Nasopharyngeal carriage of Haemophilus influenzae type b: attempted eradication by cefaclor or rifampin.

The efficacy of cefaclor and rifampin in eradicating Haemophilus influenzae type b (HITB) from the nasopharynx of day care center and household contacts of children with HITB meningitis was evaluated. In 38/50 children treated with cefaclor, the carrier state persisted, a failure rate of 76%. Although cefaclor failed to eradicate HITB from many carriers, an appreciable reduction in the intensity of colonization following treatment was noticed. When rifampin was used in 17 children who had failed to respond to cefaclor, persistence of the carrier state with HITB was found in only two children, a failure rate of only 12%. During the study, two episodes of invasive HITB disease were documented to be acquired from sources other than the index cases or from children who were screened, which suggested the need to reevaluate the usually recommended strategy to screen for carriage and to treat only the immediate contacts 6 years of age and younger. Furthermore, the most appropriate agent for eradicating nasopharyngeal carriage of HITB awaits additional studies.

Clinical and urodynamic predictors of delayed voiding after fascia lata suburethral sling.

OBJECTIVE: To determine the time to resumption of normal voiding after a fascia lata sling and whether any clinical, operative, or urodynamic variables predict it. METHODS: Between January 1993 and September 1996, 62 women underwent fascia lata suburethral sling operations for intrinsic sphincter deficiency or recurrent stress incontinence. The demographic, operative, and urodynamic data of 61 of these patients were analyzed. RESULTS: The mean number of days to resumption of normal voiding was ten. Three patients (5%) developed permanent retention. Patients 65 years and older were more likely than younger patients to have prolonged catheterization (16 versus 7 days, P=.008). Women who had additional procedures voided at a mean of 15 days compared to nine days for those having slings only (P=.029). A preoperative urine flow rate less than 20 mL/sec was associated with late voiding. There was no significant relationship between preoperative voiding mechanism and voiding time. CONCLUSION: Resumption of normal voiding occurred earlier than reported by others. Age over 65 years, additional surgical procedures, and low peak flow rates were risk factors for delayed voiding. Time to normal voiding was independent of the preoperative voiding mechanism.

Patients evaluated for venous disease may have other pathologic conditions contributing to symptomatology.

Of the more than 200 patients recently evaluated for venous disease, 8 were diagnosed with lower extremity masses. Three patients were referred for superficial phlebitis and four for deep venous obstructive disease. The eighth mass was found during work-up for varicose veins. Five masses were identified by palpation, and three were identified by duplex scan. All were confirmed by magnetic resonance imaging (MRI) or computed tomography (CT). Of the eight masses, three were malignant: a metastatic melanoma, a histiocytoma, and a myxoid liposarcoma. Nonmalignant masses included a hematoma, an inflammatory lesion, a hemangioma, and an intramuscular lipoma. One patient presented with deep venous thrombosis secondary to an occluded popliteal artery aneurysm compressing the popliteal vein. Thus, patients presenting with ostensible venous disease may have other pathologic conditions responsible for symptomatology. Careful physical examination will reveal a mass in a majority of patients who have one. Duplex scanning will identify masses that should be confirmed by MRI or CT. Definitive diagnosis should be made by biopsy, due to the high possibility of malignancy.

Primary care physician job satisfaction and turnover.

OBJECTIVE: To examine the relationship of personal characteristics, organizational characteristics, and overall job satisfaction to primary care physician (PCP) turnover. SUBJECTS AND METHODS: A cohort of 507 postresident, nonfederally employed PCPs younger than 45 years of age, who completed their medical training between 1982 and 1985, participated in national surveys in 1987 and 1991. Psychological, economic, and sociological theories and constructs provided a conceptual framework. Primary care physician personal, organizational, and overall job satisfaction variables from 1987 were considered independent variables. Turnover-related responses from 1991 were dependent variables. Bivariate and multivariate analyses were conducted. RESULTS: More than half (55%) of all PCPs in the cohort left at least 1 practice between 1987 and 1991. Twenty percent of the cohort left 2 employers. PCPs dissatisfied in 1987 were 2.38 times more likely to leave (P < .001). Primary care physicians who believed that third-party payer influence would decrease in 5 years were 1.29 times more likely to leave (P < .03). Non-board certified PCPs were 1.3 times more likely to leave (P < .003). Primary care physicians who believed that standardized protocols were overused were 1.18 times more likely to leave (P < .05). Specialty, gender, age, race, and practice setting were not associated with PCP turnover. CONCLUSIONS: Turnover was an important phenomenon among PCPs in this cohort. The results of this study could enable policy makers, managed care organizations, researchers, and others to better understand the relationship between job satisfaction and turnover.

Estimates of costs of primary care physician turnover.

OBJECTIVE: To provide estimates of the institutional costs associated with primary care physician (PCP) turnover (job exit). SUBJECTS AND METHODS: A cohort of 533 postresident, nonfederal, employed PCPs younger than 45 years of age, in practice between 2 and 9 years, participated in national surveys in 1987 and 1991. Data from a national study of physician compensation and productivity and data from physician recruiters were combined with PCP cohort data to estimate recruitment and replacement costs associated with turnover. RESULTS: By the time of the 1991 survey, slightly more than half (n = 279 or 55%) of all PCPs in this cohort had left the practice in which they had been employed in 1987; 20% (n = 100) had left 2 employers in that same 5-year period. Among those who left, self-designated specialties and proportions were general/family practice (n = 104 or 37%); general internal medicine (n = 91 or 33%); and pediatrics (n = 84 or 30%). Estimates of recruitment and replacement costs for individual PCPs for the 3 specialties were $236,383 for general/family practice, $245,128 for general internal medicine, and $264,645 for pediatrics. Turnover costs for all PCPs in the cohort by specialty were $24.5 million for general/family practice, $22.3 million for general internal medicine, and $22.2 million for pediatrics. CONCLUSIONS: Turnover was an important phenomenon among the PCPs in this cohort. This turnover has major fiscal implications for PCP employers because loss of PCPs causes healthcare delivery systems to lose resources that could otherwise be devoted to patient care.

Managed care and primary care physicians' overall career satisfaction.

Salaried employment among primary care physicians (PCPs) is becoming the rule rather than the exception. Because of this trend, the consequences of employment, types of practice revenues and overall career satisfaction will have the greatest impact on this group, their employers, and the populations they serve. This article examines the relationship between managed care contracts, managed care revenues and salaried PCP overall career satisfaction. Proportion of practice revenues from managed care and types of managed care contracts were associated with PCP overall career satisfaction. The implications of these findings and their importance to PCP turnover are discussed.

In vitro development of rifampin resistance in clinical isolates of Haemophilus influenzae type b.

Although all of 14 clinical isolates of Haemophilus influenzae type b strains demonstrated rifampin susceptibility in vitro (minimal inhibitory concentration less than or equal to 0.4 microgram/ml) when an inoculum of 10(4) colony-forming units (CFU) was used, 10 of the 14 strains manifested resistance to this agent when an inoculum of 10(8) CFU was tested. The mutation rate for rifampin resistance ranged from 1 resistant colony per 3.5 x 10(6) CFU to 1 per 4 x 10(7) CFU. The emergence of rifampin-resistant mutants was prevented when trimethoprim was combined with rifampin. This finding suggests that when used alone for prophylaxis of H. influenzae type b nasopharyngeal carriers, rifampin is likely to lead to the emergence of resistant strains.

A study of former patients placed in private proprietary homes.

The authors report on a study of 1999 residents of 26 private proprietary homes for adults in the metropolitan New York City area; 76 per cent of the residents were former psychiatric inpatients. The former patients were compared with the other residents in areas of physical and psychiatric functioning and social performance; the former patients showed more dysfunction due to psychological problems than the other residents, who tended to be older and suffer from physical problems. The former patients were also categorized into three groups according to whether their needs were considered greater than, less than, or consistent with the level of services provided in the homes; the results suggest that a substantial proportion of former patients may be more appropriately placed in other facilities.

Radioenzymatic assay for trimethoprim in very small serum samples.

A modification of the methotrexate radioassay kit (supplied by New England Enzyme Center) enabled determination of trimethoprim levels in 5-microliter serum samples. An excellent correlation between this assay and high-pressure liquid chromatography assay was found. These preliminary results suggest that with this method rapid determination of trimethoprim levels in very small samples (5 to 10 microliters) can be achieved.

Leak-point pressure: clinical application of values at two different volumes.

A prospective analysis of 306 consecutive patients with genuine stress incontinence was performed to evaluate the clinical usefulness of additional leak-point pressure (LPP) determination at 200 ml. LPP values at both volumes were compared to maximal urethral closure pressure (MUCP) in an attempt to determine a critical cut-off value for the detection of a low MUCP (< or =20 cmH2O). A positive LPP at 150 ml was found in 157 patients. The mean LPP for patients with a low MUCP was 58.5 cmH2O compared to 71.6 for those with a normal MUCP, which was statistically significant (p = 0.01). The correlation coefficient between LPP and MUCP was 0.317. A negative LPP was found in 30% (24/79) of the total having a low MUCP. The addition of values for LPP at 200 ml resulted in an increase in the number who leaked to 191, a 50% increase in the detection rate of low MUCP and a statistically significant relationship between LPP < or =60 cmH2O and low MUCP. Various critical cut-off values for LPP demonstrated good specificity but poor sensitivity for the detection of a low MUCP. It was concluded that there was a statistically significant relationship between LPP and MUCP. Performing LPP at 200 ml provides additional clinically useful diagnostic information.

Urethral instability: clinical and urodynamic characteristics.

Filling cystometry was performed on 397 patients with lower urinary tract complaints. The overall prevalence of urethral instability was 12.6% (50/397). Of these 187 patients had detrusor instability (DI). Within the DI group, clinical and urodynamic characteristics were compared. Patients with an unstable urethra had a shorter functional urethral length (P = 0.005). For those with DI, 28 of 187 (15%) had urethral instability. Forty (21%) women had a decrease in maximal urethral pressure that preceded the detrusor contraction (type II DI). When those with type II DI were excluded, the difference in functional urethral length was not observed. Patients with type II DI experienced an earlier sensation of fullness of 228 mL compared with 283 mL for the other patients with DI (P = 0.001). There was a positive association between urethral instability and type II DI. Four different patterns of urethral pressure changes were observed. Based on these findings, it appears that a urethral abnormality may be the primary disorder in patients with type II DI. The differentiation of the various subtypes of urethral instability and DI might be important for directing therapy.

In vitro and in vivo synergism between amoxicillin and clavulanic acid against ampicillin-resistant Haemophilus influenzae type b.

Eight strans of ampicillin-resistant beta-lactamase-producing Haemophilus influenzae type b were studied in vitro for synergy between amoxicillin and clavulanic acid. The minimal inhibitory concentrations for amoxicillin alone were 6.25 to 12.5 microgram/ml, and for clavulanic acid alone they were 12.5 to 25 microgram/ml. However, seven of eight strains were inhibited by a combination of 0.36 microgram of amoxicillin and 0.36 microgram of clavulanic acid per ml. Infant rat models of bacteremia and meningitis were used to test the efficacy of amoxicillin and clavulanic acid alone and in combination upon four strains of ampicillin-resistant H. influenzae. Neither amoxicillin alone (27 animals) nor clavulanic acid alone (20 animals) sterilized the blood or cerebrospinal fluid of the animals. In contrast, 30 of 33 blood cultures and 29 of 33 cerebrospinal fluid cultures were sterile when a combination of the two drugs in the same dosages was used. The observed in vitro and in vivo synergism between amoxicillin and clavulanic acid suggests that the combination may be effective therapy for invasive infections in humans caused by ampicillin-resistant H. influenzae type b.

Regional/local anesthesia: a safe and reasonable choice for patients undergoing carotid endarterectomy.

PURPOSE: The study compares the outcome of carotid endarterectomy in the community hospital setting using regional versus general anesthesia. METHODS: Two hundred thirty-six consecutive operations performed on 200 patients (99 operations using superficial and deep cervical block with local supplementation, and 137 procedures using general anesthesia) during a three-year period were analyzed retrospectively. Noncontinuous data were analyzed using Pearson chi-square, continuous data using Student's t-test. RESULTS: Demographic data and risk factors were similar for both groups. However, patients in the regional anesthesia group had a higher incidence of contralateral stroke and a lower incidence of peripheral vascular disease than patients in the general anesthesia group. Shunts were used less frequently for the regional anesthesia group. The neurologic complication rate was 2.2% for the general anesthesia group and 2.0% for the regional anesthesia group. The single death (fatal stroke) occurred in the general anesthesia group. Four of five major cardiopulmonary complications occurred in the general anesthesia group. CONCLUSIONS: Carotid endarterectomy can be performed with an acceptable neurologic complication rate under either type of anesthesia. Use of regional anesthesia decreases intraoperative shunting and may decrease the rate of cardiopulmonary complications.

Correlation of symptoms with location and severity of pelvic organ prolapse.

OBJECTIVE: The purpose of this study was to compare the symptoms that are related to pelvic floor dysfunction with the location and severity of the coexisting prolapse. STUDY DESIGN: Two hundred thirty-seven consecutive patients with symptomatic pelvic organ prolapse came to Johns Hopkins Medicine during a 24-month period beginning in July 1998 and completed a symptom-specific Likert scale questionnaire that included standardized questions that were compiled from commonly used validated instruments. All questionnaires were completed by the patients before they were seen by a physician. Further evaluation included a standardized physical examination that included the International Continence Society's system for grading uterovaginal prolapse. Symptoms were categorized according to both severity and associated anatomic compartment. Symptoms that were related to urinary and anal incontinence and voiding, defecatory, sexual, and pelvic floor dysfunction were analyzed with respect to location and severity of pelvic organ prolapse with the use of the nonparametric correlation coefficient, Kendall's tau-b. RESULTS: The mean age of the women was 57.2 years (range, 23-93 years); 109 of the women (46%) had undergone hysterectomy. Overall, stage II was the most common pelvic organ prolapse (51%) that was encountered. In 77 patients (33%), anterior compartment pelvic organ prolapse predominated; 46 patients (19%) demonstrated posterior compartment prolapse, whereas 26 patients (11%) had apical prolapse. In 88 patients (37%), no single location was more severe than another. Voiding dysfunction that was characterized by urinary hesitancy, prolonged or intermittent flow, and a need to change position was associated with the increasing severity of anterior and apical pelvic organ prolapse. Pelvic pressure and discomfort along with visualization of prolapse were strongly associated with worsening stages of pelvic organ prolapse in all compartments. Defecatory dysfunction characterized by incomplete evacuation and digital manipulation was associated with worsening posterior compartment pelvic organ prolapse. Impairment of sexual relations and duration of abstinence were strongly associated with worsening pelvic organ prolapse. An inverse correlation was observed between increasing severity of pelvic organ prolapse and urinary incontinence and enuresis. CONCLUSION: Women with pelvic organ prolapse experience symptoms that do not necessarily correlate with compartment-specific defects. Increasing severity of pelvic organ prolapse is weakly to moderately associated with several specific symptoms that are related to urinary incontinence and voiding, defecatory, and sexual dysfunction.

Evaluation of the gemini infusion pump for the safe delivery of peripheral blood progenitor cells (stem cells).

The purpose of this in vitro study was to determine whether the Gemini PC-2TX infusion pump could safely deliver peripheral stem cells (PSC) for an autologous PSC transplant. For purposes of hypothesis testing, it was assumed that there would be no significant difference in CD34+ cell counts and colony-forming units-granulocyte, macrophage (CFU-GM) when the PSCs were administered by an IMED PC-2TX infusion pump as opposed to an intravenous push method. The American Red Cross collected 50-ml samples of PSCs from four donors by apheresis. These cells were tested for CD34+ using flow cytometry and for functional progenitor cells using a CFU-GM assay. The cells were cryopreserved after testing. For our study, samples were tested simultaneously at a single facility. Each sample was individually thawed and a baseline thaw sample collected; 10 ml of the donor specimen was pushed through a syringe into a specimen container (intravenous push sample). The remainder of the specimen was infused through the IMED Gemini PC-2TX pump into a specimen container (intravenous pump sample). All samples were assayed for CD34+ cell counts and CFU-GM. Data analyses were conducted using the t-test for paired samples, with values of P < 0.05 considered significant. Results failed to demonstrate a statistically significant difference between the CD34+ or CFU-GM results of the intravenous push and intravenous pump specimens. Additionally, we failed to find a statistically significant difference when we compared the intravenous push and the intravenous pump specimens with the baseline thaw sample. The results of this study support the hypothesis that the Gemini PC-2TX infusion pump can safely deliver PSCs for the purposes of stem cell transplantation.

Outcome of carotid endarterectomy performed at a community medical center.

From 1990 to 1992 there was a 43% increase in the number of carotid endarterectomies (CEAs) performed at our institution. Not coincidentally the North American Symptomatic Carotid Endarterectomy Trial study was published in August 1991. To determine whether CEAs could be performed safely at community medical centers, records of 181 consecutive CEAs performed during a 30-month period at a suburban community medical center were reviewed. CEAs were performed by 14 surgeons: six vascular, three thoracic, and five general surgeons. Among all patients 87% had lesions with > or = 70% stenosis. Seventy percent of CEAs were performed on symptomatic patients, 84% of whom had stenoses > or = 70%. Among asymptomatic patients 96% had stenoses > or = 70%. There were five instances of neurologic complications in the perioperative period--two transient ischemic attacks, two reversible ischemic neurologic deficits, and one permanent neurologic deficit. One patient died. The mortality rate was 0.6%, the combined major stroke/mortality rate was 1.2%, and the any stroke/mortality rate was 2.2%. There were five patients with nonfatal major complications--one with myocardial infarction, one with pulmonary edema, one with congestive heart failure, and two with postoperative arrhythmia. Thirteen minor complications included eight cases of cranial nerve dysfunction. These data demonstrate that CEAs can be performed safely at community medical centers.

Laparoscopic-assisted colectomy. The learning curve.

One hundred fifty consecutive laparoscopic-assisted colectomies performed by a surgical team were analyzed in an attempt to define a learning curve. These colectomies performed by the Norfolk Surgical Group over a 24-month period, were divided chronologically into six groups of 25 patients each. The groups were then compared to determine if any improvement in length of procedure, complication rate, conversion rate, or length of stay developed as experience increased. Colon cancer and diverticular disease were the most common indications for surgery in all groups. Right hemicolectomy, left colectomy, and low anterior resection accounted for the majority of procedures in all groups. A significant decrease in mean operative time, from 250 min to 156 min over the first 35-50 cases was observed before leveling off at approximately 140 min for the remaining group. Intraoperative complications were low in all groups (range zero to two) and did not show any trend. There was no statistically significant difference in the conversion rate (23.3% overall) among the six groups. Length of stay decreased from 6 days in the first two groups to 5 days in the last four groups, although the difference was not statistically significant. The learning curve for laparoscopic-assisted colectomies is longer than appreciated by many surgeons, requiring as many as 35-50 procedures to decrease operative time to baseline. Complications can be kept at an acceptably low level while on the curve if a cautious approach is taken and the surgeon realizes that a prolonged operative time is not only acceptable, but appropriate during this long learning process. A conversion rate of 20-25% at any phase of the learning process may in fact represent a limitation of current technology. When combined with a low complication rate it may be the sign of a careful surgeon.