Identifiable Source Of Infection Research Articles

Engraftment Syndrome (ES) After Reduced-Intensity Stem Cell Transplantation (RIST): ES May Have a Negative Impact on Survival In Standard-Risk Patients

AbstractAbstract 2318 Introduction:ES has been well recognized to increase non-relapse mortality (NRM) in autologous hematopoietic cell transplantation (HCT). However, little information is available on ES in allogeneic HCT, particularly after reduced-intensity conditioning. To determine the incidence, risk factors and outcome of ES after RIST, we retrospectively reviewed the medical records of 285 patients (pts) who underwent RIST at our institution between 1999 and 2007. Patients and Methods:After excluding 37 pts who received cord blood transplantation or a second or subsequent allogeneic HCT, and those who experienced primary graft failure, 248 pts (male 153, female 95) with a median age of 55 y (range, 21–68) fulfilled the criteria of this study. The underlying diagnosis included lymphoma (106 pts; 43%), acute myeloid leukemia (59; 24%), myelodysplastic syndrome (51; 21%), and others (32; 13%). Ninety-two pts (37%) had a standard-risk disease such as acute leukemia or lymphoma in CR1, and 156 (63%) had a high-risk disease. The donor and stem cell source were related PBSC in 170 pts (69%), related BM in 8 (3%), and unrelated BM in 70 (28%). All of the pts received reduced-intensity conditioning with a purine analog and a busulfan-based regimen. With the use of G-CSF after HCT, neutrophil engraftment (ANC ≥500/μ l) was achieved at a median of 12 days (range, 5–28). ES was diagnosed when the patient showed at least 2 of the following symptoms within 96 h of neutrophil engraftment: (1) fever (>38.0°C) without an identifiable source of infection, (2) skin rash (>25% of body surface area) that was not due to a drug reaction, (3) weight gain (>2.5% of baseline body weight), and (4) hypoxia (sPO2 <94%) or pulmonary infiltrates. Results:Among the 248 pts, 45 (18%) developed ES at a median of 14 days (6-23) after allogeneic HCT. Symptoms consisted of fever (100%), skin rash (53%), weight gain (62%) and hypoxia (33%). The incidence of ES in recipients of unrelated donor grafts was significantly higher than that in recipients of related donor grafts (28% vs 14%, p=0.02), and male pts had a significantly higher incidence of ES than female pts (22% vs 12%, p=0.04). No significant difference in the incidence of ES was observed between groups stratified according to age, stem cell source, TNC or CD34+ cell dose, disease risk, GVHD prophylaxis, and the timing of engraftment. By a multivariate analysis, use of an unrelated donor (HR 2.3, 95%CI 1.3–4.1, p=0.007), pts with lymphoid malignancy (HR 2.0, 95%CI 1.1–3.7, p=0.03) and male pts (HR 2.0, 95%CI 1.0–4.0, p=0.04) were associated with a significantly increased risk of ES. Among the 40 pts who required systemic corticosteroid therapy, 31 (78%) achieved a complete response, and the remaining 9 (23%) responded partially. There was a trend toward a higher incidence of grade III-IV acute GVHD (27% vs 18%, p=0.10) in pts with ES, and the incidence of extensive chronic GVHD (69% vs 62%, p=0.04) was significantly higher in pts with ES. Overall survival (OS) and non-relapse mortality (NRM) were not significantly different between the two groups, after a median follow-up of 53 months (range, 2–108) in surviving patents. A multivariate analysis showed that pts with high-risk disease (NRM, HR 1.9, 95%CI 1.1–3.3, p=0.01; OS, HR 2.5, 95%CI 1.6–3.8, p<0.001) and those with myeloid malignancy (NRM, HR 2.0, 95%CI 1.2–3.4, p=0.01; OS, HR 1.5, 95%CI 1.0–2.2, p=0.03) were associated with an increased risk of NRM and worse OS after allogeneic HCT, whereas the development of ES did not affect NRM or OS. In a subgroup analysis of 92 pts with standard-risk disease, pts with ES had a significantly worse OS (50% vs 76% at 3 y, p=0.03, Figure, left panel) and a higher NRM (49% vs 20% at 3 y, p=0.03) compared to those without ES. In a subgroup analysis of 156 pts with high-risk disease, however, OS (42% vs 46% at 3 y, p=0.76, Figure, right panel) and NRM (48% vs 39% at 3 y, p=0.84) of pts with ES were equivalent to those of pts without ES. Conclusions:ES is a rather common complication after RIST, especially in recipients of unrelated donor grafts. Although ES shows an initial good response to corticosteroid therapy, ES may have a negative impact on survival, especially in pts with standard-risk disease, and this effect may be related to the occurrence of GVHD. The development of an optimal treatment for ES may improve the outcome of pts who have received RIST by reducing GVHD-related mortality. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Acute Coronary Syndrome Caused by Coronary Artery Mycotic Aneurysm Due to Late Stent Infection Localized With Radiolabeled Autologous Leukocyte Imaging

Mycotic coronary artery aneurysm presenting as acute coronary syndrome is an uncommon but fatal condition. The diagnosis of mycotic aneurysm can be very challenging and difficult. Therefore, a high index of suspicion along with the use of multimodality imaging may help to diagnose this condition in patients with a prior history of coronary artery bypass grafting or percutaneous coronary intervention with persistent bacteremia with no identifiable source of infection. This case highlights a possibility of late stent infection and its association to drug eluting stents.

Primary bacterial peritonitis in dogs and cats: 24 cases (1990–2006)

To determine clinical characteristics of primary bacterial peritonitis (infection of the peritoneal cavity with no identifiable intraperitoneal source of infection) and compare characteristics of primary and secondary peritonitis in dogs and cats. Retrospective case series. 24 (primary peritonitis) and 60 (secondary peritonitis) client-owned dogs and cats. Data from medical records of dogs and cats with primary and secondary peritonitis were reviewed for descriptive information regarding primary peritonitis and for comparison between the 2 forms of peritonitis. 15 dogs and 9 cats met inclusion criteria for primary peritonitis, and 49 dogs and 11 cats met inclusion criteria for secondary peritonitis. The most common historical findings in dogs and cats with primary and secondary peritonitis were lethargy, vomiting, and anorexia. Dogs with secondary peritonitis more often developed peritoneal exudates than those with primary peritonitis, and dogs with primary peritonitis were more often infected with gram-positive bacteria than those with secondary peritonitis. No difference in outcome was detected between all animals with primary versus secondary peritonitis; however, dogs with secondary peritonitis treated with surgery were more commonly discharged than those with primary peritonitis treated with surgery. Differences in primary and secondary peritonitis related to historical, physical examination, and clinical laboratory findings; bacteriologic findings; peritoneal effusion characteristics; and outcome were detected. However, larger case numbers are needed before alternative recommendations, such as avoidance of surgery, can be made.

Treatment of TIPS/Biliary Fistula–Related Endotipsitis with a Covered Stent

"Infective endotipsitis" describes a recurrent bacteremia or fungemia in patients with a transjugular intrahepatic portosystemic shunt (TIPS) in place and no other identifiable source of infection. The present report describes a patient who developed polymicrobial endotipsitis 6 years after TIPS creation. Blood cultures remained positive for polymicrobial growth despite long courses of antibiotic therapy. Communication between the TIPS and an infected biliary tree, precipitated by cholecystitis, was ultimately recognized. The biliary/TIPS fistula was closed with a polytetrafluoroethylene-covered stent. The patient remains asymptomatic and follow-up blood cultures remain negative with a low dose of oral antibiotics 2 years after the procedure.

Characterization and clinical assessment of 571 febrile intravenous drug users at risk for infective endocarditis presenting to an urban emergency department

Study objectives: Infective endocarditis remains a difficult disease to diagnose with certainty and carries a high risk of morbidity and mortality if not treated aggressively with antibiotics. Epidemiologic studies of infective endocarditis have been hampered because of the rarity of disease and lack of precise case definition. We evaluate demographic information, clinical predictability, bacteriologic studies, echocardiographic findings, and outcomes associated with infective endocarditis in a population of intravenous drug users. Methods: This was a 3-year prospective cohort study of febrile (temperature ≥38.0°C) intravenous drug users presenting to an academic, inner-city emergency department (ED). Enrollment began in 1998 and included patients who were 18 years or older and able to consent. Initial evaluation consisted of a medical history and physical examination by the emergency physician, as well as diagnostic testing that included a minimum of 3 sets of blood cultures before the initiation of antibiotic therapy. Clinicians indicated level of suspicion for infective endocarditis according to ED assessment. Patients were admitted to a dedicated research unit housed by the Department of Medicine staff. Transthoracic echocardiography (TTE) was ordered immediately on admission. Patients with an identifiable source of infection were treated with an appropriate antibiotic, whereas others were treated empirically for infective endocarditis. Results: One thousand fifteen patients were screened for this study, 632 were enrolled, and 571 had complete data (blood cultures and TTE). Of patients with complete data, 96 had the discharge diagnosis of infective endocarditis. The mean age of these 96 patients was 38.51±7.98 years. Fifty-five episodes (57.3%) occurred in men and 41 (42.7%) in women. Black patients and white patients accounted for 87 (90.6%) and 9 (9.4%) cases, respectively. Patients with a discharge diagnosis were not significantly different than the patients without infective endocarditis in terms of age, sex, or race. Of infective endocarditis–positive patients with complete data, 36% had a previous episode of infective endocarditis, whereas 23% of patients who were infective endocarditis–negative had a history of infective endocarditis ( P =.015). Clinical assessment by medical history and physical examination alone for identifying patients with infective endocarditis had a sensitivity of 0.37 (95% confidence interval [CI] 0.26 to 0.48) and specificity of 0.87 (95% CI 0.85 to 0.89). Ninety (93.8%) of 96 patients had positive blood culture findings, and 93.3% were positive in the first 24 hours. Sensitivity and specificity of positive bacteriologic findings were 0.94 (95% CI 0.87 to 0.97) and 0.77 (95% CI 0.76 to 0.78), respectively. Eighty-seven (90.6%) of 96 patients had a significant TTE finding. Sensitivity and specificity of any positive echocardiographic finding were 0.91 (95% CI 0.83 to 0.95) and 0.46 (95% CI 0.44 to 0.47), respectively. The median length of stay for patients with a discharge diagnosis of infective endocarditis was 11 days, with a mode of 9 days. For patients with a non–infective endocarditis discharge diagnosis, the median and mode length of stay were 3 and 2 days, respectively. Forty (41.7%) of the patients with infective endocarditis had at least 1 complication during their hospitalization, with embolic events being most prevalent and occurring in 29 patients (30.0%). Furthermore, 37% of infective endocarditis patients in this study were rehospitalized, and 8.3% died during this admission or within 90 days of being discharged for their infective endocarditis. Conclusion: Infective endocarditis is a significant cause of morbidity and mortality that is difficult to diagnose in a febrile intravenous drug user according to initial ED evaluation. Even with a high level of suspicion, emergency physicians identify only a small percentage of patients who eventually have infective endocarditis. Bacteriologic and echocardiographic findings are highly sensitive in detecting infective endocarditis. In fact, blood culture and TTE combined were able to identify all but 1 patient with a discharge diagnosis of infective endocarditis in our study. These findings support the current practice of hospitalizing all intravenous drug users presenting to the ED with fever for further diagnostic evaluation. Positive blood cultures within 24 hours in patients with infective endocarditis strongly argue for future investigations to develop novel approaches to rapidly evaluate at-risk patients in a short-stay setting.

Surgical pathology of infected aneurysms of the descending thoracic and abdominal aorta: Clinicopathologic correlations in 29 cases (1976 to 1999)

Infected aortic aneurysms are uncommon, and only rarely have their surgical pathological features been described. Clinical and histopathologic features were evaluated in patients undergoing surgical repair of infected aneurysms of the descending thoracic or abdominal aorta over a 24-year period. Findings were compared with observations (primarily from autopsy studies) from the previous 25-year period (1950 to 1975) and other more recent reports. Of the 29 patients in our study, 79% were men, 90% had risk factors for atherosclerosis, and 72% had an identifiable risk or source of infection. Fever was present in 76%, and abdominal or back pain was seen in 66%. Among the 20 cases with an identifiable causative organism, staphylococcus accounted for 30%, streptococcus for 20%, salmonella for 20%, Escherichia coli for 15%, and other organisms for 15%. Aneurysms were saccular in 59% and infrarenal in 42%, and had a mean diameter of 5.6 cm. Microscopically, 6 patterns were recognized: acute inflammation superimposed on severe chronic atherosclerosis (55%), atherosclerosis with chronic inflammation (20%), acute inflammation without atherosclerosis (7%), chronic adventitial inflammation (7%), pseudoaneurysm formation (7%), and necrotizing granulomatous inflammation (4%). Special stains for organisms were positive in only 38% of the cases. Pathological findings of this series of surgical specimens spanning the fourth quarter of the twentieth century were not appreciably different from those described in autopsy series from the preceding years, although the causative microorganisms and agents used to treat them, preoperative diagnostic modalities, and surgical approaches have evolved.

Efficacy of Early Steroid Therapy in Acute Interstitial Pneumonia

Background : Steroid therapy has been shown to improve the clinical outcome in acute respiratory distress syndrome (ARDS) patients with histological evidence of fibroproliferation in the lung tissue and no identifiable source of infection. Because the histopathological features of acute interstitial pneumonia(AIP) are identical with that of ARDS, early steroid therapy was used in AIP patients who had histological evidence of fibroproliferation in the lung tissue and no identifiable source of infection. We analyzed seven years of our experience to evaluate the efficacy of early steroid therapy in AIP. Materials and Methods : A retrospective review was performed on AIP patients who received steroid therapy within 7 days of mechanical ventilatory support in Dankook university Hospital between May 1995 and May 2002. AIP was diagnosed clinically by ARDS without a known cause of the etiology and pathologically by a lung biopsy showing a fibroproliferative stage of diffuse alveolar damage. The clinical response and physiologic parameters were evaluated during steroid therapy. Results : Five AIP patients received intravenous methylprednisolone (1-2 mg/kg every 6 hours) after days of mechanical ventilatory support. Lung biopsies were performed after days of mechanical ventilatory support. Four patients(80%) survived and were extubated after days of steroid therapy with improvement in the ratio ( at day 0 to at day 7) by steroid therapy. However, one patient(20%) died of respiratory failure after 15 days of steroid therapy. Conclusion : Early steroid therapy sppears to be beneficial in AIP patients without evidence of infection. However, as our study group was too small, further large scale studies to define the effectiveness of steroids are required.

Bacterial meningitis

With nearly 8,000 cases in the United States per year, and 2,000 deaths annually, bacterial meningitis continues to be a significant source of morbidity and mortality. The principal pathogens are Neisseria meningitidis, Streptococcus pneumoniae, group B streptococci, and Hemophilus influenzae. In immunocompromised patients, Listeria monocytogenes is also an important pathogen. Rapid identification and evaluation of the patient with bacterial meningitis and prompt initiation of antibiotics are the cornerstones of therapy. Except in the rare patient with papilledema, focal neurologic symptoms, or a seizure, a lumbar puncture should be performed without delay, and antibiotic therapy should be administered promptly. Patients without a readily identifiable source of infection should be treated empirically with intravenous ceftriaxone. Ampicillin should also be administered in populations at increased risk for L. monocytogenes. The risk of meningitis in some populations can be reduced by administration of vaccines against selected pathogens such as N. meningitidis, S. pneumoniae, and H. influenzae.

Occult Pneumonias: Empiric Chest Radiographs in Febrile Children With Leukocytosis

Study objective: We sought to determine the incidence of radiographic findings of pneumonia in highly febrile children with leukocytosis and no clinical evidence of pneumonia or other major infectious source. Methods: We conducted a prospective cohort study at a large urban pediatric hospital. Clinical practice guidelines for the use of chest radiography in febrile children were established by the emergency medicine attending staff. All records of emergency department patients with leukocytosis (WBC count ≥ 20,000/mm 3), triage temperature 39.0°C or higher, age 5 years or less were reviewed daily for 12 months. Physicians completed a questionnaire to note the diagnosis, the presence of respiratory symptoms and signs, and the reason for the chest radiograph (if one was obtained). Patients were excluded for immunodeficiency, chronic lung disease, or major bacterial sources of infection other than pneumonia. Pneumonia was defined by an attending radiologist’s reading of the radiograph. Results: We studied 278 patients. Chest radiographs were obtained in 225 for the following reasons: 79 because of respiratory findings suggestive of pneumonia and 146 because of leukocytosis and no identifiable major source of infection. Fifty-three patients did not undergo radiography. Pneumonia was found in 32 of 79 (40%; 95% confidence interval, 20% to 52%) of those with findings suggestive of pneumonia and in 38 of 146 (26%; 95% confidence interval, 19% to 34%) of those without clinical evidence of pneumonia. If patients who did not have a radiograph are assumed to not have pneumonia, the minimum estimate of occult pneumonia was 38 of 199 patients (19%; 95% confidence interval, 14% to 25%). Conclusion: Empiric chest radiographs in highly febrile children with leukocytosis and no findings of pneumonia frequently reveal occult pneumonias. Chest radiography should be considered a routine diagnostic test in children with a temperature of 39°C or greater and WBC count of 20,000/mm 3 or greater without an alternative major source of infection. [Bachur R, Perry H, Harper MB: Occult pneumonias: Empiric chest radiographs in febrile children with leukocytosis. Ann Emerg Med February 1999;33:166-173.]

Cirrhotic fever in the 1990s: a prospective study with clinical implications.

Fifty consecutive patients with fever and cirrhosis were prospectively studied to assess if cirrhotic fever was a true clinical entity and to determine its characteristics and outcome. In 20% (10) of the 50 patients, an identifiable source of fever or infection, was not documented (these patients were defined as having cirrhotic fever). The patients with cirrhotic fever were significantly less toxic, as indicated by lower temperature (P = .0001), tachycardia (P = .0005), and tachypnea (P = .05), but had fever for a longer duration (P = .009) than did patients with infectious fever. Patients with cirrhotic fever were significantly less likely to have focal signs or symptoms (P < .0001) or a portal of infection confirmed by culture (P = .0001), as compared with patients with infectious fever. Outcome (at 30-days or long-term) was not different for patients with cirrhotic fever vs.-patients with infectious fever or matched controls who did not have fever. Eight (80%) of the 10 patients with cirrhotic fever underwent transplantation; fever did not recur after transplantation in any of these patients. Thus, fever in up to 20% of the febrile patients with cirrhosis may be attributable to cirrhosis itself; such patients may be spared the ongoing diagnostic maneuvers and unnecessary trials of antibiotics.

Sudden ‘stroke-like’ onset of homonymous hemianopsia due to bacterial brain abscess

A previously healthy 40-year-old man experienced the sudden ‘stroke-like’ onset of homonymous hemianopsia due to a bacterial brain abscess. Clinical features and initial computed tomography (CT) suggested a stroke. Subsequent CT and magnetic resonance (MR) demonstrated a cerebral abscess, proven at surgery. It is extremely rare that a healthy individual without various risk factors, such as congenital heart disease, immunologic deficiency, diabetes mellitus, or pregnancy, presents with the above symptoms. The exact mechanism of this sudden ‘stroke-like’ onset in a patient with a bacterial brain abscess is unknown. One possibility is that paroxysmal septic emboli led to abscess formation within or near areas of embolic infarction. Another possibility is that a primary cerebral infarction was associated with secondary bacteremia. Surgical drainage revealed a bacterial ( Streptococcus) abscess, but no identifiable source of infection.

Central venous catheter-related infections

Central venous catheter-related infections

Cessation of Antibiotics Regardless of ANC Is Safe in Children with Febrile Neutropenia

This study was designed to evaluate the safety and efficacy of stopping antibiotic treatment regardless of absolute neutrophil count (ANC) or signs of impending neutrophil recovery in children with febrile neutropenia (FN) and no identifiable infectious source. Thirty-two consecutive cases of FN without identifiable source were prospectively evaluated. Patients were examined, cultured, and initially treated with ceftazidime +/- vancomycin. Antibiotics were discontinued and patients discharged regardless of ANC (WBC/microliter x [% segs + bands]) once all the following criteria were met: afebrile > or = 24 h; cultures negative at 48 h; thermometer and telephone available at home. Prompt notification of fever (T > 38.3 degrees C) and readmission were required. Median ANC was 60/microliters on admission and 160/microliters at discharge. Median length of treatment was 3 days. Four patients were readmitted for FN, and two patients were readmitted afebrile for cultures which became positive after discharge. None of the 32 cases suffered apparent complications from early discharge. Results of this preliminary trial suggest that cessation of antibiotics regardless of ANC is safe in cases of FN without identifiable source, provided that marrow is not infiltrated and that recurrent fever receives prompt antibiotic retreatment.

Clinical Aspects of Bacteremia in Medical and Surgical Intensive Care Units

Background: Intensive care units(ICUs) probably represent the single largest identifiable source of infection within the hospital. Although there are several studies on ICU infections in respect to their bacteriology or mortality rate for individual types of ICU, few studies have compared ICU infections between different types of ICU. The aim of this study was to identify clinical differences in bacteremia between medical ICU(MICU) and surgical ICU(SICU) patients. Methods: 256 patients with bacteremia were retrospectively evaluated. Medical records were reviewed to obtain the clinical and bacteriologic informations. Results: 1) The mean age of the patients with bacteremia of MICU() was greater than that of all MICU patients()(p, all SICU patients: )(p>0.05). ICU stay was longer(MICU patients: day, SICU patients: day) than the mean stay of all patients( day)(p

Intravenous drug abuse--the major route of hepatitis C virus transmission among alcohol-dependent individuals?

As the prevalence of hepatitis C virus (HCV) antibodies has been reported to be high among alcohol-dependent individuals, we screened prospectively 310 consecutive non-selected alcoholic outpatients for HCV and possible routes of transmission. Using a second-generation enzyme-linked immunosorbent assay test and retesting all positive sera with a second-generation recombinant immunoblot assay, we found the prevalence of anti-HCV to be 14.5% (45 of 310). Of the 45 anti-HCV-positive individuals, 39 (88.7%) had a history of intravenous drug abuse, 2 had received blood transfusions, and only 4 lacked an identifiable source of infection. The magnitude of alcohol consumption, number of hospital admissions, duration of alcohol dependence, or presence of tattooing could not be shown to be factors of importance for the transmission of HCV infection. Our results suggest that a history of intravenous drug abuse is a common phenomenon and the predominant route of HCV transmission among alcoholics. True community-acquired infection would appear to be rare.

Fever, Hyperdynamic Shock, and Multiple-System Organ Failure: A Pseudo-sepsis Syndrome Associated with Chronic Salicylate Intoxication

To describe a sepsis-like syndrome associated with chronic salicylate intoxication.Retrospective clinical study.University-affiliated county hospital.Five patients who became accidentally intoxicated while ingesting salicylates on a long-term daily basis.All five salicylate-intoxicated patients had clinical and laboratory features that were highly suggestive of sepsis, but no bacteriologic or pathologic evidence of infection could be documented. Features included fever, leukocytosis with increased band forms, hypotension with a reduced SVR and multiple system organ failure (ARDS, encephalopathy, renal failure, and DIC). A diagnosis of salicylate intoxication was made at the time of admission to the hospital in only one case. In the other four cases, the presumptive diagnosis was sepsis; a correct diagnosis of salicylate intoxication was not established until between 16 h and 10 days after admission in these four cases. Two patients died, one patient required permanent hemodialysis, and two patients recovered fully only after prolonged and complicated hospitalizations. The pathogenesis of this syndrome is uncertain. In two cases, serum levels of TNF-alpha, IL-1 beta and IL-6 were measured by ELISA. In both cases serum IL-6 was markedly increased, and in one case serum TNF-alpha was also elevated.Occult salicylate intoxication should be considered when apparent sepsis syndrome occurs without a readily easily identifiable source of infection.

What's new in infectious diseases

Hepatitis C Virus The term non-A, non-6 (NANB) hepatitis has been used for the past decade or so to include those acute hepatitic illnesses that clearly are not related to infection with hepatitis A virus, hepatitis B virus, cytomegalovirus, or Epstein-Barr virus. NANB hepatitis accounts for an estimated 150,000 cases yearly in the United States, of which 5% to 10% are transfusion-related; 40% are associated with intravenous drug abuse; 5%, with occupational (health care) exposure; and lo%, with heterosexual activity with multiple partners, or household and/or sexual contact with an individual with hepatitis. Forty percent are without an identifiable source of infection. It has been clearly established that a prolonged NANB hepatitis carrier state develops frequently and, more importantly, that chronic hepatitis may develop in about half of patients with NANB hepatitis. Twenty percent of the latter group progress to cirrhosis. In addition, NANB hepatitis may be causally related to hepatocellular carcinoma and to sporadic community-acquired hepatitis. Until recently, attempts to identify a specific viral agent that could be associated with significant numbers of cases of NANB hepatitis had been frustrating and unsuccessful. Choo and associates, using techniques of modern molecular biology and working with sera capable of transmitting NANB hepatitis to primates, isolated a cDNA clone derived from the genome of a blood-borne NANB hepatitis agent.’ This agent, the hepatitis C virus (HCV), is thought to be an RNA virus, probably related to the togaviruses or flaviviruses. An assay for measuring antibodies to this agent was quickly developed,2 and there has been a veritable explosion of related knowledge. It has already been established that HCV is the major cause of posttransfusion NANB hepatitis. Screening of blood donors for antibody to HCV should prevent the majority of such cases and has recently been instituted. In addition, HCV appears to be the etiologic agent of up to 90% of sporadic, community-acquired NANB hepatitis that occurs in patients without a history of parenteral exposure. Studies of sera from patients in Italy and Japan, as well as from those in the United States, have confirmed HCV as a major cause of NANB hepatitis worldwide. Development of anti-HCV antibody is delayed, being first detected an average of 22 weeks after transfusion, or some 15 weeks after onset of clinical hepatitis. It is important to note that some patients do not become seropositive for anti-HCV until as long as 1 year after infection. 3 In patients with chronic liver disease, antiHCV has persisted, but in patients with acute resolving hepatitis, anti-HCV disappeared after approximately 4 years. Treatment trials that utilized interferon alfa for patients with chronic hepatitis C have shown promising results.4 We can expect much additional data to be generated in the next few years to elucidate more fully the impact of HCV. A readily available diagnostic test for anti-HCV has been developed and is now widely available.

Comparison of Clinical Characteristics in Myogenic, TMJ Internal Derangement and Atypical Facial Pain Patients

Temporomandibular joint (TMJ) disorders have been collectively grouped as myofascial pain-dysfunction syndrome (MPDS) or temporomandibular joint dysfunction syndrome (TMJDS). In the past, these terms have been used synonomously to describe a set of clinical signs and symptoms that include pain in the TMJ and muscles of mastication, limited or deviant opening of the mandible, and/or joint sounds. The present study segregated two major subgroups subsumed within this diagnostic classification and assigned them to a myogenic facial pain (MFP) group and a TMJ internal derangement (TMJID) group. Previous studies may have included both of these disorders as MPDS/TMJDS. While some signs and symptoms are similar, the primary differentiation is based on meniscus displacement present with TMJID patients and pain distribution patterns between the two groups. While MFP/TMJID patients comprise the majority of the facial pain population, a third major group of patients is encountered, being classified under the diagnostic appellation of atypical facial pain (AFP). Patients with AFP usually complain of vague and wandering pain in the maxilla or mandible; however, no identifiable source of infection or organic disease can be uncovered. One hundred fifty patients seeking consultation and care for facial pain met the criteria for inclusion into one of three clinical groups. The groups were compared for age, sex, duration of symptoms, bruxism and/or clenching habits, and disturbed sleep patterns. Differences in surface electromyographic levels from the facial and cervical muscles were also examined. Minnesota Multiphasic Personality Inventory (MMPI) scores from 95 subjects were compared with self-report measures of depression and anxiety. It was concluded that subcategorization of myofascial pain dysfunction patients into a MFP and TMJID group is justified on the basis of psychometric differences, clenching habits, masseter EMG levels, and male:female ratio. Furthermore, psychopathological factors are more significant among MFP and AFP subjects than TMJID patients.

Intra-abdominal sepsis following liver trauma.

Of 330 consecutive patients with liver trauma having a celiotomy over a 5-year period, 295 (89%) survived more than 72 hours. Of these 295, 35 (12%) developed sepsis, and 11 (31%) of these septic patients died. The sources of the sepsis in 30 of these patients included: abdominal abscesses--23, pneumonia or empyema--seven, acalculous cholecystitis--two, gangrene of right colon--two, and thigh abscess--one. In five other patients, the source of the sepsis was not found, even at autopsy. The mortality rate in the 30 patients with one or more identifiable foci of infection was 23%. In contrast, when the source of the sepsis could not be found, the mortality rate was 80% (4/5) (p less than 0.05). Factors associated with an increased incidence of abdominal abscess included: splenectomy, 75% (3/4); liver packs, 63% (5/8); 20+ units of blood, 57% (8/14); Class IV-V liver injury, 35% (8/23); 10-19 units of blood, 25% (7/28); colon injury, 19% (7/36); and open (Penrose) drainage of the abdomen, 11% (23/213). None of 82 patients without drains developed an intra-abdominal abscess. Thus early control of an identifiable source of infection provides the best results with sepsis following liver trauma. The most effective method for preventing intra-abdominal abscesses appears to be avoidance of drains in mild (Class I-II) liver injuries. The use of a closed system in the most severe injuries is still controversial and needs to be addressed in a prospective trial.

Deep-wound infection after total hip replacement under contemporary aseptic conditions.

The role of the combination of perioperative antibiotics, laminar air-flow operating rooms, and body-exhaust systems in reducing the incidence of deep-wound sepsis after total hip replacement remains controversial. We evaluated the incidence of deep-wound infection as associated with the magnitude of the operation in 575 patients (659 procedures) who had all three methods of prophylaxis. The same surgeon performed all of the operations. The procedures were divided into five groups, according to the complexity of the operation and the need for major bone-grafting. Only one patient (who had previously had an infection) had early sepsis. After the 376 standard primary operations, the over-all incidence of sepsis (early and late) was 0.38 per cent. No infection occurred after fifty-four complex primary operations without femoral-head autografting. After fifty-nine complex primary operations with femoral-head autografting, three patients had a late deep infection. No infection occurred within two years after the 170 revision operations. There was no late infection after the 104 revisions without major bone-grafting, but late sepsis developed in two patients after the sixty-six revisions with major bone-grafting. Of the total of six cases of late infection in five patients, five had an identifiable source of infection that was extrinsic to the wound. The incidence of early postoperative sepsis after total hip replacement, even complex primary total hip replacement and revision, was extremely low when using the three contemporary methods of prophylaxis for infection.(ABSTRACT TRUNCATED AT 250 WORDS)