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Biomedical subjects

T F Keys

Publications and source records attributed to T F Keys.

At least 37 records · Page 2Linked to original sources
PubMed1989

Decreased infections in cardiac transplant recipients on cyclosporine with reduced corticosteroid use.

Fifty patients undergoing orthotopic cardiac transplantation were monitored over 34 months for evidence of infection. Four separate immunosuppressive protocols were used during the course of the study; the most recent protocol (protocol 4) employed significantly lower overall steroid dosages than the earlier protocols (protocols 1,2, and 3). All immunosuppressive regimens used cyclosporine, and azathioprine was added in the last three protocols. Statistical techniques to compare the occurrence of infection in protocols 1,2, and 3 v protocol 4 showed that patients in protocol group 4 (n = 21) had significantly more time free of pneumonia (P = .02) and major infections (P = .04) and marginally more time free of symptomatic cytomegalovirus infection (P = .08) than patients in protocol groups 1, 2, and 3 (n = 29). The median incidence of major infection per month was lower for protocol group 4 (P = .02). The time free of viral infection did not differ significantly between the two groups (P = .75) nor did the median incidence of rejection per month (P = .19). The authors conclude that reduction of steroid dosages in cardiac transplant patients receiving cyclosporine is associated with a significant decrease in the incidence of clinically important infections.

Adrenal Cortex Hormones↗
PubMed1989

Enumerative, Bayesian, and analytic statistical analysis of nosocomial infection for quality improvement: first of two parts.

Readmission rates are used by the Health Care Financing Administration (HCFA) as an indicator of a hospital's quality of care. Specifically, HCFA seeks to relate readmission to complications of the primary admission. A recent study at the Cleveland Clinic Foundation examined patients readmitted within 30 days of dismissal during two non-consecutive months to the cardiovascular surgery, cardiology, and gastroenterology services at this 1,008 bed hospital, accounting for 31% (1640-5342) of all hospital discharges. Only 17% (25/149) of readmissions were due to a complication of the previous hospital admission. Examining those who were readmitted for complications of their primary admission, we found that 36% (9/25) of such readmitted patients had infections that occurred during their primary admission. Otherwise stated, 5.4% (9/149) of readmissions were for nosocomial infections. These patients were compared with 20 retrospectively matched, non-readmitted patients chosen randomly from a group of 100 patients retrospectively matched for gender, age, type, and date of surgery. Using these controls, a computer-based expert system was used to help identify patient variables that are associated with readmission due to nosocomial infection. We found if a patient had (1) a weight less than 66 Kilograms or (2) had a first postoperative total serum protein greater than 6.1 or (3) was reoperated, we could predict with 100% specificity and 60% sensitivity that the patient would have an unplanned readmission. Total readmission rates do not accurately reflect complications of the primary admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1988

Infections of the cardiac suture line after left ventricular surgery.

PURPOSE: Infections of the cardiac suture line after left ventricular surgery are rare but may be fatal if not diagnosed promptly and treated effectively. In order to alert physicians to this entity, we reviewed data from three patients who presented at the Cleveland Clinic Hospital and from 22 patients in the literature. PATIENTS AND METHODS: The three patients in the current report underwent treatment at the Cleveland Clinic Hospital. Additional cases of infection of the left ventricular suture line were identified by reviewing the English literature pertaining to surgery for left ventricular aneurysms, pseudoaneurysms, and postoperative cardiac infections. RESULTS: Infection presented on average 16 months after surgery with cardiocutaneous fistulae, chest wall masses, hemoptysis or other pleuropulmonary symptoms, or systemic illness with bacteremia resembling endocarditis. Staphylococci and gram-negative bacilli were the most frequent pathogens. Diagnosis was often delayed and mortality was high. Left ventricular false aneurysms were identified in 15 of the 25 patients. Bleeding from sinuses in the chest wall or epigastrium or repeated hemoptysis were important clinical clues. In some instances, ill-advised surgical or instrumental procedures precipitated life-threatening hemorrhage. Treatment with antibiotics alone was insufficient. Excision of all infected sutures and Teflon pledgets and adequate debridement of the infected suture line were required to achieve cures. CONCLUSION: Since infection of the left ventricular suture line has protean clinical manifestations and may present months or years after the initial surgery, a high index of suspicion is of paramount importance in diagnosing the condition. Institution of cardiopulmonary bypass and reoperation through median sternotomy is recommended to achieve a cure.

Aged↗
PubMed1988

A multivariate analysis of the risk of cytomegalovirus infection in heart transplant recipients.

Thirty-four consecutive heart transplant recipients were studied over a two-year period for evidence of cytomegalovirus (CMV) infection. Twenty-three episodes of CMV infection were identified; 19 of these occurred within 120 d after transplantation and were statistically analyzed. Fifteen potential risk factors were evaluated, including the following: pretransplant CMV serological status of donor and recipient; recipient's age, sex, race, and cardiac disease; number and type of blood products transfused; type and intensity of immunosuppression; occurrence of rejection; and leukopenia. The Cox proportional hazards model identified both greater than average steroid dosage and positive recipient CMV serology as significant risk factors for CMV infection (P = .014 and .048, respectively). In a separate analysis, however, only greater than average steroid dosage was associated with clinically significant CMV infection (P = .005).

Adrenal Cortex Hormones↗
PubMed1988

A multivariate analysis of risk factors for pneumonia following cardiac transplantation.

Fifty cardiac transplant recipients were followed over a 34-month period for evidence of pneumonia that developed in twelve patients. Potential risk factors evaluated fell into three categories: demographic (age, sex, race, and underlying cardiac disease); pretransplant status (hospitalized, intubated, pulmonary infiltrate, requirement for antibiotics, or the need for a ventricular assist device); and posttransplant therapy (amount and type of blood products, prolonged endotracheal intubation or reintubation, use of ventricular assist devices, immunosuppressive protocols, lymphocyte subset ratios, and occurrence of rejection, leukopenia, or CMV infection). The Cox proportional hazards model identified posttransplant reintubation (P = 0.009) and the use of protocols employing larger steroid dosages (P = 0.02) as significant risk factors for pneumonia. In a separate analysis, the occurrence of pneumonia was shown to be a significant risk factor for mortality (P = 0.018).

Heart Transplantation↗
PubMed1988

Vertebral osteomyelitis presenting as spinal compression fracture. Six patients with underlying osteoporosis.

Six patients with osteoporosis had vertebral osteomyelitis (VO) with infection of a single vertebra that presented with a collapsed vertebral body, thought to be a simple compression fracture. The resulting delay in correctly diagnosing VO was associated with disabling sequelae in a high proportion of cases. This distinctive presentation accounted for 13% of all hospitalized patients with VO and 2.4% of inpatients with osteoporotic compression fractures during the last five years; it may be more common than suggested by the paucity of published cases. In patients with osteoporosis and vertebral compression fractures, osteomyelitis should be considered when there is severe back pain, persistent unexplained fever, unexplained elevation of the erythrocyte sedimentation rate, or bacteremia without an obvious extravertebral focus of infection, particularly if the patient is immunocompromised. Early biopsy and culture of the collapsed vertebral body will facilitate diagnosis and therapy.

Acute Disease↗
PubMed1987

Viral hepatitis. A population-based study in Rochester, Minn, 1971-1980.

The incidence of acute viral hepatitis among Rochester, Minn, residents 1971-1980 was 28.6 per 100,000 person-years (p-y) (age- and sex-adjusted to the 1980 white population in the United States). The adjusted incidence of hepatitis B (12.9 per 100,000 p-y) was somewhat less than for hepatitis non-B (15.6 per 100,000 p-y). Each type was more frequent among young adults, especially males. The incidence of hepatitis was greater among those employed in the health service industry than among nonmedical employees (53.4 vs 20.0 per 100,000 p-y). Medical employees had nearly a fivefold increased incidence of hepatitis B and a twofold increased incidence of hepatitis non-B. Exposure to known hepatitis cases was common, but other possible causative factors were not frequent. In this midwestern community, the incidence of acute viral hepatitis is substantial, with medical employees at significantly increased risk.

Adolescent↗
PubMed1987

Nosocomial clonal dissemination of methicillin-resistant Staphylococcus aureus. Elucidation by plasmid analysis.

An outbreak of methicillin sodium-resistant Staphylococcus aureus (MRSA) infection and colonization, mainly centered in the vascular surgery service, occurred in a 1000-bed tertiary care center between December 1983 and December 1984. Methicillin-resistant S aureus isolated before and during the outbreak was studied by both bacteriophage typing and by restriction endonuclease digestion of bacterial plasmid DNA. Bacteriophage typing was discrepant in nine (56%) of the 17 repeated analyses compared with one (3.4%) of the 29 for plasmid profiling. These typing methods revealed that the epidemic strain was introduced to the hospital from the community 15 months before the outbreak. The outbreak was caused by cross-transmission of the epidemic strain by health care personnel and was controlled by treatment of colonized personnel, education of personnel, and institution of barrier precautions for colonized or infected patients. Plasmid profiling with restriction endonuclease digestion was easier, more rapid, and more specific than bacteriophage typing in the evaluation of this outbreak.

Cross Infection↗
PubMed1987

Therapeutic considerations in the treatment of Legionella infections.

Selection of therapy for legionella infections originated with the clinical observation after the 1976 Philadelphia outbreak that patients treated with erythromycin or tetracycline did better than those who received cephalosporins or aminoglycosides. Early in vitro antibiotic susceptibility studies suggested that rifampin and erythromycin were both active against Legionella pneumophila. However, subsequent in vitro susceptibility studies to other antibiotics have produced variable results, depending on the medium and methodology used. Antibiotic studies within polymorphonuclear leukocytes and alveolar macrophages indicate that those actively concentrated within these cells are predictive of successful therapy. These include erythromycin, rifampin, and certain quinolones. On the other hand, beta-lactam antibiotics such as penicillin, cefoxitin, and imipenem are less likely to be successful because of their lack of concentration within phagocytes. These observations have been confirmed in animal model studies where erythromycin, rifampin, and quinolones have demonstrated efficacy. The addition of rifampin to erythromycin or to doxycycline may be more effective than therapeutic results with either antibiotic alone. Although erythromycin is presently the treatment of choice for legionellosis, the addition of rifampin is recommended, particularly in immunocompromised patients. Doxycycline has served as an appropriate alternative agent, the newer quinolones may be useful and are deserving of carefully designed clinical trials.

Animals↗
PubMed1986

Left-sided endocarditis due to Pseudomonas aeruginosa. A report of 10 cases and review of the literature.

Ten confirmed cases of left-sided endocarditis due to Pseudomonas aeruginosa were reported in detail and the English literature was reviewed. In recent years, venous access (usually illicit) has been the major predisposing factor to this infection and abuse of pentazocine and tripelennamine has been particularly associated with endocarditis due to this organism. This infection involves previously damaged as well as normal valves. The development of congestive heart failure did not adversely affect the prognosis of this infection. However, the development of azotemia was associated with a greater likelihood of a fatal outcome. In the current series, deaths were due to uncontrolled infection. This often occurred despite inhibitory and bactericidal activity in serum generally considered adequate for treatment of endocarditis. Medical treatment alone rarely produced cure of infection. Our experience with a high frequency of major vessel embolization (4/10) and the improved survival after medical/surgical treatment suggests that prompt valve replacement combined with high doses of an aminoglycoside plus carbenicillin or ticarcillin provide the best opportunity for successful outcome in patients with left-sided endocarditis due to P. aeruginosa.

Adult↗
PubMed1984

Empiric therapy with moxalactam alone in patients with bacteremia.

Moxalactam was administered (20 mg/kg intravenously every 8 hours) as single-drug empiric antimicrobial therapy to 63 patients with bacteremia who were neither neutropenic nor immunosuppressed. Six patients (10%) had microorganisms that were susceptible to moxalactam and resistant to all other antimicrobial agents tested; two patients (3%) had microorganisms that were resistant to moxalactam and other agents tested. Of these 63 patients, 47 (75%) were cured with moxalactam therapy. Nine patients (14%) had breakthrough bacteremia while receiving other antimicrobial therapy and were cured subsequently with moxalactam therapy alone. The two major risk factors for failure of moxalactam therapy were polymicrobial bacteremia and an extrahepatic intra-abdominal source of infection; these two conditions frequently coexisted. Six of nine patients with polymicrobial bacteremia died. Superinfection (one pseudomonal, five enterococcal) was responsible for 6 of the 16 treatment failures. Enterococcal superinfection occurred exclusively among patients who had received relatively prolonged therapy with moxalactam for extrahepatic intra-abdominal infection, especially intraabdominal abscess. These five patients died, and postmortem examination showed that enterococcal superinfection was the major cause of death in all. Mild, reversible adverse reactions associated with use of moxalactam occurred in 14 of the 63 patients (22%). None had clinically overt bleeding. The use of moxalactam alone seems to be safe and effective and a cost-effective alternative empiric antimicrobial therapy for most patients with bacteremia who are not immunosuppressed or neutropenic and who are not at high risk of having Pseudomonas or polymicrobial bacteremia.

Abdomen↗
PubMed1984

Acute cystitis: a prospective study of laboratory tests and duration of therapy.

The efficacy of single-dose therapy with trimethoprim-sulfamethoxazole (TMP-SMZ) and the cost-effectiveness of routine urinalyses and cultures were studied in a prospective randomized trial of 200 women who presented with symptoms of acute lower urinary tract infection. Without the physician's knowledge of the results of urinalysis or culture, the patients were randomly assigned to receive either a single dose or a 10-day multiple-dose course of TMP-SMZ and were followed up for 6 months. Of the 136 patients with positive urine cultures, 68 received single-dose therapy with TMP-SMZ--10 of whom had relapses--and 68 received multiple-dose therapy with TMP-SMZ--only 2 of whom had relapses (P less than 0.02). Fifteen patients in each treatment group experienced reinfection. Side effects of rash and vaginitis were more common in patients who received multiple-dose therapy, but they were mild and well tolerated. Of the 51 patients with urethral syndrome, 48 became asymptomatic after therapy. None of the following tests predicted treatment outcome: pretreatment urinalysis, urine culture or susceptibility testing, antibody-coated bacteria testing, or routine follow-up urinalyses or urine cultures. Empiric therapy with TMP-SMZ in selected women with symptoms of acute uncomplicated urinary tract infection seems practical, safe, and cost-efficient. Considerable savings can be achieved by reserving urinalyses and urine cultures for patients with persistent or recurrent symptoms. Higher cure rates can be expected in patients who receive a standard 10-day course of therapy with TMP-SMZ compared with those who receive single-dose therapy with TMP-SMZ.

Acute Disease↗
PubMed1983

A suspected hospital outbreak of pseudobacteremia due to Pseudomonas stutzeri.

Pseudomonas stutzeri was recovered from blood cultures of 24 patients from 1977 through 1979 at one Mayo Clinic-affiliated hospital. During the investigation it was determined that aqueous green soap--used throughout the hospital to prepare the skin for iv insertions--had probably become contaminated with P. stutzeri. The use of aqueous green soap was discontinued, but eight additional cases of pseudobacteremia occurred in 1980-1981 and one case occurred in 1982. With one exception, all of the patients appeared to have pseudobacteremia rather than true bacteremia; the outbreak ceased only after aqueous green soap was deleted as a standard stock item from the hospital formulary.

Adolescent↗
PubMed1983

Antifungal agents used for deep-seated mycotic infections.

The main antifungal agents used for deep-seated mycotic infections are the broad-spectrum antifungal drug amphotericin B, the narrow-spectrum agent flucytosine, and the newer broad-spectrum agents miconazole and ketoconazole. Amphotericin B remains the cornerstone of antifungal therapy. For the treatment of cryptococcal meningitis, the current recommendation is for the combined use of amphotericin B and flucytosine. 2-Hydroxystilbamidine is used only in indolent cases of blastomycosis; however, this condition is usually treated with amphotericin B. Clinical experience with the newer agents is limited. Not all patients from whom fungal agents have been isolated require treatment; the extent of the fungal infection should be determined, when possible, for evaluation of the need for treatment.

Amphotericin B↗