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Biomedical subjects

K B Kirkland

Publications and source records attributed to K B Kirkland.

18 recordsLinked to original sources
PubMed2006

Risk factors for Clostridium difficile-associated diarrhea on an adult hematology-oncology ward.

Nosocomial diarrhea caused by Clostridium difficile causes significant morbidity and mortality in an increasing proportion of hospitalized patients annually. This case-control study of patients admitted to the hematology-oncology ward of a tertiary academic medical center over a 2-year period demonstrates that patients with Clostridium difficile-associated diarrhea (CDAD) were 22 times more likely than ward-matched controls with diarrhea to have received any antibiotic either during hospitalization or in the month preceding admission (p < 0.005), and they were nearly three times as likely as controls to have received a cephalosporin during the same period (p < 0.005). Diarrhea among lung cancer patients was approximately three times more likely to be caused by this organism than to be due to other causes (p = 0.04). A trend towards CDAD patients receiving higher numbers of different antibiotics during hospitalization (3.3 vs. 2.6, 95%CI -1.42-0.02, p = 0.06) was noted. Administration of interleukin-2 either during hospitalization or in the 30 days preceding admission was seven times more likely to have occurred in CDAD cases (p = 0.04), raising the question of whether or not this agent increases risk.

Adult↗
PubMed2000

A pseudo-outbreak of Aureobasidium species lower respiratory tract infections caused by reuse of single-use stopcocks during bronchoscopy.

OBJECTIVE: To investigate and control an apparent outbreak of lower respiratory tract infections due to Aureobasidium species. DESIGN: Outbreak investigation. SETTING: University-affiliated medical center. PATIENTS: Nine patients who underwent bronchoscopy between June and August 1998. RESULTS: Ten bronchoalveolar lavage (BAL) fluid cultures from nine patients grew Aureobasidium species during the outbreak period; whereas, respiratory specimens from only two patients grew Aureobasidium species during the preceding 6 years. No patient was judged to have true infection due to Aureobasidium species either before or after bronchoscopy. Nine of the 10 bronchoscopies that yielded Aureobasidium species were performed in the outpatient bronchoscopy suite. The Aureobasidium isolates were not associated with any one bronchoscope. Observation of bronchoscopy procedure revealed that plastic stopcocks labeled for single use were reused on different patients during BAL. There was no record of how many times each stopcock was being reused. After each use, the stopcocks were placed in an automated disinfection machine designed for bronchoscopes. Culture of the stopcocks after they had been "disinfected" yielded a heavy growth of Aureobasidium species, while culture of fluid from the automated disinfection machine was negative. Reuse of the stopcocks was halted, and, during the following 6-month period, Aureobasidium species were not isolated from any BAL specimen. CONCLUSIONS: Reuse of medical equipment labeled for single use is potentially hazardous, especially if no quality control system is in place to monitor sterility and function after reprocessing.

Bronchoalveolar Lavage↗
PubMed1999

Adverse effects of contact isolation.

Health-care workers are half as likely to enter the rooms of patients in contact isolation, but are more likely to wash their hands after caring for them than after caring for patients not in isolation.

Hand Disinfection↗
PubMed1999

The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs.

OBJECTIVE: To determine mortality, morbidity, and costs attributable to surgical-site infections (SSIs) in the 1990s. DESIGN: A matched follow-up study of a cohort of patients with SSI, matched one-to-one with patients without SSI. SETTING: A 415-bed community hospital. STUDY POPULATION: 255 pairs of patients with and without SSI were matched on age, procedure, National Nosocomial Infection Surveillance System risk index, date of surgery, and surgeon. OUTCOME MEASURES: Mortality, excess length of hospitalization, and extra direct costs attributable to SSI; relative risk for intensive care unit (ICU) admission and for readmission to the hospital. RESULTS: Of the 255 pairs, 20 infected patients (7.8%) and 9 uninfected patients (3.5%) died during the postoperative hospitalization (relative risk [RR], 2.2; 95% confidence interval [CI95], 1.1-4.5). Seventy-four infected patients (29%) and 46 uninfected patients (18%) required ICU admission (RR, 1.6; CI95, 1.3-2.0). The median length of hospitalization was 11 days for infected patients and 6 days for uninfected patients. The extra hospital stay attributable to SSI was 6.5 days (CI95, 5-8 days). The median direct costs of hospitalization were $7,531 for infected patients and $3,844 for uninfected patients. The excess direct costs attributable to SSI were $3,089 (CI95, $2,139-$4,163). Among the 229 pairs who survived the initial hospitalization, 94 infected patients (41%) and 17 uninfected patients (7%) required readmission to the hospital within 30 days of discharge (RR, 5.5; CI95, 4.0-7.7). When the second hospitalization was included, the total excess hospitalization and direct costs attributable to SSI were 12 days and $5,038, respectively. CONCLUSIONS: In the 1990s, patients who develop SSI have longer and costlier hospitalizations than patients who do not develop such infections. They are twice as likely to die, 60% more likely to spend time in an ICU, and more than five times more likely to be readmitted to the hospital. Programs that reduce the incidence of SSI can substantially decrease morbidity and mortality and reduce the economic burden for patients and hospitals.

Adult↗
PubMed1999

Clinician judgement as a tool for targeting HIV counseling and testing in North Carolina state mental hospitals, 1994.

HIV infection increasingly affects populations that may not appear at high risk based on the use of some traditional targeting strategies. To shed some light on how to more sensitively/effectively identify people who need routine HIV testing and counseling, the objective of this study is to determine the prevalence of HIV infection in North Carolina state mental hospitals and to evaluate clinician judgment as a tool for targeting HIV counseling and testing. The design used is a blinded seroprevalence study. The study population includes all patients admitted to North Carolina state mental hospitals between March 1st and May 31st, 1994. The main outcome measures are the HIV seroprevalence, demographic and diagnostic features, and clinician assessment of the likelihood of HIV infection. The results of the study find that of 2159 study subjects, 35 persons (1.6%) were infected with HIV; of these, 14 (40%) were not previously known to be infected. All 35 HIV infections occurred in persons aged 13-59 years. Within this age group, infection rates were significantly higher for Blacks, males, persons who had a diagnosis of organic brain disease, and persons who had multiple psychiatric diagnoses. However, testing strategies that targeted any of the higher risk groups were insensitive. The rate of HIV infection for persons judged by the admitting clinician to have a high or intermediate likelihood of HIV infection was 26.4 times higher than the rate for those judged to have a low likelihood of infection (2.1 vs. 0.1%, 95% confidence intervals: 3.5-201.3). Of the 14 previously undiagnosed HIV-infected persons, 13 were judged by clinicians to have a high or intermediate likelihood of HIV infection. Moreover, 1258 persons were correctly assessed to have a low likelihood of infection. Conclusions from this study are that an HIV counseling and testing strategy targeting persons (in this setting aged 13-59 years) who were judged by clinicians to have a high or intermediate likelihood of infection, would have identified more than 90% of previously undetected infections while substantially reducing the number of negative HIV tests performed.

Adolescent↗
PubMed1998

Infection control: past, present, and future issues.

Primary care providers serve as role models for the prevention of nosocomial infections through membership on hospital infection-control committees and daily patient care. This article will review five fundamental infection control measures: surveillance, isolation, hand washing, disinfection, and sterilization.

Cross Infection↗
PubMed1997

Catheter-related bacteremia and outcome of attempted catheter salvage in patients undergoing hemodialysis.

BACKGROUND: Dual-lumen cuffed catheters are used for vascular access in patients undergoing hemodialysis. The incidence and appropriate management of catheter-related bacteremia are unknown. OBJECTIVE: To determine the incidence and outcome of catheter-related bacteremia and to assess the efficacy of catheter salvage. DESIGN: Prospective, observational study. SETTING: University hospital inpatient service and four affiliated outpatient dialysis units. PATIENTS: 102 patients with end-stage renal disease who underwent hemodialysis with dual-lumen cuffed catheters between 1 April 1995 and 1 January 1996. MEASUREMENTS: Number of days that the catheter remained in situ, treatment (catheter removal or attempted salvage with antibiotic therapy), and outcome of bacteremia. Microbiological cultures were done to identify catheter-related bacteremia. RESULTS: 102 patients had a total of 16,081 catheter-days. Forty-one patients (40%) developed 62 episodes of bacteremia (3.9 episodes per 1000 catheter-days [95% CI, 3.0 to 4.9 episodes per 1000 catheter-days]). Twenty-four catheters (39%) were removed immediately, and 38 (61%) were left in place during treatment. Only 12 (32%) of the 38 catheters were salvaged successfully. Salvage was less likely to succeed in patients with gram-positive bacteremia than in patients with gram-negative bacteremia, but this difference was not statistically significant (P = 0.14). Nine of the 41 patients (22%) who developed bacteremia had the following complications: osteomyelitis (6 patients), septic arthritis (1 patient), infective endocarditis (4 patients), and death (2 patients). All complications followed an episode of gram-positive bacteremia, and none was associated with attempted catheter salvage. CONCLUSIONS: Bacteremia frequently occurs in patients undergoing hemodialysis with dual-lumen catheters. Antibiotic therapy without catheter removal is unlikely to eradicate catheter-related bacteremia in these patients, but attempted salvage may not increase the risk for complications.

Adult↗
PubMed1997

Failure of cooking to prevent shellfish-associated viral gastroenteritis.

BACKGROUND: In January 1995, Florida experienced the largest outbreak of oyster-associated gastroenteritis ever reported. METHODS: We interviewed both the cohort of persons from 38 gatherings where illness was reported and a sample of harvesters and harvest-area residents. Oysters were traced by means of tags and dealer records, and water quality measures in harvest areas were reviewed. We examined stool specimens for small round structured viruses by means of electron microscopy and amplification of RNA by reverse-transcriptase polymerase chain reaction. We also tested serum specimens for antibodies to Norwalk virus. RESULTS: Of 223 oyster eaters, 58% (129/223) became ill, compared with 3% (2/76) of non-oyster eaters (relative risk, 22; 95% confidence interval, 5.6-87.0). Most oyster eaters (67% [149/223]) ate only cooked (grilled, stewed, or fried) oysters. Oyster eaters who reported eating only thoroughly cooked oysters were as likely to become ill as those who ate raw oysters (relative risk, 0.68; 95% confidence interval, 0.45-1.0; P = .1). In 29 clusters, implicated oysters were from Apalachicola Bay, Florida. A community outbreak occurred in 2 bayside communities before the oyster harvest, leading to an increase in the reportedly common practice of overboard dumping of feces. Small round structured viruses were identified in the stool specimens of 2 harvest-area residents and 9 persons from 8 clusters. Results of water quality tests for fecal coliforms were within acceptable limits. CONCLUSIONS: This large outbreak of gastroenteritis associated with oysters may have resulted from overboard dumping of feces during a community outbreak of diarrheal illness. Our findings of acceptable water quality measures for fecal contamination and the lack of appreciable protective effect from cooking leave the consumer with no assurance of safety.

Adolescent↗
PubMed1995

Therapeutic delay and mortality in cases of Rocky Mountain spotted fever.

We conducted a retrospective cohort study of patients with Rocky Mountain spotted fever (RMSF) at a university hospital in order to assess the relationship between delay in treatment and mortality and to identify predictors of delay in initiating therapy. Patients with RMSF who received antirickettsial therapy within 5 days of the onset of symptoms were significantly less likely to die than were those who received treatment after the 5th day of illness (6.5% vs. 22.9%, respectively; P < .03). Ninety percent of patients were seen by a physician during this 5-day period, yet less than one-half of them received treatment before day 6. Three factors were independent predictors of failure by the physician to initiate therapy the first time a patient was seen: absence of a rash, presentation between 1 August and 30 April, and presentation within the first 3 days of illness. Until reliable early diagnostic tests become available, physicians may be able to decrease the mortality associated with RMSF by instituting empirical treatment of suspected cases within the first 5 days of illness.

Adolescent↗
PubMed1995

A multistate outbreak of oyster-associated gastroenteritis: implications for interstate tracing of contaminated shellfish.

In November 1993, clusters of gastroenteritis in six states following oyster consumption were investigated to identify common features, and stool samples were obtained to identify a pathogen. Efforts were made to account for all potentially contaminated oysters using harvest tags and the interstate recall system. Consumption of oysters was associated with illness in 10 clusters; no other food was implicated. A Norwalk-like virus was detected by electron microscopy in 9 of 18 samples and by reverse transcription-polymerase chain reaction in 20 of 26 samples from 6 clusters. Nucleotide sequences of a 123-bp fragment from all specimens were identical, consistent with a common source outbreak. Implicated oysters were harvested from the Louisiana coast between 9 and 12 November. Although some were recalled and destroyed, most oysters harvested from the area during this time remain unaccounted for. Current regulations and commercial practices need to be revised to permit thorough tracing and recall of contaminated oysters and to improve control of future epidemics.

Animals↗
PubMed1993

Rocky Mountain spotted fever complicated by gangrene: report of six cases and review.

Although mortality due to fulminant Rocky Mountain spotted fever (RMSF) is well appreciated, the ability of the disease to cause survivors to become permanently disabled is not as widely known. We report six cases of RMSF complicated by gangrene. Although four patients required multiple limb and/or digital amputations, only one death resulted. Our review of the English-language literature revealed 23 additional cases of RMSF complicated by gangrene. Pathophysiologically, gangrene is most likely related to small-vessel occlusion. Skin necrosis and gangrene in association with RMSF are the extreme end on a continuum from reversible to irreversible skin and tissue damage caused by Rickettsia rickettsii. Most patients with RMSF have a typical skin rash that resolves without sequelae. Some patients develop minute cicatrices marking the location of focal cutaneous necrosis; for other patients, digital ischemia occurs transiently or evolves to produce severe ischemic changes without gangrene that result in permanent impairment. At the far end of this clinical continuum are patients who develop gangrene requiring amputation.

Adult↗
PubMed1990

The sequence of the major protein stored in ovine ceroid lipofuscinosis is identical with that of the dicyclohexylcarbodiimide-reactive proteolipid of mitochondrial ATP synthase.

The ceroid lipofuscinoses are a group of neurodegenerative lysosomal storage diseases of children and animals that are recessively inherited. In diseased individuals fluorescent storage bodies accumulate in a wide variety of cells, including neurons. Previous studies of these bodies isolated from tissues of affected sheep confirmed that the storage occurs in lysosomes, and showed that the storage body is mostly made of a single protein with an apparent molecular mass of 3500 Da with an N-terminal amino acid sequence that is the same as residues 1-40 of the c-subunit (or dicyclohexylcarbodi-imide-reactive proteolipid) of mitochondrial ATP synthase. In the present work we have shown by direct analysis that the stored protein is identical in sequence with the entire c-subunit of mitochondrial ATP synthase, a very hydrophobic protein of 75 amino acid residues. As far as can be detected by the Edman degradation, the stored protein appears not to have been subject to any post-translational modification other than the correct removal of the mitochondrial import sequences that have been shown in other experiments to be present at the N-terminal of its two different precursors. No other protein accumulates in the storage bodies to any significant extent. Taken with studies of the cDNAs for the c-subunit in normal and diseased sheep, these results indicate that the material that is stored in lysosomes of diseased animals has probably entered mitochondria and has been subjected to the proteolytic processing that is associated with mitochondrial import. This implies that the defect that leads to the lysosomal accumulation concerns the degradative pathway of the c-subunit of ATP synthase. An alternative, but less likely, hypothesis is that for some unknown reason the precursors of subunit c are being directly mis-targeted to lysosomes, where they become processed to yield a protein identical with the protein that is normally found in the mitochondrial ATP synthase assembly, and which then accumulates.

Amino Acid Sequence↗
PubMed1988

Ovine ceroid-lipofuscinosis II: Pathologic changes interpreted in light of biochemical observations.

Ceroid-lipofuscinosis is studied in a breed of sheep and the histochemical and ultrastructural changes are interpreted in light of the known chemical composition of cytosomes. It is concluded that the ovine disease is a lysosomal proteinosis. It is postulated that the multilamellar arrays reflect a complex three-dimensional structure of alternating lipid and protein with the proteinaceous component being specific polypeptides. This is supported by powder X-ray diffractions at 10A implying a repeating proteinaceous unit in the structures. The coherent size of diffracting units was remarkably similar to the periodicity of lamellae observed in electron micrographs of lipopigment cytosomes. The fluorescent and staining characteristics of lipopigment can be explained by the above conclusion and postulate.

Animals↗
PubMedDate not supplied

Steaming oysters does not prevent Norwalk-like gastroenteritis.

OBJECTIVES: To determine whether steaming oysters prevents gastroenteritis caused by small round structured (Norwalk-like) viruses and to identify risk factors for illness. METHODS: The authors interviewed all 48 people who ate oysters at two church suppers that were followed by outbreaks of gastroenteritis from a Norwalk-like virus. Data were collected on demographics, clinical illness, number of oysters eaten, and the extent to which they were cooked. RESULTS: Among the 48 persons, the attack rate was 56%. The risk of illness increased with the number of oysters eaten (chi-square for trend = 5.7, P = 0.02). There was no decrease in attack rates among persons who ate oysters that were better done (chi-square for trend = 1.1, P = 0.29). CONCLUSIONS: In these outbreaks, the risk of illness increased with the number of oysters eaten. Steaming oysters did not appear to prevent illness, suggesting that steaming may not be adequate to inactivate small round structured viruses. Public health messages that have emphasized the role of raw shellfish in the transmission of enteric viruses should be altered to increase the public's awareness that eating steamed oysters may also pose health risks.

Animals↗
PubMedDate not supplied

Erythema migrans-like rash illness at a camp in North Carolina: a new tick-borne disease?

BACKGROUND: Borrelia burgdorferi, the causative agent of Lyme disease, has never been isolated from a patient thought to have acquired Lyme disease in any southeastern state. OBJECTIVE: To investigate 14 cases of an erythema migrans (EM)-like rash illness that occurred during 2 summers at an outdoor camp in central North Carolina in an effort to determine the etiologic, epidemiological, and clinical aspects of this illness. METHODS: Using active surveillance, we identified cases of clinically diagnosed EM in residents and staff of the camp. We collected clinical and demographic information; history of exposure to ticks; acute and convalescent serum antibodies to B. burgdorferi, Rickettsia rickettsii, and Ehrlichia chaffeensis; and cultures for spirochetes from biopsy specimens of skin lesions. Serum samples from a group of residents and staff who did not develop rashes were tested for the same antibodies. We speciated ticks removed from people and collected from vegetation. RESULTS: We identified 14 cases of EM-like rash illness during the 2 summers. Of the 14 case-patients, 10 had associated mild systemic symptoms and 1 had documented fever. All 14 case-patients had removed attached ticks, and 8 remembered having removed a tick from the site where the rash developed a median of 12 days earlier (range, 2-21 days). One tick removed from the site where a rash later developed was identified as Amblyomma americanum, the Lone Star tick; 97% of ticks collected from vegetation and 95% of ticks removed from people were A. americanum. No spirochetes were isolated from skin biopsy specimens. Paired serum samples from 13 case-patients did not show diagnostic antibody responses to B. burgdorferi or other tick-borne pathogens. CONCLUSIONS: This investigation suggests the existence of a new tick-associated rash illness. We suspect that the disease agent is carried by A. americanum ticks. In the southern United States, EM-like rash illness should no longer be considered definitive evidence of early Lyme disease.

Adolescent↗