Invasive Haemophilus influenzae disease in adults.

In a five-year period, 29 cases of bacteremia and/or meningitis in adults caused by Haemophilus influenzae were seen in our large community hospital. There were 17 cases of bacteremic pneumonia and 12 cases of serious extrapulmonary infections. The extrapulmonary infections included cases of endocarditis, meningitis, cholecystitis, epiglottitis, tubo-ovarian abscess, and cellulitis. In contrast with the pediatric experience, H influenzae type B was the causative pathogen in only 45% of patients and only one isolate was ampicillin resistant.

The truth is in the water: metastatic prostate cancer presenting as an intermittent facial nerve palsy.

An elderly man presented to the acute ear, nose and throat (ENT) services with a history of intermittent, self-limiting facial nerve palsy. Full ENT examination was normal, with all cranial nerves and peripheral neurology intact. Multiple imaging modalities suggested an aggressive bony lesion, secondary to locally advanced prostate malignancy with extensive metastatic infiltration. Prostate cancer is known to preferentially metastasise to bone and has been known to cause multiple cranial nerve palsies and ophthalmoplegia. This is the first case described in the literature of metastatic prostate cancer presenting with intermittent facial nerve palsy.

Nosocomial infection in adult patients with sickle cell anemia.

Although the vulnerability of patients with sickle cell disease to infection with encapsulated organisms is well recognized, nosocomial transmission of infection has not been studied in this population. We describe eight serious, nosocomially transmitted infections in four adult patients hospitalized for complications of sickle cell disease, which led to death in one patient and prolonged hospital stays in three others. Although we have not surveyed all patients with sickle cell disease for rates of nosocomial infection, the cases presented suggest that these patients may be at increased risk. Risk can be reduced if health care workers are especially vigilant in adhering to handwashing and other infection control measures when caring for these patients. Additionally, we recommend that a patient with sickle cell disease not share a room with a patient known to have or suspected of having a nosocomial or community-acquired infectious disease.

Effect of including recommendations for antimicrobial therapy in microbiology laboratory reports.

Innovative approaches are needed to improve cost-effective antibiotic use in hospitals. We established an algorithm to provide a recommendation for both a single oral and a single parenteral antimicrobic, including dosage, to be placed in the bacteriology laboratory report for therapy guidance of 174 episodes of lower respiratory infection in a group of "program" patients with no evidence of infection at other sites. The initial recommendation was based on the Gram-stained direct smear of secretions. The recommendation was updated when preliminary culture results were available, and again with final identification and susceptibility data. We compared the severity of illness, length of stay, and cost of therapy for 68 episodes in program patients who received the recommended therapy with 111 episodes in a control group of patients who received antimicrobial therapy but for whom no recommendations were reported. There was a significantly greater use of the recommendations for sicker patients. Antimicrobial therapy, in general, was more often used for the program patients than for the controls. There was no difference in length of stay or therapy cost. We recommend that this approach be used in settings where there is more problematic use of antimicrobics.

Second-generation delivery systems for laser prostatic ablation.

OBJECTIVE: To assess the effectiveness of a second-generation laser delivery system (Side-Fire) in the treatment of benign prostatic hyperplasia (BPH). METHODS: Thirty-three patients with documented BPH were treated and evaluated pre- and post-operatively with a follow-up period of twelve to thirty-six weeks. RESULTS: There was marked improvement demonstrated at three months post lasing in all patient outcome parameters (symptom score, flow rate, and post-void residual volume) using the new Side-Fire right-angled delivery system. CONCLUSION: Side-Fire catheter laser ablation therapy produces an excellent transition zone ablation in established BPH.

Antibiotic formulary selection.

Physicians worldwide are being forced to consider economics in the care of patients. In most hospitals, antibiotics are a steadily increasing segment of the pharmacy budget. This article discusses how the authors used drug pharmacokinetics, restriction policies, and cost benefit analysis to design a cost-effective antibiotic formulary.

Effect of continuous arteriovenous hemodiafiltration on the pharmacokinetics of fluconazole.

In critically ill patients with acute renal failure, continuous arteriovenous hemodiafiltration (CAVHD) has become an increasing popular supportive technique. An adult with acute renal failure during CAVHD therapy received fluconazole. Drug clearance by the hemodiafilter system and its total body clearance during the CAVHD period were 23-28 ml/minute and 22 ml/minute, respectively, indicating that the rate of systemic clearance was solely dependent on CAVHD in this patient. Total body clearance, area under the curve, and half-life values for this patient closely resembled those in healthy subjects. These observations suggest that patients treated with fluconazole during CAVHD should receive standard maintenance dosages, and neither supplementation nor dosage adjustment is required.

Antibiotic use in the critical care unit.

The antimicrobial management of patients in the critical care unit is complex. Not only must the clinician be familiar with a number of clinical, microbiological, pharmacological, and epidemiological observations but also fundamental pharmacodynamic concepts. It is an understanding of these concepts that forms the basis for the design of dosing strategies that maximize clinical efficacy and minimize toxicity. Antimicrobial selection is further complicated by the plethora of new antimicrobial agents available with varying clinical utility. Nowhere is this more evident than in the quinolone class of antibiotics. To aid the clinician in differentiating between quinolones it now seems reasonable to create a classification system akin to the generation grouping applied to the cephalosporins. Our classification is based upon the pharmacodynamic principles discussed within this article.

Noncontact sidefire laser ablation of the prostate.

Continuing experience with Nd:YAG noncontact sidefiring laser fibers over the past 4 years has shown encouraging results. Thus far, of the 198 patients treated with the 60 W/60 seconds technique since October 1990, a total of 74 were available for long-term evaluation (69 at 12 months and 29 at 24 months). The AUA Symptom Scores, Qmax (peak uroflow rates), and postvoiding residual urine volumes demonstrated marked improvement. The complications included 16 instances of recurrent obstructive symptoms necessitating revision. Three patients suffered urinary tract infections, two patients developed bladder neck stenosis, four anticoagulated patients with clot retention required blood transfusions, and three patients had epididymoorchitis. Follow-up at 12 and 24 months showed sustained reduction in AUA Symptom Scores and maintained improvement of the peak flow rates and residual volumes. These results demonstrate the safety and clinical applicability of laser ablation of the prostate and its potential usefulness as a less invasive therapy for benign hyperplasia.

Simple automatic initiator for microwave induced plasmas.

A simple circuit is described which is used to maintain continuity of a radio-frequency or microwave induced plasma. The microwave power reflected from the discharge is monitored. Upon an increase of the reflected power which indicates that the plasma has become extinguished, a high-voltage pulse is applied to a coil wrapped around the discharge region. The repetition rate, voltage of the pulse, and threshold of reflected power are adjustible. This circuit is applicable to resonance fluorescence, atomic absorption and emission, and kinetic determinations.

Psychophysiological and perceptual responses to infant cries varying in pitch: comparison of adults with low and high scores on the Child Abuse Potential Inventory.

Based on their scores on the Child Abuse Potential (CAP) Inventory, 30 nonparent adults were classified as either having high CAP scores (n = 15) or low CAP scores (n = 15). Subjects' heart rate and skin conductance were assessed as they listened to audio-taped presentations of four "normal" phonated infant cries and four high-pitched, hyperphonated infant cries. Subjects also rated the cries on several perceptual items. Results showed that both groups of subjects found hyperphonated cries more aversive, distressing, urgent, arousing, and sick than phonated cry sounds. Similarly, all listeners' showed higher skin conductance levels (SCL) in response to hyperphonated than phonated cries. SCL became attenuated over time in response to phonated, but not hyperphonated, cries. Adults in the high-CAP group, showed marginally higher heart rates than low-CAP adults following presentation of all infant cry sounds and responded to phonated cries with marginally higher skin conductance levels than low-CAP adults. The responses of high-CAP nonparent adults are similar to those of parents with histories of physically abusive interactions with their infants.

A randomised single institution study comparing laser prostatectomy and transurethral resection of the prostate.

We concluded a prospective randomised study comparing conventional electrocautery transurethral resection of the prostate (TURP) to laser prostatectomy using a right-angled Nd:YAG beam reflector. Seventy-one patients were evaluable, 34 laser and 37 TURP. Fifty patients have completed 6 months of follow-up. Using standard post prostatectomy outcome parameters of maximum flow rate and post void residual urine, laser prostatectomy shows equivalence at 6 months, with mean maximum flow rates of 8.76 ml/sec preoperatively improving to 15.47 ml/sec at 6 months, whilst for TURP patients, flow rates improved from a mean of 9.48 ml/sec preoperatively to 19.1 ml/sec at 6 months. Symptom scores remain higher for the laser patients at this time with a mean score of 9.27 compared to 4.43 for TURP patients. However, morbidity in the laser group is less, particularly given the absence of postoperative bleeding and the necessity for blood transfusion.

Rational vancomycin use recommendations.

The increasing occurrence of VRE will dramatically affect the management of infections in hospitalized patients, as well as increase morbidity and mortality. Vancomycin is the therapy of choice for certain gram-positive infections in patients with significant allergic histories to beta-lactam antibiotics and for infections with gram-positive microorganisms that are resistant to beta-lactam antibiotics. Conservative use of vancomycin in the future may help to avoid the further development of resistant organisms.

Oral ciprofloxacin, ofloxacin, and lomefloxacin as alternatives to intravenous antimicrobial therapy.

Ciprofloxacin, ofloxacin, and lomefloxacin are oral fluoroquinolones with ideal characteristics for oral antimicrobial therapy. These agents provide 1) appropriate and reliable serum concentrations, 2) broad antimicrobial activity, 3) proven efficacy in the treatment of serious infections, and 4) good tolerability. Although cations decrease the absorption of these drugs, there are proven means of avoiding these interactions. Therefore, these agents could easily be utilized as alternatives to prolonged intravenous treatment of many infectious diseases in patients who do not have conditions which impair drug absorption.

Randomized study of the effect of midnight removal of urinary catheters.

This study shows that removal of urinary catheters at midnight has several advantages over removal at 6 AM. The midnight group had a significantly greater initial voided volume and a longer time to first void than the equivalent 6 AM group. Advantages to midnight catheter removal also exist for nursing staff. Midnight tends to be less busy on the nursing unit compared with 6 AM, thus making it a preferable time for performance of routine tasks. Catheter removal at midnight also allows for convenient observation of patient voiding and assessment earlier in the day. This means that any necessary intervention can take place during working hours when more staff are on duty. There is also the potential for earlier discharge, with economic benefits related to shorter bed stay and more efficient discharge planning. We believe midnight catheter removal offers considerable benefits over the traditional 6 AM time on both general and urology units.

Changing trends in HIV diagnosis in an inner city London teaching hospital 2007-2011.

In 2008, guidelines aimed at reducing undiagnosed HIV infection were published, recommending normalization of testing. Local initiatives were carried out in south-west London including an extensive primary care education programme. This study aimed to establish the impact of these initiatives on HIV diagnoses. Data on all new diagnoses referred to our centre were collected and analysed from patient records. A total of 394 patients were newly diagnosed with HIV from 2007 to 2011. Diagnosis in primary care and other non-sexual health (SH) settings increased by 184% during this period. There was an increase of 37% in the median CD4 count at diagnosis, taking the figure to 372 cells/mm³ in 2011. The proportion of patients presenting with a CD4 count of <200cells/mm³ decreased by 24%. The evidence suggests that these local initiatives were successful in increasing HIV diagnoses outside SH settings, particularly in very late presenters.

Robotic radical prostatectomy in Australia: initial experience.

The purpose of this study is to describe the initial experience of robotic-assisted radical prostatectomy (RARP) in Australia. Since the installation of the daVinci system at the Australian Institute for Robotic Surgery, Epworth Hospital, Melbourne in December 2003, 275 robotic-assisted radical prostatectomies have been performed by two surgeons. A prospective database is compiled for each procedure including patient, operative and outcome details. We report on the initial learning curve, surgical technique and modifications, anaesthetic considerations and surgical results comparative to open radical prostatectomy in a single surgeons experience along with margin positivity rates for the first 200 cases of RARP. RARP is the single most frequent adaptation of robotic-assisted surgery with promising initial results. Increasing availability of this modality will inevitably give rise to further adaptations. We present the initial Australian experience.