International Society of Cardiovascular Infectious Diseases Guidelines for the Diagnosis, Treatment and Prevention of Disseminated Mycobacterium chimaera Infection Following Cardiac Surgery with Cardiopulmonary Bypass.

Mycobacterial infection-related morbidity and mortality in patients following cardiopulmonary bypass surgery is high and there is a growing need for a consensus-based expert opinion to provide international guidance for diagnosing, preventing and treating in these patients. In this document the International Society for Cardiovascular Infectious Diseases (ISCVID) covers aspects of prevention (field of hospital epidemiology), clinical management (infectious disease specialists, cardiac surgeons, ophthalmologists, others), laboratory diagnostics (microbiologists, molecular diagnostics), device management (perfusionists, cardiac surgeons) and public health aspects.

Mycobacterium immunogenum sp. nov., a novel species related to Mycobacterium abscessus and associated with clinical disease, pseudo-outbreaks and contaminated metalworking fluids: an international cooperative study on mycobacterial taxonomy.

PCR-restriction enzyme pattern analysis of a 439 bp hsp65 gene segment identified 113 unique isolates among non-pigmented rapidly growing mycobacteria (RGM) from clinical and environmental sources that failed to match currently recognized species patterns. This group represented 40% of isolates recovered from bronchoscope contamination pseudo-outbreaks, 0% of disease-associated nosocomial outbreaks and 4% of routine clinical isolates of the Mycobacterium abscessus/Mycobacterium chelonae group submitted to the Mycobacteria/Nocardia laboratory for identification. It is grouped within the Mycobacterium fortuitum complex, with growth in less than 7 d, absence of pigmentation, positive 3-d arylsulfatase reaction and growth on MacConkey agar without crystal violet. It exhibited overlapping biochemical, antimicrobial susceptibility and HPLC characteristics of M. abscessus and M. chelonae. By 16S rRNA gene sequencing, these isolates comprised a homogeneous group with a unique hypervariable region A sequence and differed by 8 and 10 bp, respectively, from M. abscessus and M. chelonae. Surprisingly, this taxon contained two copies of the ribosomal operon, compared with single copies in the two related species. By DNA-DNA hybridization, this new group exhibited <30% homology with recognized RGM species. The name Mycobacterium immunogenum sp. nov. is proposed for this new taxon.

Design and validation of instruments to measure knowledge.

BACKGROUND: Measuring health care providers' learning after they have participated in educational interventions that use experimental designs requires valid, reliable, and practical instruments. METHODS: A literature review was conducted. In addition, experience gained from designing and validating instruments for measuring the effect of an educational intervention informed this process. RESULTS: The eight main steps for designing, validating, and testing the reliability of instruments for measuring learning outcomes are presented. The key considerations and rationale for this process are discussed. Methods for critiquing and adapting existent instruments and creating new ones are offered. CONCLUSIONS: This study may help other investigators in developing valid, reliable, and practical instruments for measuring the outcomes of educational activities.

Successful treatment of disseminated Mycobacterium chelonae infection with linezolid.

We describe a 57-year-old man with steroid-dependent myasthenia gravis and progressive ulcerating leg nodules due to clarithromycin-resistant Mycobacterium chelonae. The patient was successfully treated with linezolid.

Instruments to measure cancer management knowledge of rural health care providers.

BACKGROUND: Instruments to measure cancer management knowledge of rural physicians, nurses, and pharmacists were needed to evaluate the effect of an educational intervention. Since such instruments did not exist, the authors designed and validated a new instrument for each discipline. METHODS: The design and validation process for these instruments are described. RESULTS: These three instruments were shown to be practical and to have high content and construct validity. Content validation demonstrated that all items were rated as essential or useful by 90% or more of the respondents. Construct validation show highly significant differences in mean scores among several levels of learners and practitioners as expected. CONCLUSIONS: These instruments may be useful to other investigators for measuring cancer management knowledge of rural physicians, nurses, and pharmacists.

Health needs of people living below poverty level.

BACKGROUND AND OBJECTIVES: Low-income populations, especially persons without health insurance, suffer disproportionately with a variety of chronic ailments, postpone getting medical care, and have shorter life spans. This study was conducted to better understand the health care needs and behaviors of people living in poverty. METHODS: Participants for the study were recruited through agencies serving low-income and homeless people, neighborhood businesses, churches, and subsidized housing units. All participants were adults who had incomes below 200% of the federal poverty level. Subjects completed face-to-face interviews to answer questions about demographics and their concerns about health care. Quantitative and qualitative analyses were performed. RESULTS: A total of 750 people were interviewed, with 729 providing usable data. Thirty-seven percent of subjects reported spending at least part of the previous year without health insurance. Fifty-six percent of these individuals were persons who were employed but whose employers did not provide health insurance. Reported health concerns were access to care (reported by 21% of subjects), costs of care (13%), and ability to purchase medications (15%). Forty-five percent of subjects reported receiving mental health services; these subjects were concerned about their ability to continue receiving care and to afford medications. CONCLUSIONS: The portion of the low-income population that is uninsured for part or all of a year is greater than in published reports. The health behaviors of this group are easily understood when coverage (if any), level of income, age, and health care needs are considered.

In vitro activities of linezolid against multiple Nocardia species.

Linezolid was tested by broth microdilution against 140 clinical Nocardia isolates belonging to seven species. The MIC at which 50% of the strains are inhibited (MIC50) and MIC90 for all species other than Nocardia farcinica were 2 and 4 microg/ml. Linezolid is the first antimicrobial agent demonstrated to be active against all Nocardia species.

Activities of linezolid against rapidly growing mycobacteria.

Linezolid is an oxazolidinone available as an oral drug which has activity against most gram-positive bacteria. However, few species of the genus Mycobacterium have been studied. We tested 249 clinical isolates and 10 reference strains of rapidly growing mycobacteria for susceptibility to linezolid by broth microdilution. Clinical species included the Mycobacterium fortuitum group (n = 74), M. abscessus (n = 98), M. chelonae (n = 50), M. mucogenicum (n = 10), and M. fortuitum third biovariant complex (10). The modal MIC for M. mucogenicum was 1.0 microg/ml, and the MIC at which 90% of the isolates tested are inhibited (MIC(90)) was 4 microg/ml; the modal MIC for the M. fortuitum group was 4 microg/ml, and the MIC(90) was 16 microg/ml; the modal MIC for the M. fortuitum third biovariant complex was 4 microg/ml, and the MIC(90) was 8 microg/ml; the modal MIC for M. chelonae was 8 microg/ml, and the MIC(90) was 16 microg/ml; and the modal MIC for M. abscessus was 32 microg/ml, and the MIC(90) was 64 microg/ml. Based on peak levels of linezolid in serum of 15 to 20 microg/ml, we propose the following broth MIC breakpoints for these species: susceptible, < or = 8 microg/ml; moderately susceptible, 16 microg/ml; and resistant, > or =32 microg/ml). These studies demonstrate the excellent potential of linezolid for therapy of rapidly growing mycobacteria.

Lake Superior Rural Cancer Care Project, part I: an interventional trial.

PURPOSE: To date, effective cancer care and control intervention studies have been carried out largely in urban and suburban populations. This study was conducted to test innovative interventions, using experimental designs, to improve the care and outcomes of patients with cancer in rural settings. DESCRIPTION OF STUDY: The Lake Superior Rural Cancer Care Project (LSRCCP) tested an innovative, multimodal, multidisciplinary intervention that involved rural healthcare providers and their healthcare system. An experimental design was used, with the rural community as the unit of randomization. Outcomes were measured at three levels: rural providers' knowledge of cancer management, providers' practice performance, and patient outcomes. This 5-year study was conducted in rural areas of northern Minnesota, Wisconsin, and the western part of the Upper Peninsula of Michigan. RESULTS: Baseline data from the study are provided, and details of the design and methods are presented. The study outcomes are reported in part in "Lake Superior Rural Cancer Care Project Part II" in this issue and will be reported further in future issues. CLINICAL IMPLICATIONS: This article describes the hypotheses, design, and methods of the LSRCCP. The design and methods as well as the results of this study may be useful to cancer researchers and clinicians in rural areas across the United States.

Lake Superior Rural Cancer Care Project, part II: provider knowledge.

PURPOSE: The purpose of this article is to report the main learning outcomes of the Lake Superior Rural Cancer Care Project. DESCRIPTION OF STUDY: The authors designed and tested a multimodal intervention directed at rural providers and their healthcare systems in a large rural area in the north central United States. An experimental design was used to randomize rural providers at the group level. The intervention consisted of providing increased education for rural providers with a number of approaches, including the use of clinical opinion leaders. The main outcome of the intervention was knowledge scoring on discipline-specific cancer management tests. RESULTS: Knowledge scores for providers in the experimental group significantly increased from pretest to post-test: 66 to 79 for physicians (and physician assistants) (P=.02); 58 to 71 for nurses (P=.01); and 54 to 64 for pharmacists (P=.01). At post-test, participating providers in the experimental group performed significantly better on the knowledge tests (P <.01) than those in the control groups. CLINICAL IMPLICATIONS: This study may be the first to test educational interventions to improve rural providers' knowledge about cancer practice using an experimental design. The intervention may possibly change provider practice behaviors and, thus, patient outcomes, data that will be reported in a future issue. Finally, this educational intervention may prove useful for providers in other rural areas.

Diagnosing childhood attention-deficit/hyperactivity disorder. Do family practitioners and pediatricians make the same call?

BACKGROUND: The purpose of this study was to determine whether--and if so, how--primary care physicians in Minnesota differ in diagnosing and treating childhood ADHD. METHODS: A questionnaire was mailed to 200 family physicians (100 urban; 100 rural) and 100 pediatricians (60 urban; 40 rural). The questionnaire asked about assessment, diagnosis, and treatment strategies physicians would use in response to three patient vignettes. RESULTS: While all physicians in both specialities reported similar differential diagnoses, pediatricians used more special tests and assessment scales than family physicians (p < 0.05). More family physicians referred patients for further evaluation (p < 0.05). Eighty-nine percent of pediatricians used DSM-IV criteria compared with 37% of family physicians (p < 0.001). Parents (98%) and teachers (82%) were usually involved in management planning, and methylphenidate (Ritalin) was the most commonly prescribed drug (87%). CONCLUSION: Regardless of specialty, size of community, or distance from mental health services, physicians in this study did not differ in the diagnosis or treatment of ADHD in response to hypothetical cases. Pediatricians reported using DSM-IV criteria in their practices when making diagnoses more often than family physicians.

Arthritis in Indian country: determining the prevalence and effects.

OBJECTIVE: This project was designed to determine the prevalence of self-reported arthritis and its effect on the daily lives of Chippewa Indian people on tribal lands in Wisconsin. DESIGN AND METHODS: After review and approval by the LCO Tribal Council and the University of Minnesota Human Subjects Committee, face-to-face interviews with randomly selected tribal residents were conducted, followed by focus group formation, and medical chart reviews. RESULTS: Eighty-one percent (N = 82) of the eligible sample were interviewed. Fifty-six percent (N = 46) self-reported a diagnosis of arthritis, either by physician report or description of symptoms confirmed by a rheumatologist. Seventy-eight percent of this group (N = 36) reported limitations in their activities that can be attributed to arthritis. Only half of the medical charts included the diagnosis of arthritis or any tests to document its diagnosis. CONCLUSIONS: In this Chippewa population, the prevalence of and limitations due to arthritis are extremely high. Reasons for this need further investigation. The implications of these findings for tribal and health planning include housing, community activities, and medical services to accommodate the needs of this group.

An investigation of the effect of 2 sedation regimens on patient mood state following upper extremity surgery using local anesthesia.

Sedation techniques for patients undergoing minor outpatient surgery frequently include a variety of intravenous agents. The present study was designed to look for differential effects of 2 different sedation regimens on perioperative mood states. Twenty-two patients undergoing upper extremity surgery using local anesthesia were randomized to receive either propofol or midazolam intravenously for intraoperative sedation. Subjects were asked to complete a Profile of Mood States survey before and after surgery. The results of this survey were examined for differences in mood between the 2 groups that may be attributable to differences in drug effect. No significant differences were identified between propofol or midazolam regarding their effect on patient mood. Patients in both groups experienced a reduction in perioperative anxiety.

Rural Minnesota family physicians. Practice characteristics, gender, income, and job satisfaction.

This study investigated rural physicians' job satisfaction, income, and working conditions through a survey of a random sample of rural family physicians in Minnesota. Of the 300 surveys sent, 210 (70%) were returned and usable. Male physicians reported more years of experience, work hours, and call hours per week than female physicians (p < 0.0005). On a scale of 1 to 5, average overall job satisfaction among the physicians was 4.04, with men averaging 4.0 and women, 4.3. Overall job satisfaction was positively correlated with the presence of a hospital in town (p < 0.05) and negatively correlated with the number of work hours, including hours on call, per week (p < 0.05). Overall job satisfaction was lowest for those in practice 20-34 years. Average reported annual income was $127,213 (men, $131,400; women, $97,800; p < 0.0001). In a comparison of physicians working the same number of hours including call, men earned more than women. Rural Minnesota family physicians reported high job satisfaction. Income was positively correlated with size of practice, years of experience, and number of hours worked. In addition, men earned more than women, and physicians whose pay was based on production earned more than physicians on straight salary.

Public health nurses' responses to domestic violence: a report from the Enhanced Domestic Abuse Intervention Project.

Public health nurses (PHNs) can play an important role in the detection of domestic violence. This study examines whether the introduction of a domestic violence assessment protocol by public health nurses in a maternal and child health visiting program increases the identification and referral rates of women experiencing domestic violence. Data collected from case files during the baseline year prior to the initiation of the protocol were compared to case file information after the protocol had been implemented. When the protocol was used, there was a higher rate of identification, although the difference was not statistically significant. Significantly more women, however, were provided with information about domestic violence resources after the protocol was in place, and significantly more women were referred to services in the second year after the protocol had been implemented. This study provides support for the use of a domestic violence protocol to improve the public health nursing response to domestic violence.

Enhancing Cancer Pain Control among American Indians (ECPCAI): a study of the Ojibwe of Minnesota.

BACKGROUND AND OBJECTIVES: This study addressed one American Indian group's experience with cancer, its associated pain, and the resulting barriers in cancer pain management (CPM). METHODS: The project researched the identified problems and implemented solutions. Focus groups at four reservations with clinic personnel and tribal elders reviewed culturally specific experiences and barriers to CPM. Culturally sensitive brochures for patients and guidelines for providers were developed, and health care providers participated in CME sessions. RESULTS: Ojibwe elders report pain when it is >6 (1-10 scale), believe pain always accompanies cancer, and do not believe it can be relieved, although traditional healers can help. They also have addiction concerns. Developed materials changed knowledge (pre-post tests, p = 0.000) and are culturally sensitive (> 92% agreement). CONCLUSION: Medically sound CPM for this population can also be culturally sensitive.

Expression and regulation of phosphate stress inducible genes in Sinorhizobium meliloti.

Sinorhizobium meliloti 104A14 was mutated with transposon Tn5B22, which creates lacZ transcriptional fusions when inserted in the correct orientation relative to the promoter. This promoter reporter allowed us to identify six phosphate stress inducible (psi) genes in S. meliloti that are up-regulated in response to inorganic phosphate (Pi) starvation. The transposon and flanking DNA were cloned from each psi::Tn5B22 reporter mutant and the junction DNA sequenced. High identity/similarity of the inferred peptides with those in major data bases allowed identification of the following genes: dnaK, expC, pssB, ackA, vipC, and prkA. The prkA homolog was also found to be up-regulated in response to carbon starvation and when nitrate replaced ammonium as the nitrogen source. Through allele replacement techniques, PhoB- mutants were generated for the expC, ackA, vipC, and pssB reporter strains. Loss of a functional PhoB resulted in the absence of Pi-sensitive induction in all four genes. These experiments suggest the Pho regulon in S. meliloti includes genes that presumably are not directly linked to Pi acquisition or assimilation. The psi strains were tested for their symbiotic properties under growth conditions that were Pi-limiting or Pi-nonlimiting for the host plant. All were Nod+ and Fix+ except the reporter strain of dnaK transcription, which was less effective than the wild-type strain under both P treatments, indicating DnaK is required for optimum symbiotic function.

Two hospice quality of life surveys: a comparison.

This study's objective tested the utility of two quality of life (QOL) forms in a hospice setting. The compared forms were the McGill Quality of Life Questionnaire (MQOL) and the Hospice Quality of Life Index-Revised (HQLI). Using a crossover design, hospice nurses first administered one survey to eligible patients and then, in the study's second phase, administered the other survey to newly enrolled eligible patients. Nurses were interviewed regarding each form and possible changes in patient care that were made due to the assessment. Hospice care plans were reviewed looking for specific changes as a result of the surveys. The results showed that the QOL assessments were useful for the nurses in planning the care of the hospice patients and that the MQOL was preferred by the nurses over the HQLI.