Biomedical subjects
Publications and source records attributed to M Ringer.
To assess the rubella immune status of a cohort of high-risk pregnant women visiting a Midwestern clinic, we retrospectively studied 50 random pregnancies per year from 1990 through 1996. Of 350 patients analyzed, 53 (15.1%) were not immune to rubella, and vaccination opportunities were missed.
More than 90% of all intravascular device-related septicaemias are due to central venous or arterial catheters. To assess the efficacy of cutaneous antisepsis to prevent catheter-associated infection, we prospectively studied three antiseptics for disinfection of patients' central venous and arterial catheter insertion sites in a surgical intensive care unit. 668 catheters were randomised to 10% povidone-iodine, 70% alcohol, or 2% aqueous chlorhexidine disinfection of the site before insertion and for site care every other day thereafter. Chlorhexidine was associated with the lowest incidence of local catheter-related infection (2.3 per 100 catheters vs 7.1 and 9.3 for alcohol and povidone-iodine, respectively, p = 0.02) and catheter-related bacteraemia (0.5 vs 2.3 and 2.6). Of the 14 infusion-related bacteraemias (4 due to contaminated infusate or catheter hub, 10 due to infected catheters), 1 was in the chlorhexidine group and 13 were in the other two groups (odds ratio 0.16, p = 0.04). We conclude that use of 2% chlorhexidine, rather than 10% povidone-iodine or 70% alcohol, for cutaneous disinfection before insertion of an intravascular device and for post-insertion site care can substantially reduce the incidence of device-related infection.
OBJECTIVE: To identify risk factors for infusion-related phlebitis with peripheral intravenous catheters. DESIGN: A randomized trial of two catheter materials, with consideration of 21 potential risk factors. SETTING: A university hospital. PATIENTS: Hospitalized adults without granulocytopenia who received a peripheral intravenous catheter. INTERVENTIONS: House officers or ward nurses inserted the catheters, and each insertion was randomized to a catheter made of tetrafluoroethylene-hexafluoropropylene (FEP-Teflon) or a novel polyetherurethane without leachable additives (PEU-Vialon). MEASUREMENTS: Research nurses scored insertion sites each day for inflammation and cultured catheters at removal. RESULTS: The Kaplan-Meier risk for phlebitis exceeded 50% by day 4 after catheterization. intravenous antibiotics (relative risk, 2.00), female sex (relative risk, 1.88), prolonged (greater than 48 hours) catheterization (relative risk, 1.79), and catheter material (PEU-Vialon: FEP-Teflon) (relative risk, 0.73) strongly predicted phlebitis in a Cox proportional hazards model (each, P less than 0.003). The best-fit model for severe phlebitis identified the same predictors plus catheter-related infection (relative risk, 6.19), phlebitis with a previous catheter (relative risk, 1.54), and anatomic site (hand: forearm, relative risk, 0.71; wrist:forearm, relative risk, 0.60). The low incidence of local catheter-related infection was comparable with the two catheter materials (5.4% [95% CI, 3.8% to 7.6%] and 6.9% [CI, 4.9% to 9.6%]); none of the 1054 catheters prospectively studied caused bacteremia. CONCLUSIONS: Multiple factors, including the infusate and the duration of cannulation, contribute to the development of infusion-related phlebitis. The use of peripheral intravenous catheters made of PEU-Vialon appears to pose the same risk for catheter-related infection as the use of catheters made of FEP-Teflon, and PEU-Vialon can permit longer cannulation with less risk for phlebitis. The risk for catheter-related bacteremia with FEP-Teflon and PEU-Vialon catheters is sufficiently low that it no longer seems justifiable to recommend the use of small steel needles for most peripheral intravenous therapy.
PURPOSE: Percutaneously inserted central venous catheters are widely used. Catheter-related bacteremia or fungemia is the most frequent serious complication of these catheters. In an attempt to reduce the frequency of such infections, a subcutaneous cuff constructed of a biodegradable collagen matrix impregnated with bactericidal silver was developed. Our goal was to assess, in a multicenter clinical trial, the effectiveness of this cuff in preventing catheter-related infection. MATERIALS AND METHODS: Central venous catheters needed for fluid or drug therapy, hemodynamic monitoring, or hyperalimentation in patients in three centers were randomly assigned to be inserted with or without the cuff. Patients and catheters in the two groups were comparable in terms of risk factors predisposing to infection, including colonization of skin about the insertion site. RESULTS: The results with 234 catheters inserted into a new site showed that catheters inserted with the cuff were threefold less likely to be colonized on removal (more than 15 colony-forming units) than were control catheters (28.9 percent versus 9.1 percent, p = 0.002) and were nearly fourfold less likely to produce bacteremia (3.7 percent versus 1.0 percent). Adverse effects from the cuff were not seen. The cuff did not confer protection, however against infection with catheters inserted over a guidewire into old sites. Most of the catheter-related infections identified in this study, including four of the six bacteremias, appear to have been caused by microorganisms colonizing skin about the insertion site, affirming the pathogenetic basis for benefit seen with the cuff in this clinical trial; two may have derived from contamination of the catheter hub. CONCLUSION: This novel, silver-impregnated, attachable cuff can substantially reduce the incidence of catheter-related infection with most percutaneously inserted central venous catheters, can extend the time catheters can be left in place safely, and can prove cost-beneficial.
Four dressing regimens for peripheral venous catheters were studied in a prospective randomized clinical trial with 2088 Teflon catheters: (1) sterile gauze, replaced every other day, and three dressings left on for the lifetime of the catheter; (2) gauze; (3) a transparent polyurethane dressing; and (4) an iodophor-transparent dressing. The four dressings provided comparable coverage, except moisture accumulated more frequently under the transparent dressings (26% to 28% vs 20% to 21%). Cutaneous colonization under the dressing was low level and comparable with all four dressings (range, 10(0.58) to 10(0.70) colony-forming units). The rate of local catheter-related infection (greater than or equal to 15 colony-forming units) was also low and did not differ significantly (range, 4.6% to 5.9%); no catheter caused bacteremia. Stepwise logistic multivariate analysis showed cutaneous colonization of the insertion site (relative risk [RR] of infection, 3.86), contamination of the catheter hub (RR, 3.78), moisture under the dressing (RR, 2.48), and prolonged catheterization (RR, 1.75) to be significant risk factors for catheter-related infection. These data indicate that it is not cost-effective to redress peripheral venous catheters at periodic intervals; for most patients, either sterile gauze or a transparent dressing can be used and left on until the catheter is removed.
Twenty-four subjects with oral lichen planus and twelve control subjects without oral mucosal disease were patch tested with dental restorative metals and selected metallic salts. Twenty-one percent of the lichen planus population exhibited a positive skin response to one or more challenge materials, as compared to 8% of the control population. It is concluded that oral lichen planus subjects show a higher correlation with delayed hypersensitivity to dental metals than a control population; however, a cause-and-effect relationship cannot be substantiated.
A 53 year old man died of cerebral hemorrhage while being treated for Streptococcus mutans endocarditis. At autopsy the only endocarditic lesion was on the left atrial mural endocardium. The noninfected mitral valve demonstrated prolapse and mucinous degeneration. The latter had led to rupture of several chordae tendineae, with the resultant jet stream predisposing to endocarditis at its point of atrial impact. The case provides confirmation of current concepts of the pathogenesis of endocarditis and has important therapeutic implications.
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