The benefits of telephone-access medical consultation.

A major disadvantage of rural medical practice is the limited reserve of consultative options. To determine the perceived clinical utility and educational impact of the West Virginia University Medical Access and Referral System (MARS), a 24-hour prompt telephone-consultation service, a mailed questionnaire was administered to 303 West Virginia clinicians who had used MARS for infectious disease problems. The overall questionnaire response rate was 62 percent. Callers included family practitioners (35%), medical specialists (32%), surgical specialists (13%), pediatricians (11%), obstetricians (5%), and nonphysicians (4%). Major referral questions posed were therapeutic (60%), diagnostic (48%), and epidemiologic (10%) in nature. On a scale of 1 (not useful) to 5 (very useful), survey responders rated the overall clinical usefulness of MARS as either a 4 (22%) or 5 (76%). Callers felt that MARS consultation assisted in accurate case diagnosis in 80 percent of cases, and aided in successful therapeutic management of 96 percent of cases. An educational benefit was reported by 96 percent of responders. Physicians located in more rural, underserved areas tended to use MARS to a greater degree than colleagues in more populated, medically accessible areas (P < 0.005). These findings suggest that an academic telephone-access consultation program can be a clinically relevant and educational consultative tool for practicing clinicians, especially those located in rural areas.

Decreased virulence of gentamicin-resistant strains of Pseudomonas aeruginosa in a rat model.

Previous studies have reported that GR strains of Pseudomonas aeruginosa were less likely to cause serious infections. In the present study, this clinical observation of decreased virulence of GR strains of P. aeruginosa was documented in Andriole's rat model. A significantly higher mortality in rats was noted with GS strains of P. aeruginosa (MIC less than 10 microgram/ml) compared to moderately resistant strains (MIC 12.5 to 312 microgram/ml) and highly resistant strains (MIC greater than 312 microgram/ml). Slower growth rates of GR strains of P. aeruginosa were observed in both the lag and the log phases as compared to GS strains. Average counts of in vivo quantitative blood cultures with the use of GR strains were lower at 30 min, 8 hr, and 24 hr compared to those with GS strains. The mortality in mice injected intraperitoneally with CFS's from GS strains (MIC 0.78 to 3.125 microgram/ml) was significantly higher at 8 and 24 hr than those injected with supernatants from GR strains (MIC 25 to 400 microgram/ml). Human neutrophils killed GR and GS strains of P. aeruginosa equally. Decreased virulence of GR strains of P. aeruginosa may be due in part to slower growth rates and to a decreased ability to produce heat-labile toxic components.

Granulomatous hepatitis in a healthy adult following BCG injection into a plantar wart.

This is the first reported case of granulomatous hepatitis in a healthy adult following intralesional injection of BCG into a plantar wart. Previous reports of disseminated disease following intralesional injections have all been in patients with malignancies. The clinical course in this patient was characterized by fever, chills and drainage from the injection site. Diagnosis was made by demonstration of noncaseating granulomas on liver biopsy. No acid-fast organisms were identified by stain or culture. The patient responded to antituberculous therapy.

An attenuated influenza virus vaccine: protection against homologous and heterologous strains of virus.

An effective influenza virus vaccine should be capable of inducing protection against both the homologous strain of virus and the heterologous strains representing antigenic drift. For evaluation of the protection provided by an attenuated influenza virus vaccine, volunteers were immunized intranasally with either placebo or influenza A/England/42/72 (H3N2) virus vaccine in a double-blind fashion in two doses administered two weeks apart. Forty-seven subjects were challenged 30-100 days after the second dose with either the homologous or a virulent heterologous strain of virus [A/Dunedin/73 (H3N2)]. The vaccine resulted in good clinical protection against challenge with both the homologous and heterologous strains of virus. The rates of protection against infection (as judged by antibody responses, irrespective of signs and symptoms) were also good (72% and 60% against the homologous and heterologous strains, respectively). Thus, immunity induced by this attenuated influenza virus vaccine extends to provide protection against a related but nonidentical influenza virus.

Fatal sepsis associated with an intrauterine device and pregnancy.

The 15th case of maternal death associated with sepsis in pregnancy in a patient using the Dalkon Shield intrauterine device is reported. Intrauterine sepsis appears to be a complication of the use of this device. B acteria enter the uterus during pregnancy through the multifilament tail of the device. The management of sepsis during pregnancy associated with an in situ IUD often requires a combined medical and obstetrical approach. The removal of all Dalkon Shields is strongly recomended.