Biomedical subjects
Publications and source records attributed to R B Brown.
This report reviews the successful surgical experience with a diabetic patient with bronchial obstruction due to Mucorales infection. A review of the reported medical and surgical experience is included. The danger of a lethal pulmonary hemorrhage makes early surgical intervention mandatory.
While the bacterial origin of otitis media has been studied extensively in children, there are few data regarding adults with this disease. We undertook this study to identify the incidence, prevalence, and bacteriologic origin of purulent otitis media in adults. This was accomplished through a review of the English-language literature on adult otitis media and a retrospective review of adult patients with this disease who were hospitalized at our institution. Results of literature review indicate that Streptococcus pneumoniae and Haemophilus influenzae are the most common causes of otitis media in ambulatory adults, but this illness is uncommon, with an incidence of only 0.25%. Hospitalized patients in whom this diagnosis was established suffered a variety of serious suppurative complications such as mastoiditis, meningitis, or brain abscess. Otalgia and fever were the most common symptoms noted in this patient population. Further studies of adult otitis media need to be performed to determine bacteriologic, symptomatic, and high-risk patient groups.
Ammonium and potassium ion-selective membranes formulated with PVC/hydroxylated PVC, polyurethane/hydroxylated PVC, and moisture-curable silicone rubber matrices are studied in an effort to extend the lifetime of solid-state ion sensors through improved membrane adhesion. The PVC/membranes exhibit electrochemical performance equivalent to that of conventional PVC membranes in terms of slope, detection limit, and selectivity. The polyurethane- and silicone-rubber-based membranes have better adhesion to silicon nitride than do PVC or hydroxylated PVC matrices. Incorporating a silanizing reagent (silicon tetrachloride) significantly improves the adhesion of the polyurethane matrix. The use of silicon tetrachloride in membrane matrices also enhances the electrochemical stability of the interfacial potential between ion-selective polymer-matrix membranes and silver epoxy inner reference electrodes of solid-state sensors. The biocompatibility of the polymer matrices is examined via radiotracer protein adsorption studies and whole blood clotting time measurements. The polyurethane- and silicone-rubber-based membranes exhibit less overall nonspecific protein adsorption than the PVC or hydroxylated PVC matrices.
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Neuropeptides may be used to stimulate or inhibit neurocircuitry involved in regulation of visceral organ function, including glucose metabolism. Through the use of different peptides with different specificities, it may be possible to characterize the neuroendocrine and autonomic pathways involved in the physiologic regulation of glucose homeostasis.
This study compared the effect of "standard" dose metaproterenol delivered by hand-held nebulizer (HHN) with two puffs of metaproterenol delivered by a metered dose inhaler (MDI) via a spacer (InspirEase) (MDI-spacer). Seventeen patients with an acute exacerbation of obstructive pulmonary disease were studied. Each patient received both MDI-spacer and HHN. Alternate patients were randomized to either MDI-spacer or HHN as initial treatment. Each subject was tested four different times: before and 30 minutes after the initial aerosol delivery technique, and before and 30 minutes after the alternate aerosol delivery technique. Testing consisted of spirometry, lung auscultation, and measurement of vital signs. The interval between treatments for all subjects was 2.96 +/- 0.27 hours (mean +/- SEM) and was not different for subjects who received therapy via MDI-spacer first or HHN first. The patient population studied demonstrated severe airways obstruction (baseline FEV1 33.3 percent predicted +/- 4.9 percent). There was a statistically significant improvement in FVC and FEV1 after metaproterenol delivered by HHN, but not after MDI-spacer. Metaproterenol treatment with HHN resulted in a greater improvement in FEV1 (p less than .05) than MDI-spacer when the data were reported as absolute improvement (0.19 +/- 0.05 L for HHN) vs (0.06 +/- 0.03 L for MDI-spacer) or reported as percent change (23.2 +/- 6.6 percent for HHN) vs (9.5 +/- 3.4 percent for MDI-spacer). Asthmatic patients exhibited a significantly greater (p less than 0.05) improvement in FEV1 after HHN (23.4 +/- 4.7 percent change) than after MDI-spacer (6.6 +/- 4.5 percent change). Patients with chronic obstructive pulmonary disease (COPD) exhibited a greater improvement in FVC (p less than 0.05) after HHN (25.2 +/- 6.7 percent change) than after MDI-spacer (5.8 +/- 4.7 percent change). We conclude that the "standard" dosage of metaproterenol delivered by HHN results in greater spirometric improvement in patients with acute obstructive pulmonary disease than the conventional dosage of metaproterenol delivered by MDI-spacer. It is likely that this reflects the fact that the recommended dose of metaproterenol delivered by MDI is too low and should be increased.
A prospective, double-blind, placebo-controlled study was conducted to determine the safety and efficacy of endotracheal tobramycin (ETT) for treatment of gram-negative bacterial pneumonia. Patients were randomized to either 40 mg of tobramycin or a placebo instilled endotracheally every 8 h. Patients also received intravenous tobramycin plus either cefazolin or piperacillin. Of 85 patients enrolled, 41 were assessable. Most microbiologic diagnoses were made by endotracheal aspiration with strict grading criteria. The clinical-radiographic responses of patients and standard demographic data were recorded. Pseudomonas aeruginosa, "multiple pathogens," and Klebsiella-Enterobacter-Serratia-Citrobacter species were isolated in 41, 32, and 15% of the instances, respectively. Causative pathogens were eradicated from sputum significantly more frequently by patients who received ETT (P less than 0.05). However, no significant differences were noted in the clinical outcomes of the two study groups. No local adverse reactions attributable to the administration of this agent were observed, but four patients had supraventricular tachycardia, compared with none who received the placebo (P = 0.053). ETT may be considered as adjunctive therapy for seriously ill individuals.
We compared treatment with one daily intravenous dose of cefonicid and multidose nafcillin in 65 patients with severe infections of the skin or skin structure. Clinical cure or improvement was achieved in 91% of the patients given cefonicid and in 87% of the patients given nafcillin (P = 0.97). The use of cefonicid may allow outpatient therapy of some severe infections.
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Flavobacterium meningosepticum is an uncommon cause of adult nosocomial infection. On a medical/surgical intensive care unit we recently encountered an adult outbreak of respiratory colonization and infection caused by this organism, which was associated with the prophylactic use of aerosolized polymyxin B that had been used in an attempt to abort an outbreak of infection caused by highly resistant strains of Pseudomonas aeruginosa. Twenty isolates (95% from respiratory secretions) of F. meningosepticum from nine persons were identified during a 2 1/2-month period. No environmental source has been identified to date. Pneumonia developed in five patients, and two deaths associated with this organism occurred. All isolates were sensitive to ciprofloxacin; none were sensitive to other antibiotics tested, including third-generation cephalosporins, aminoglycosides, erythromycin, trimethoprim-sulfamethoxazole, antipseudomonal penicillins, aztreonam, and imipenem/cilastatin. Two patients with nosocomial pneumonia were successfully treated with oral ciprofloxacin. F. meningosepticum may emerge as an important pathogen if prophylactic use of polymyxin B becomes more widespread. Ciprofloxacin may become the agent of choice for treatment of this organism.
Bronchitis is a common diagnosis in the primary care physician's office, especially during winter. Acute bronchitis is usually caused by viruses but a number of other pathogens may also be responsible. Therapy for acute bronchitis is generally supportive. Chronic bronchitis, characterized by prolonged sputum production, is most often caused by cigarette smoking, which decreases mucociliary transport velocity. This and other pathophysiologic effects of smoking can lead to exacerbations of the disease that may necessitate antimicrobial therapy. Antimicrobial agents and vaccines may have both prophylactic and therapeutic roles in the management of chronic bronchitis.
Adverse reactions to antibiotics comprise a number of classes of reactions, including toxicity, side effects, and allergy. Each one of these differs in its implication for treatment of the patient. The authors discuss some of the more common and unusual reactions to antibiotics frequently used in the practice of podiatric medicine.
Outpatient intravenous antibiotic therapy is a cost-effective modality to shorten hospital stays and provide continued care to patients with infections. The recent availability of tamper-proof pumps that can deliver multiple antibiotics on independently timed regimens will further expand the use of home intravenous antibiotics. Problems with reimbursement remain, and new classes of oral antibiotics may provide alternatives to parenteral medications.
We investigated prospectively clinical bleeding in 1,328 consecutive patients admitted to a medical/surgical ICU over 1 yr. One hundred thirty-eight (10.4%) patients bled after ICU admission, and an additional 388 (29.2%) bled coincident with admission. The upper GI tract was the site of bleeding in 34.8% of patients whose bleeds commenced in the ICU, and accounted for 22% of total sites. Patients with clinical bleeding after ICU admission had a significantly (p less than .001) higher likelihood of death than those who did not bleed, and those with multiple bleeding sites had a higher mortality (54.9%) than those with single sites (31%) (p less than .006). Multiple logistic regression analyses revealed that risk ratios (RR) for bleeding after ICU admission were mechanical ventilation (RR = 1.82), nutritional failure (RR = 3.45), acute renal failure (RR = 3.36), antiulcer medication (RR = 3.36), and anticoagulants (RR = 4.19). No antibiotics could be specifically incriminated. This study defines the scope, characteristics, and importance of bleeding in ICU patients and establishes risk factors.
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The elderly represent an increasing percentage of the population, and an important group of users of intravenous antibiotics. Therapy at home can provide a cost-effective means of treating many infectious diseases. Special problems to be anticipated include those related to reimbursement, possibility of adverse drug interactions, non-compliance, and need for venous access. Choice of antimicrobial agent is dependent upon ease of administration, safety, efficacy, and cost. Careful patient selection, availability of appropriate home health care services, and diligent physician follow-up can allow many elderly patients to receive long-term intravenous antibiotic therapy outside the hospital.
Recurrent aseptic meningitis as a manifestation of systemic lupus erythematosus (SLE) has most often been reported as an adverse reaction to the use of nonsteroidal antiinflammatory drugs. We present a case of recurrent aseptic meningitis and transverse myelitis as the initial manifestation of SLE.