Thrombophilia in short peripheral catheter thrombophlebitis.
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Anticoagulants↗
Biomedical subjects
Michael D Libman
Publications and source records attributed to Michael D Libman.
Comparison of Gram and Kopeloff stains in the diagnosis of bacterial vaginosis in pregnancy.
Bacterial vaginosis (BV) is commonly diagnosed by using the Nugent score, a semiquantitative scoring system to evaluate bacterial morphotypes on Gram stain of vaginal secretions. Some authors have suggested using the Kopeloff modification of the Gram stain. Asymptomatic BV in pregnancy has been associated with adverse outcomes. We performed both stains on simultaneously collected vaginal smears from 2652 women at 24-26 weeks of gestation. Gram staining gave significantly higher (more abnormal) Nugent scores than Kopeloff staining. Compared to the Kopeloff stain, the number of specimens graded as indeterminate or consistent with BV by Gram stain increased by 29% (469 versus 364, P<.001). Interrater reliability of the Nugent score (n=413) for Kopeloff staining was significantly better than Gram staining (agreement=74% versus 63%, intraclass correlation coefficient=0.87 versus 0.79, P<.05, 95% confidence intervals 0.85-0.89 and 0.75-0.82, respectively).
Adult↗
The sequence of vaccinations and increased female mortality after high-titre measles vaccine: trials from rural Sudan and Kinshasa.
OBJECTIVE: West African studies have hypothesized that increased female mortality after high-titre measles vaccine (HTMV) was due to subsequent diphtheria-tetanus-pertussis (DTP) and inactivated polio vaccine (IPV) vaccinations. We tested two deductions from this hypothesis in HTMV studies from rural Sudan and Kinshasa; first, there should be no excess female mortality for HTMV recipients when DTP was not given after HTMV and second, excess female mortality should only be found among those children who received DTP after HTMV. STUDIES: The Sudanese trial randomised 510 children to Edmonston-Zagreb (EZ) HTMV, Connaught HTMV or a control vaccine (meningococcal). Both the Connaught HTMV and the control group received standard measles vaccine at 9 months. In the Kinshasa study 1023 children received one dose of HTMV at 6 months or two doses at 312 and 912 months of age. FINDINGS: First, the Sudan trial is one of the few randomised studies of measles vaccine; the EZ HTMV group had lower mortality between 5 and 9 months of age than controls, the mortality ratio (MR) being 0.00 (p = 0.030). This effect was not due to prevention of measles infection. Second, both studies provided evidence that HTMV per se was associated with low mortality. In a combined analysis comparing both HTMV groups with controls, the HTMV groups had a MR of 0.09 (0.01-0.71) between 5 and 9 months of age. In Kinshasa, the HTMV recipients who did not receive simultaneous DTP had an annual mortality rate of only 1.0% between 6 months and 3 years of age. Third, the female-male MR was related to subsequent DTP vaccinations. In Kinshasa, the female-male MR was only 0.40 (0.13-1.27) among the HTMV recipients who did not receive further doses of DTP. In Sudan, the female-male mortality ratio in the EZ group was 3.89 (95% CI 1.02-14.83) and the female-male MR increased with number of doses of DTP likely to have been given during follow-up (trend, p = 0.043). Fourth, in Kinshasa, mortality was higher among children who had received HTMV and DTP simultaneously than among children who had received HTMV alone (MR = 5.38 (1.37-21.2)). CONCLUSIONS: Measles vaccine is associated with non-specific beneficial effects. When not given with DTP, HTMV per se was associated with low mortality. Increased female mortality was not found among children who did not receive DTP after HTMV. Hence, our deductions were supported and the sequence or combination of vaccinations may have an effect on sex-specific mortality patterns in low-income countries.
Age Factors↗
A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality.
BACKGROUND: In March 2003, several hospitals in Quebec, Canada, noted a marked increase in the incidence of Clostridium difficile-associated diarrhea. METHODS: In 2004 we conducted a prospective study at 12 Quebec hospitals to determine the incidence of nosocomial C. difficile-associated diarrhea and its complications and a case-control study to identify risk factors for the disease. Isolates of C. difficile were typed by pulsed-field gel electrophoresis and analyzed for binary toxin genes and partial deletions in the toxin A and B repressor gene tcdC. Antimicrobial susceptibility was evaluated in a subgroup of isolates. RESULTS: A total of 1703 patients with 1719 episodes of nosocomial C. difficile-associated diarrhea were identified. The incidence was 22.5 per 1000 admissions. The 30-day attributable mortality rate was 6.9 percent. Case patients were more likely than matched controls to have received fluoroquinolones (odds ratio, 3.9; 95 percent confidence interval, 2.3 to 6.6) or cephalosporins (odds ratio, 3.8; 95 percent confidence interval, 2.2 to 6.6). A predominant strain, resistant to fluoroquinolones, was found in 129 of 157 isolates (82.2 percent), and the binary toxin genes and partial deletions in the tcdC gene were present in 132 isolates (84.1 percent). CONCLUSIONS: A strain of C. difficile that was resistant to fluoroquinolones and had binary toxin and a partial deletion of the tcdC gene was responsible for this outbreak of C. difficile-associated diarrhea. Exposure to fluoroquinolones or cephalosporins was a risk factor.
Aged↗
Clostridium difficile: a formidable foe.
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Canada↗
No evidence for short or long term morbidity after increased titer measles vaccination in Sudan.
BACKGROUND: Increased mortality rates have been reported after high titer measles [>10(5.0) plaque-forming units (PFU)] vaccination in several large studies in the developing world. An increased titer measles vaccine study conducted in Sudan included a prolonged prospective evaluation of childhood morbidity after vaccination. METHODS: Five hundred ten children (170 per group) were randomized to receive 1 of 3 regimens at 5 and 9 months of age: (1) meningococcal vaccine, then standard titer (50% tissue culture-infective dose, 103.8) Schwarz measles vaccine; (2) increased titer (10(4.7) PFU) Edmonston-Zagreb measles vaccine followed by meningococcal vaccine; and (3) increased titer (10(4.7) PFU) Connaught vaccine followed by standard titer Schwarz measles vaccine. RESULTS: Health workers collected information at 31,582 semi-monthly and monthly visits during 5 years. No increase in infant mortality was observed, but the statistical power was limited. There were 13, 13 and 10 deaths in the Schwarz, Edmonston-Zagreb and Connaught groups, respectively. There were no differences in duration or incidence of illness between groups at any time during the 5-year follow-up, with comparisons stratified by age and sex. Statistical power for each pairwise comparison was good, with at least 80% power to detect a difference of 1 day per month of illness and a 12% difference in the proportion of visits with an illness recorded. CONCLUSIONS: We were unable to document increased morbidity in recipients of the increased titer measles vaccines used in this study. These data do not support the hypothesis that increased mortality after increased titer vaccine exposure is the result of increased and cumulative morbidity.
Age Factors↗
Confirmation by 16S rRNA PCR of the COBAS AMPLICOR CT/NG test for diagnosis of Neisseria gonorrhoeae infection in a low-prevalence population.
The COBAS AMPLICOR CT/NG test is widely used for the diagnosis of Neisseria gonorrhoeae infection using genital swabs or urine samples. Although highly specific, cross-reactivity occurs with some nonpathogenic strains of Neisseria and Lactobacillus species. In low-prevalence populations, even highly specific assays may require confirmatory testing of positive results. We assessed the positive predictive value (PPV) of this test in a low-prevalence (0.5%) setting. Genital and urine specimens testing positive using the COBAS AMPLICOR NG test were retested using an investigational 16S rRNA PCR assay. Additionally, 737 specimens were tested in parallel by both culture and the above PCR protocol. Of 9,772 specimens tested in-house, 168 were positive by the AMPLICOR test; in addition, 62 AMPLICOR-positive specimens were referred to our laboratory for confirmatory testing, yielding 230 positive specimens. Of these, 72 were confirmed positive by 16S rRNA PCR, yielding a specificity of 98.7% and a PPV of 31.3%. Specificity was similar for all specimen types, whereas PPV varied with prevalence: specimens from males, females, urine specimens, and genital swabs had PPVs of 70.8, 13.3, 51.9, and 20.1%, respectively. The PPV was higher when the initial AMPLICOR optical density (OD) was > or =3.5 versus initial and repeat OD readings in an equivocal zone of > or =0.2 to <3.5 (65.1 versus 10.1%; P < 0.001). On repeat testing of specimens with ODs in the equivocal zone, 54 gave ODs of > or =0.2 and <2.0, 35 gave ODs of > or =2.0 and <3.5, and 12 gave ODs of > or =3.5, with 3.7, 20, and 33.3% confirmed positive, respectively (P = 0.004). Comparing PCR to culture as the "gold standard," specificity increased from 96.8 to 99.9% when 16S rRNA PCR was performed on specimens positive by the COBAS AMPLICOR NG test. Confirmatory testing with a more specific method such as 16S rRNA PCR should be considered in low-prevalence populations, especially for specimens with an OD in the equivocal zone.
Cervix Uteri↗