RESUMO
Widening of the supravalvular aorta by means of a lozenge-shaped dacron patch was performed in 9 cases of stenosis and/or aorta insufficiency. Marked improvement was noted in the 8 patients followed up: the transvalvular gradient was not significant and neither haemolytic anaemia nor hyperhaemolysis were present. This expedient is both useful and indicated in cases where the calibre of the descending aorta is small.
Assuntos
Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Prótese Vascular , Próteses Valvulares Cardíacas , Adolescente , Adulto , Humanos , Pessoa de Meia-IdadeAssuntos
Comunicação Interatrial , Adolescente , Adulto , Criança , Diagnóstico Diferencial , Eletrocardiografia , Feminino , Comunicação Interatrial/embriologia , Humanos , Masculino , MétodosAssuntos
Tetralogia de Fallot/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , Eletrocardiografia , Feminino , Seguimentos , Humanos , Lactente , Masculino , Radiografia TorácicaRESUMO
Recent studies of the human Pneumocystis carinii dihydropteroate synthase (DHPS) gene suggest that P. carinii is developing resistance to sulfamethoxazole (SMX) and dapsone. To explore whether P. carinii is also developing resistance to trimethoprim (TMP), the human P. carinii dihydrofolate reductase (DHFR) gene was cloned, DHFR and DHPS genes in 37 P. carinii isolates from 35 patients were sequenced, and the relationship between TMP-SMX or dapsone use and gene mutations was analyzed. The DHFR gene sequences were identical in all isolates except 1 with a synonymous substitution. In contrast, the DHPS gene sequences showed mutations in 16 of the 37 isolates; prior sulfa/sulfone prophylaxis was associated with the presence of these mutations (P<.001). In addition to suggesting that there is less selective pressure on DHFR than on DHPS, this study reinforces the hypothesis that mutations in the DHPS gene are likely involved in the development of sulfa resistance in P. carinii.
Assuntos
Dapsona/uso terapêutico , Di-Hidropteroato Sintase/genética , Pneumocystis/enzimologia , Tetra-Hidrofolato Desidrogenase/genética , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , Sequência de Aminoácidos , Animais , Anti-Infecciosos/uso terapêutico , Clonagem Molecular , Dapsona/farmacologia , Di-Hidropteroato Sintase/metabolismo , Resistência Microbiana a Medicamentos/genética , Genes Fúngicos , Humanos , Dados de Sequência Molecular , Mutação , Pneumocystis/efeitos dos fármacos , Pneumocystis/genética , Pneumonia por Pneumocystis/tratamento farmacológico , Pneumonia por Pneumocystis/prevenção & controle , Ratos , Alinhamento de Sequência , Análise de Sequência de DNA , Tetra-Hidrofolato Desidrogenase/metabolismo , Combinação Trimetoprima e Sulfametoxazol/farmacologiaRESUMO
A number of methicillin-resistant Staphylococcus aureus (MRSA) isolates were recovered over a period of several weeks from blood samples and from the heart valve of a patient who underwent extensive vancomycin chemotherapy for persistent S. aureus bacteremia. Consecutive isolates showed gradually decreasing growth rates during in vitro cultivation and increasing vancomycin MICs, from an MIC of 1 micro g/ml for the initial isolate to an MIC of 8 micro g/ml for the final MRSA isolates, which also became tolerant to vancomycin. Major changes were observed in the oxacillin resistance phenotype of several of the isolates-apparently related to in vivo exposure to imipenem, which was also used during a period of chemotherapy. Both the gradually increasing vancomycin MICs and the changes in oxacillin resistance could be reproduced by appropriate exposure of the initial MRSA isolate to antibiotics in vitro. All isolates had the same pulsed-field gel electrophoresis pattern, spaA type, and multilocus sequence type (MLST), which was identified as a single-locus variant of ST5, the MLST characteristic of previously characterized MRSA isolates with reduced susceptibility to vancomycin in the United States and Japan.
Assuntos
Bacteriemia/tratamento farmacológico , Farmacorresistência Bacteriana , Infecções Estafilocócicas/tratamento farmacológico , Staphylococcus aureus/efeitos dos fármacos , Vancomicina/uso terapêutico , Antibacterianos/farmacologia , Bacteriemia/microbiologia , Evolução Molecular , Humanos , Resistência a Meticilina , Testes de Sensibilidade Microbiana , Fenótipo , Infecções Estafilocócicas/microbiologia , Staphylococcus aureus/classificação , Staphylococcus aureus/genética , Staphylococcus aureus/crescimento & desenvolvimento , Vancomicina/farmacologiaRESUMO
On October 9, 2001, a letter containing anthrax spores was mailed from New Jersey to Washington, DC. The letter was processed at a major postal facility in Washington, DC, and opened in the Senate's Hart Office Building on October 15. Between October 19 and October 26, there were 5 cases of inhalational anthrax among postal workers who were employed at that major facility or who handled bulk mail originating from that facility. The cases of 2 postal workers who died of inhalational anthrax are reported here. Both patients had nonspecific prodromal illnesses. One patient developed predominantly gastrointestinal symptoms, including nausea, vomiting, and abdominal pain. The other patient had a "flulike" illness associated with myalgias and malaise. Both patients ultimately developed dyspnea, retrosternal chest pressure, and respiratory failure requiring mechanical ventilation. Leukocytosis and hemoconcentration were noted in both cases prior to death. Both patients had evidence of mediastinitis and extensive pulmonary infiltrates late in their course of illness. The durations of illness were 7 days and 5 days from onset of symptoms to death; both patients died within 24 hours of hospitalization. Without a clinician's high index of suspicion, the diagnosis of inhalational anthrax is difficult during nonspecific prodromal illness. Clinicians have an urgent need for prompt communication of vital epidemiologic information that could focus their diagnostic evaluation. Rapid diagnostic assays to distinguish more common infectious processes from agents of bioterrorism also could improve management strategies.
Assuntos
Antraz/diagnóstico , Bacillus anthracis/isolamento & purificação , Bioterrorismo , Infecções Respiratórias/microbiologia , Esporos Bacterianos/isolamento & purificação , Dor Abdominal/complicações , Antraz/sangue , Antraz/fisiopatologia , Antraz/terapia , Antibacterianos/uso terapêutico , Sangue/microbiologia , Bradicardia/etiologia , District of Columbia , Dispneia/complicações , Evolução Fatal , Febre/complicações , Parada Cardíaca/etiologia , Homicídio , Humanos , Leucocitose , Masculino , Mediastinite/diagnóstico por imagem , Pessoa de Meia-Idade , Náusea/complicações , Exposição Ocupacional , Derrame Pleural/diagnóstico por imagem , Serviços Postais , Radiografia Torácica , Respiração Artificial , Infecções Respiratórias/sangue , Infecções Respiratórias/diagnóstico , Infecções Respiratórias/fisiopatologia , Infecções Respiratórias/terapia , Taquicardia/etiologia , Tomografia Computadorizada por Raios XRESUMO
Pneumocystis carinii pneumonia (PCP) can be diagnosed by direct microscopic examination of induced sputum or by bronchoalveolar lavage (BAL). However, many institutions have little diagnostic success with induced sputum, and BAL is invasive and expensive. This prospective, blinded study assessed oral washes as a more convenient specimen than either sputum or BAL fluid and used a dissociation-enhanced lanthanide fluoroimmunoassay time-resolved fluorescent hybridization polymerase chain reaction (PCR) detection system that is feasible for clinical laboratories. The study assessed 175 oral washes, each paired with either an induced sputum that was positive for Pneumocystis or a BAL sample. The PCR test based on the Pneumocystis major surface glycoprotein primers had a sensitivity of 91% and a specificity of 94%, compared with a test based on mitochondrial large subunit rRNA primers, which had a sensitivity of 75% and a specificity of 96%. These results suggest that oral washes can provide a useful sample for diagnosis of PCP when a sensitive PCR detection system is used.