated. Given the relatively low prevalence of untreated syphilis in the United States today, serologic results that are highly predictive of syphilis are obtainable only from the most proficient laboratories, if unselected sera are tested. Reactivity in the VDRL and FTA-ABS tests does not prove the diagnosis of syphilis. Physicians must use clinical judgment to preselect patients for serologic testing.
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The substantial prevalence of malnutrition in the hospitalized patient population has only been recently recognized. Preoperative nutritional and immunological assessment was performed prospectively on admission in 64 consecutive surgical patients. Factors measured included weight loss, triceps skinfold, midarm muscle circumference, creatinine-height index, serum albumin level, serum transferrin level, total lymphocyte count, serum complement level, serum immunoelectrophoresis, lymphocyte T rosettes formation, neutrophil migration, and delayed hypersensitivity. Using these criteria for malnutrition, 97% of the patients had at least one abnormal measurement and 35% had at least three abnormal measurements. Patients were monitored for complications during their hospital course. Serum albumin level, serum transferrin level, and delayed hypersensitivity reactions were the only accurate prognostic indicators of postoperative morbidity and mortality. Substantial unrecognized malnutrition exists in the surgical patient population. An isolated indicator of malnutrition should be interpreted with caution. The visceral protein compartment (serum albumin and serum transferrin levels and delayed hypersensitivity) is the most accurate prognostic indicator of postoperative morbidity and mortality. Perioperative nutritional support may reduce operative morbidity and mortality in the malnourished operative candidate.
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Investigation of an outbreak of contamination of dialysis drainage fluid with Acinetobacter calcoaceticus var. anitratus identified a previously unrecognized source for dialysis associated infections. Over a 4-month period, 25 peritoneal dialysis treatments were administered to 13 hospital patients. Of the 25 treatments for which culture results were available, 14 were associated with dialysis drainage fluid cultures positive for A. calcoaceticus. A water bath used to warm bottles of peritoneal dialysate before use was the reservoir for the bacteria, and investigation showed in vitro that bath water could contaminate the dialysate. It appears likely that the dialysate became contaminated when the prong of the fluid administration set was inserted through the rubber bung on the dialysate bottles. This outbreak illustrates the potential importance of environmental reservoirs in infections complicating peritoneal dialysis.
Two patients had community-acquired Acinetobacter calcoaceticus var anitratus pneumonia. Both patients were alcoholic and one was cirrhotic. One patient died and the other received two weeks of gentamicin therapy and survived. Misinterpretation of the sputum Gram stain delayed diagnosis and institution of proper therapy in both cases. In addition to organisms sensitive to penicillins such as Neisseria or Haemophilus, Acinetobacter must be considered in the differential diagnosis of community-acquired Gram-negative coccobacillary pneumonia.