Risk for transmission of Naegleria fowleri from solid organ transplantation.

Primary amebic meningoencephalitis (PAM) caused by the free-living ameba (FLA) Naegleria fowleri is a rare but rapidly fatal disease of the central nervous system (CNS) affecting predominantly young, previously healthy persons. No effective chemotherapeutic prophylaxis or treatment has been identified. Recently, three transplant-associated clusters of encephalitis caused by another FLA, Balamuthia mandrillaris, have occurred, prompting questions regarding the suitability of extra-CNS solid organ transplantation from donors with PAM. During 1995-2012, 21 transplant recipients of solid organs donated by five patients with fatal cases of PAM were reported in the United States. None of the recipients developed PAM, and several recipients tested negative for N. fowleri by serology. However, historical PAM case reports and animal experiments with N. fowleri, combined with new postmortem findings from four patients with PAM, suggest that extra-CNS dissemination of N. fowleri can occur and might pose a risk for disease transmission via transplantation. The risks of transplantation with an organ possibly harboring N. fowleri should be carefully weighed for each individual recipient against the potentially greater risk of delaying transplantation while waiting for another suitable organ. In this article, we present a case series and review existing data to inform such risk assessments.

Evaluation of coagulation factors and platelet function from an off-line modified ultrafiltration technique for post-cardiopulmonary bypass circuit blood recovery.

Modified ultrafiltration (MUF) is a technique that hemoconcentrates residual CPB circuit blood and the patient at the same time. Hemoconcentration and MUF are Class 1-A recommendations in the anesthesia and surgical blood conservation guidelines. This study evaluated the off-line MUF process of the Hemobag (HB, Global Blood Resources, Somers, CT, USA) to quantitate coagulation factor levels, platelet (PLT) count and function in one facility and cellular growth factor concentrations of the final product that were transfused to the patient in another facility In two cardiac surgery facilities, after decannulation, the extracorporeal circuit (ECC) blood from 22 patients undergoing cardiac surgery was processed with the HB device. In eleven patients from the first facility by the study design, blood samples for coagulation factor levels and PLT aggregation were drawn from the reservoir of the MUF device pre- and post-processing. The samples (n = 11) were sent to a reference laboratory where testing for prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), reptilase time, fibrinogen, clotting factors II, V, VII, VIII, IX, X, ADAMTS-13, protein C, protein S, antithrombin III, von Willebrand Factor (vWF), and platelet (PLT) aggregation were performed. A portion of the final concentrated HB blood samples (n = 5-10) from the second facility by design were evaluated for transforming and platelet-derived cellular growth factor concentrations. On average, approximately 800 - 2000 mls of whole blood were removed from the ECC post-CPB for processing in the HB device. After processing, there was, on the average, approximately 300 - 950 mls of concentrated whole blood salvaged for reinfusion. The PT and INR were significantly lower in the post-processing product compared to the pre-processing samples while the aPTT times were not significantly different. All coagulation factors and natural anti-coagulants were significantly increased in the final product. The PLT number, although increased by 24%, was not statistically significant. While PLT function assays showed a statistically significant decrease in the levels post-processing, there was substantial platelet function in the MUF product. Overall, the decrease in function was in the range of 10% to 15%. Final product PDGF-αß and TGF-ß1 averaged 11,048 and 2,040 pg/ml, respectively. In these two case series, (ECC) circuit blood concentrated using the HB device showed coagulation studies with significantly lower PT and INR and significantly increased levels of all clotting factors. The findings are similar to trends reported in other studies utilizing conventional MUF and the HB. Functioning platelets remain in the final product, with growth factor concentrations similar to some methods employed to create platelet concentrates to enhance coagulation. Based on the ability of the HB off-line MUF procedure to concentrate circuit blood, the clinical utility of the HB device to decrease allogeneic blood product exposure should be evaluated in a prospective randomized clinical trial.

Iowa FICSIT trial: the feasibility of elderly wearing a hip joint protective garment to reduce hip fractures.

Hip fractures exact a heavy toll in the elderly population. While intervention strategies are being investigated to reduce the numbers of geriatric falls and to improve the body's resiliency, the geriatric population remains at risk for the mortality and morbidity associated with fractures. The Iowa FICSIT site is investigating the feasibility of passive protection of the proximal femur through the use of hip pads. The pad is designed to disperse throughout the pad the energy created in a fall. The focus of the Iowa trial is to determine if elderly will wear hip pads for the majority of their waking hours. Thirty subjects are being recruited from each of six elderly populations who are at high risk to fall and at increased risk of injury. To facilitate compliance, the following strategies are utilized: run-in period, graduated implementation, tailoring of wearing times, and self-report of compliance. Outcome measures include compliance rates and injuries sustained during falls.

Comparison of 2 interferometers for predicting visual acuity in patients with cataract.

Two clinical interferometers generated gratings directly on to the retina in young experienced observers and also in patients about to undergo cataract surgery. Eyes in the patients with no media opacities were used as controls. We agreed with the manufacturers' claims that gratings are seen on the retina independent of refractive state and that gratings can still be seen through most cataracts. However, we did not find that preoperative retinal visual acuity was of any value in predicting postoperative Snellen visual acuity. Reasons for this are discussed.

Contrast sensitivity and visual disability in chronic simple glaucoma.

A battery of vision tests was used to quantify visual defect in a group of 50 patients with chronic simple glaucoma. The vision tests were near and distance visual acuity, visual fields, and contrast sensitivity to static and temporally modulated sinusoidal grating patterns. Of these, static contrast sensitivity function appears to be the most sensitive method of measuring visual defect in glaucoma patients. The visual disability experienced by the glaucoma patients was quantified by means of a questionnaire, and the relationship between perceived visual disability and visual defect was examined. It was found that results from a group of tests, near visual acuity, visual field, and contrast sensitivity measures, are the best predictors of the difficulty experienced by patients in performing visually dependent daily activities.

Effect of age on contrast sensitivity function: uniocular and binocular findings.

Monocular and binocular contrast sensitivity function for a range of spatial frequencies was measured in two groups of subjects with normal vision. Statistically significant differences in performance between the younger group (age 20-30 years) and the older group (age 50-87 years) were found at all spatial frequencies sampled between 0.40 and 19 X 25 cpd. In the age range 50-87 years there was a linear decline in contrast sensitivity with age for medium and high spatial frequencies, but sensitivity for low spatial frequencies was independent of age.

Detection of optic nerve damage in ocular hypertension.

Thirty patients with ocular hypertension were tested for contrast sensitivity loss. Seventeen were not on treatment, and thirteen were receiving some form of pressure reducing therapy. The contrast sensitivity results of 63% of ocular hypertensive eyes were abnormal (greater than 2 SDs from the age matched norm). Thus it appears that contrast sensitivity can detect early visual loss in patients who have normal visual fields and it is suggested that this test might be used as a criterion for therapy in ocular hypertension. There was no significant difference in the intraocular pressures between patients who gave abnormal contrast sensitivity results and those who did not in the untreated group (p greater than 0.05), suggesting that intraocular pressure level is a poor predictor of optic nerve fibre damage in patients with ocular hypertension.

Iatrogenesis in the elderly. Contributors to falls.

Persons who are susceptible to falls can be identified before a fall occurs. A risk prediction tool must be evaluated for its usefulness; if a tool is not feasible, elderly persons who have fallen once are at high risk of falling again. Once high risk has been identified, strategies must be planned to prevent subsequent falls. One of the most important strategies is to communicate to all staff which patients are at high risk and the general circumstances surrounding any patient fall. Few interventions have been shown through rigorous clinical studies to be effective. Passive interventions, such as alarms, are usually more reliable than active interventions that staff must administer. Interventions must be individualized, based on the patient's deficits.

Eight-year (2002-2009) summary of the linezolid (Zyvox® Annual Appraisal of Potency and Spectrum; ZAAPS) program in European countries.

The linezolid surveillance network (ZAAPS program) has been monitoring linezolid activity and susceptibility rates for eight years (2002-2009) in european medical centers. Samples from 12-24 sites annually in 11 countries were monitored by a central laboratory design using reference MIC methods with international and regional interpretations (EUCAST). A total of 13,404 gram-positive pathogens were tested from 6 pathogen groups. Linezolid remained without documented resistance from 2002 through 2005, but beginning in 2006 resistant strains emerged at very low rates among Staphylococcus aureus (G2576T mutant in ireland, 2007), coagulase-negative staphylococci (CoNS; usually Staphylococcus epidermidis, France and Italy in 2006-2009) and enterococci (Enterococcus faecium in Germany [2006, 2008, 2009] and E. faecalis in Sweden [2008], United Kingdom [2008] and Germany [2009]); all but one strain having a target mutation. A mobile cfr was detected in an italian CoNS strain (2008 and 2009), and clonal spread was noted for linezolid-resistant strains (PFGE results). Overall the linezolid susceptibility rates were >99.9, 99.7 and 99.6% for S. aureus, CoNS and enterococci, respectively; and all streptococcal strains were susceptible (MIC(90), 1 mg/l). In conclusion, the ZAAPS program surveillance confirmed high, sustained levels of linezolid activity from 2002-2009 and without evidence of MIC creep or escalating resistance in gram-positive pathogens across monitored european nations.

Naproxen-induced anaphylaxis. A case report.

Anaphylactic reactions to aspirin and other nonsteroid antiinflammatory agents may occur in patients unaware of their intolerance and as a result of the clinical syndrome "Aspirin-induced Asthma". A case report is presented.

Clinical detection of abnormalities in central vision in chronic simple glaucoma using contrast sensitivity.

Visual defect was assessed by contrast sensitivity and perimetry in 50 patients with chronic simple glaucoma. Abnormal contrast sensitivity using static gratings was found in patients with full central fields (i.e. a field of 15 degrees or more around fixation for the 12e isopter). It appears that central vision is affected by nerve fibre damage in the early stages of glaucoma, even in the presence of full central fields and normal visual acuity. Contrast sensitivity using temporally modulated gratings was reduced in the glaucoma patients, although this was found to be a less sensitive measure of visual loss than static contrast sensitivity function. These findings are discussed, and it is suggested that static contrast sensitivity function provides a simple method for detecting early visual defect in glaucoma and ocular hypertension.

Primary umbilical adenocarcinoma. A case report and review of literature.

A case of primary adenocarcinoma of the umbilicus is reported along with a review of the literature and discussion of possible origins of glandular tissue within this area. Multiple connections are present within the umbilicus (vascular, lymphatic, and embryologic) that may give this area access to metastatic lesions. The primary tumors may originate within the usual umbilical tissue (skin and soft tissue). Glands that are not normally present in the region of the umbilicus rarely develop malignant neoplasms. As postulated, glandular tissue may arise either as metaplasia from squamous epithelium or from glandular embryologic rests including omphalomesenteric duct remnants and urachal remnants.

Benzodiazepine use among injecting heroin users.

OBJECTIVES: To determine the extent and patterns of benzodiazepine use among heroin users, and whether preferences for different benzodiazepines exist among this group. SUBJECTS AND METHODS: 210 heroin users who were current users of benzodiazepines volunteered for the study and completed a structured questionnaire. RESULTS: Heroin users had used a median of five different benzodiazepines, most commonly diazepam. Almost half the subjects (48%; 95% CI, 41-55) had injected benzodiazepines, 17% (95% CI, 12-22) within the preceding six months. Diazepam and temazepam were the most widely injected benzodiazepines. CONCLUSIONS: Flunitrazepam, diazepam and temazepam should be prescribed to heroin users with caution. A less popular and rarely injected benzodiazepine, nitrazepam, may be a better option for this group.

Quality review in the Peer Review Organization Program.

Several major, national forces have created the mandate of the Peer Review Organizations (PROs) for the evaluation of the quality of care received by Medicare patients. The shift of the Medicare Program to prospective payment to hospitals has caused concern that this change in financial incentives may have adverse effects on quality. An analysis and review of the experience of the California PRO (California Medical Review, Inc.)--including the application of sanctions--suggests that corrective actions have been successful in addressing quality deficiencies. However, the relationship between those deficiencies and the prospective payment mechanism remains unclear.

Test-retest reliability of the Arden Grating Test: inter-tester variability.

The aim of this study was to investigate the test-retest reliability of the Arden Grating Test (AGT), and to assess the extent to which any variance in AGT score on retest can be attributed to intra-subject and inter-tester differences. Twelve patients with various pathologies and whose contrast sensitivity covered a wide range were each tested twice by six testers. It was shown that variance attributable to testing by different clinicians accounted for approximately 25% of the total variance, and that the 95% confidence limits about any observed score were +/- 15 AGT units, which is about one quarter of the total dynamic range of the test. The large range of scores encompassed by the 95% confidence limits represents considerable unreliability, the consequence of which is a high misclassification rate, i.e. many false positives and false negatives, especially in the context of primary vision screening for which it was designed.