Biomedical subjects
Publications and source records attributed to J Govan.
Peacetime assault-related injuries amongst soldiers are common. Whilst the majority of incidents of assault do not result in permanent physical incapacity, some may be devastating, ruining careers and lives. Here we describe one such injury. There is no national register of such injuries; they may, therefore, be under-reported.
We present a patient who collapsed with chest pain and dyspnoea on a transatlantic flight. She was found to have Pneumocystis carinii pneumonia (PCP) and human immunodeficiency virus infection. Platypnoea and orthodeoxia, which have not been previously reported in association with PCP, were major features of her illness. The PCP predominantly affected her lung bases and it is likely that gravity increased intrapulmonary blood flow through poorly ventilated lung bases with failure of pulmonary vasoconstriction to increase upper zone perfusion, exacerbating desaturation on sitting up. The partial DNA sequence of the infecting P carinii was identical to previously described isolates.
Eight patients with cystic fibrosis [CF] colonized with Pseudomonas aeruginosa (P. aeruginosa) had serial lung function, peripheral blood inflammatory markers, and serum IgG antibodies to Burkholderia cepacia (B. cepacia) lipopolysaccharide measured in the months preceding and following colonisation with B. cepacia. One patient experienced a fall in FEV(1) from 33% to 19% of predicted values, coinciding with the first sputum isolation of B. cepacia, and he died 12 weeks later. He had a rise in inflammatory markers preterminally, and this change was refractory to antibiotic therapy. There was no significant fall in FEV(1) % of predicted values in the remaining seven patients, and no significant changes in their serum markers of inflammation following colonization with B. cepacia over a median (range) period of 10.9 (7.3-12.0) months.
OBJECTIVE: To determine the incidence of complications in low birth weight neonates with surgically inserted central venous catheters (CVCs). STUDY DESIGN: Retrospective chart review of all neonates < or = 1500-gm birth weight from three tertiary care neonatal intensive care units who required CVC insertion. RESULTS: A total of 112 CVCs was inserted in 104 neonates with birth weight of 798 (490 to 1380) gm, age 16 (3 to 179) days, for a duration of 21 (1 to 130) days. The birth weights of 85 neonates were < or = 1000 gm. One or more complications associated with the CVC occurred in 59 patients (57%). Sepsis was the commonest complication, with 43 episodes in 38 patients, at a rate of 14.5 episodes/1000 catheter days. Using regression analysis, sepsis was associated with birth weight, male sex, and the duration for which the CVC remained in place. Five of the nine who developed superior vena cava syndrome and/or pleural effusions died. CONCLUSION: CVCs can provide venous access that is durable. However, in the LBW neonate, and especially in those of < or = 1000 gm, there is a high incidence of associated complications.
PURPOSE: To compare two methods of conjunctival closure in phacoemulsification. SETTING: Frimley Park Hospital NHS Trust, Surrey, England. METHODS: This prospective, randomized study comprised 40 patients (40 eyes) who had phacoemulsification via superior axis scleral tunnels and implantation of a poly(methyl methacrylate) intraocular lens with a 5.5 mm optic diameter. In 24 eyes, the conjunctival wound was closed manually with a Moorfields forceps (Group A). In 16, 0.5 ml of balanced salt solution was injected subconjunctivally to reappose the conjunctival wound (Group B). Conjunctival reapposition was assessed by measuring the maximum radial distance of bare sclera preoperatively and during outpatient clinic visits at 1, 7, and 28 days postoperatively. RESULTS: Follow-up was obtained on 38 eyes. One day after surgery, total wound closure was achieved in 15 of 16 eyes in Group B; however, closure was still incomplete in 13 of 22 Group A eyes. At 7 days postoperatively, the size of the conjunctival wound remained significantly smaller in Group B eyes (P < .01). CONCLUSION: The saline injection produced a faster rate of conjunctival wound closure than standard manual reapposition.
A patient with a cholesteatoma secondary to chronic suppurative otitis media developed infective complications including cerebellar and cerebello-pontine abscesses. Burkholderia cepacia was isolated from ear swabs, infected tissue and surgical pus on five occasions over a six-month period. Despite exhibiting three different antibiotic susceptibility profiles, all five isolates were confirmed as clonally indistinguishable by pulsed-field gel electrophoresis. To the best of the authors' knowledge there are no previous reports of Burkholderia cepacia causing infection of the adult central nervous system.
Lung disease is the major cause of death in cystic fibrosis (CF), but there is no evidence for overt lung involvement at birth. We show here that the same is true for the gene targeted cftrm1HGU mutant mouse. Furthermore, this CF mouse model demonstrates an impaired capacity to clear Staphylococcus aureus and Burkholderia (Pseudomonas) cepacia, two opportunistic lung pathogens closely associated with lung disease in CF subjects. The cftrm1HGU homozygotes display mucus retention and frank lung disease in response to repeated microbial exposure. Thus, lung disease in the cftrm1HGU mouse develops in response to bacterial infection, establishing a model to dissect the pathogenesis of CF pulmonary disease and providing a clinically relevant end point to assess the efficacy of pharmacologic or genetic interventions.
The effect of repeated doses of dexamethasone (0.25 mg/kg/dose every 12 h) on time averaged mean velocity in the middle cerebral artery was assessed in ten ventilated very low birth weight infants requiring treatment with dexamethasone for bronchopulmonary dysplasia or airway obstruction. The infants were studied by colour/duplex Doppler technique prior to the administration of the first and the third dose of dexamethasone, and 10, 30, and 120 min after these doses. Dexamethasone treatment was associated with an improvement in infant lung condition, an increase in mean arterial blood pressure and a decrease in heart rate. The time averaged mean velocity was statistically significantly reduced at 120 min after the first dose. This was not associated with a decrease in PCO2. The observed reduction of 18% from baseline in the time averaged mean velocity is unlikely to be of clinical importance.
In a study of 110 Pseudomonas cepacia isolates from patients without cystic fibrosis, the in vitro potencies of three new compounds, meropenem, PD 127391, and PD 131628, were comparable to those of ceftazidime and ciprofloxacin and exceeded those of chloramphenicol and co-trimoxazole. The MICs of ceftazidime, ciprofloxacin, meropenem, and the PD compounds for 90% of strains tested were < or = 4 micrograms/ml, whereas they were 32 micrograms/ml for chloramphenicol and co-trimoxazole. Data for 20 isolates from patients with cystic fibrosis indicated that the isolates were less susceptible to all seven antibiotics tested, with the most active compounds being meropenem and PD 127391.
The effect of repeated doses of indomethacin on mean peak velocity (MPV) and time-averaged mean velocity in the middle cerebral artery was assessed in 10 ventilated neonates with a patent ductus arteriosus using colour/duplex Doppler technique prior to, and 10, 30, and 120 min after the first and the third dose. Velocities were significantly reduced up to 120 min after the first dose. The third dose resulted in a significant reduction in MPV at 10 and 30 min following treatment. This reduction was half of that observed after the first dose. Systemic blood pressure (BP) and heart rate did not change significantly after each separate dose. However, by the third dose, mean and diastolic BP were significantly increased from pretreatment levels. The attenuated response of cerebral blood flow (CBF) velocities to the third dose of indomethacin compared with the first dose is probably related to altered haemodynamics. Indomethacin should be used cautiously in infants with other conditions which are known to decrease CBF such as hypotension, hypocarbia and polycythaemia.
We have investigated the use of the new cephalosporin ceftazidime for the treatment of pseudomonas infection in cystic fibrosis, using 100 to 240 mg/kg intravenously daily. The clinical and microbiological results of 18 courses of therapy, lasting from 1 to 4 weeks have been satisfactory, particularly since the patients had previously proved refractory to treatment with most other appropriate antibiotics. However, in common with other anti-pseudomonal antibiotics, a first course of ceftazidime proved the most successful, subsequent courses being less effective. Three patients died because of chronic respiratory infection. In cystic fibrosis pseudomonal infections rapidly relapse after therapy and therefore we have been examining the interactions of antibiotics with relevant host defence mechanisms. In one patient who received a 4 g infusion of ceftazidime there was enhancement of neutrophil phagocytosis-triggered chemiluminescence. We conclude that, used in high doses, ceftazidime is a useful addition to the available antibiotics for therapy of pseudomonas infection in cystic fibrosis.
The results of a questionnaire survey of the partners of psychiatrists and general practitioners are presented. The questionnaire was designed to elicit feelings about the respective professions. Methodological issues are discussed, and the wisdom of comparing different medical groups is questioned. Although significantly fewer psychiatrists' partners initially had positive feelings towards their spouse's career, the majority of both groups reported currently positive feelings. Only a minority, and in equal proportions in the two groups, reported that their spouse's profession had interfered with their relationships with friends or had influenced their marital relationship. A significantly greater number of general practitioners' partners reported that their spouse's profession was more stressful than that of other professionals. The results also indicated that a significantly greater number of psychiatrists than general practitioners as perceived by their partners as using psychiatric interpretation and jargon in the family setting. Furthermore, the comments provided, although representative of only a minority of respondents, demonstrated that this could provide a unique stress for the families of some psychiatrists.
A previously healthy man developed fulminating pneumonia and bacteraemia due to Pseudomonas aeruginosa. This organism was isolated from sputum and blood before death, and from the lung, liver and spleen at autopsy. Bacteraemic psuedomonas pneumonia is rare, carries a high mortality, and is usually associated with serious underlying disease.
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To determine the utility of available Pseudomonas cepacia typing systems for confirming the relatedness of isolates, we applied these methods to isolates associated with previously investigated nosocomial outbreaks. We compared chromosome analysis, serologic reactions, biochemical tests, bacteriocin production and susceptibility, and antimicrobial susceptibility in their ability to determine outbreak relatedness. Chromosome analysis, serologic reactions, and biochemical tests were each demonstrated to be epidemiologically useful methods for typing isolates. Determination of the sensitivity and specificity of these typing techniques will facilitate their application in the epidemiologic study of this increasingly important nosocomial pathogen.
In the past 2 decades, Burkholderia cepacia has emerged as a human pathogen causing numerous outbreaks, particularly among cystic fibrosis (CF) patients. One highly transmissible strain has spread across North America and Britain, and another between hospitalized CF and non-CF patients. Meanwhile, the organism has been developed as a biopesticide for protecting crops against fungal diseases and has potential as a bioremediation agent for breaking down recalcitrant herbicides and pesticides. However, B. cepacia is inherently resistant to multiple antibiotics; selection of strains "safe" for environmental application is not at present possible phenotypically or genotypically; molecular epidemiology and phylogenetic studies demonstrate that highly transmissible strains emerge randomly; and the organism has a capacity for rapid mutation and adaptation (facilitated by numerous insertion sequences), and a large, complex genome divided into separate chromosomes. Therefore, the widespread agricultural use of B. cepacia should be approached with caution.