RESUMO
A retrospective chart review was undertaken at Columbia Presbyterian Medical Center to assess the incidence, etiology and management of head and neck infections in pediatric cardiac transplant patients on immunosuppression. From June 1984 to February 1992, 59 cardiac transplants were performed on 57 pediatric patients. Standard immunosuppressive therapy was used. Thirteen of these patients died within three months of transplant and were not included. Of the 44 patient charts reviewed, 82 head and neck infections were documented in 27 patients (61%). There were 26 episodes of sinusitis, 27 episodes of otitis media and 20 episodes of tonsillitis/pharyngitis. Unusual middle-ear pathogens seen included Morganella morgagni and Pseudomonas aeruginosa. These preliminary data suggest that children on immunosuppression for cardiac transplant may be at risk for head and neck infections from unusual or unsuspected organisms, and tympanocentesis plays an important role in diagnosis and treatment. A prospective study is planned to gain further data.
Assuntos
Infecções Bacterianas/epidemiologia , Transplante de Coração , Terapia de Imunossupressão , Infecções Respiratórias/epidemiologia , Adolescente , Antibacterianos/uso terapêutico , Infecções Bacterianas/etiologia , Infecções Bacterianas/terapia , Criança , Pré-Escolar , Terapia Combinada , Feminino , Humanos , Incidência , Lactente , Masculino , Prognóstico , Infecções Respiratórias/etiologia , Infecções Respiratórias/terapia , Estudos RetrospectivosAssuntos
Fibrinólise , Hipertensão Pulmonar/genética , Adolescente , Adulto , Idoso , Contagem de Células Sanguíneas , Fatores de Coagulação Sanguínea/análise , Plaquetas , Cateterismo Cardíaco , Pré-Escolar , Eletrocardiografia , Feminino , Humanos , Hipertensão Pulmonar/sangue , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/fisiopatologia , Masculino , Linhagem , Fonocardiografia , Tempo de Protrombina , Pulso Arterial , VetorcardiografiaAssuntos
Doença das Coronárias/fisiopatologia , Rim/fisiopatologia , Resistência Vascular , Animais , Aorta Abdominal , Velocidade do Fluxo Sanguíneo , Doença das Coronárias/etiologia , Vasos Coronários , Cães , Rim/irrigação sanguínea , Rim/efeitos dos fármacos , Ligadura , Métodos , Perfusão , Propranolol/farmacologia , Fluxo Sanguíneo RegionalAssuntos
Circulação Sanguínea , Hiperventilação/fisiopatologia , Reflexo , Animais , Pressão Sanguínea , Débito Cardíaco , Cães , Coração/fisiopatologia , Frequência Cardíaca , Membro Posterior/irrigação sanguínea , Contração Muscular , Respiração com Pressão Positiva , Circulação Pulmonar , Fluxo Sanguíneo RegionalAssuntos
Angina Pectoris/cirurgia , Adulto , Angina Pectoris/complicações , Angina Pectoris/diagnóstico , Cateterismo Cardíaco , Ponte de Artéria Coronária , Seguimentos , Humanos , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Prognóstico , Veia Safena/transplante , Transplante HomólogoAssuntos
Aortografia/efeitos adversos , Meios de Contraste/efeitos adversos , Nefropatias/induzido quimicamente , Paraplegia/induzido quimicamente , Traumatismos da Medula Espinal/induzido quimicamente , Animais , Doenças Desmielinizantes/induzido quimicamente , Cães , Humanos , Túbulos Renais/efeitos dos fármacos , Punções , Artéria Renal/patologia , Medula Espinal/irrigação sanguíneaAssuntos
Guerra Biológica/prevenção & controle , Bioterrorismo/prevenção & controle , Defesa Civil/organização & administração , Planejamento em Desastres/organização & administração , Surtos de Doenças/prevenção & controle , Serviços Médicos de Emergência/organização & administração , Antibacterianos/provisão & distribuição , Antibacterianos/uso terapêutico , Colorado/epidemiologia , Tomada de Decisões Gerenciais , Planejamento Hospitalar , Humanos , Liderança , Projetos Piloto , Peste/tratamento farmacológico , Peste/epidemiologia , Peste/prevenção & controle , Administração em Saúde Pública , Estados UnidosAssuntos
Bioterrorismo/prevenção & controle , Defesa Civil/organização & administração , Tomada de Decisões Gerenciais , Planejamento em Desastres/organização & administração , Surtos de Doenças/prevenção & controle , Peste/prevenção & controle , Administração em Saúde Pública , Antibacterianos/provisão & distribuição , Notificação de Doenças , Órgãos Governamentais/organização & administração , Planejamento Hospitalar/organização & administração , Humanos , Relações Interinstitucionais , Liderança , Meios de Comunicação de Massa , Peste/diagnóstico , Peste/epidemiologia , Quarentena , Governo Estadual , Estados Unidos/epidemiologiaRESUMO
The United States Congress directed the Department of Justice to conduct an exercise engaging key personnel in the management of mock chemical, biological, or cyberterrorist attacks. The resulting exercise was called "TOPOFF," named for its engagement of top officials of the United States government. This article offers a number of medical and public health observations and lessons discovered during the bioterrorism component of the exercise. The TOPOFF exercise illuminated problematic issues of leadership and decision-making; the difficulties of prioritization and distribution of scarce resources; the crisis that contagious epidemics would cause in health care facilities; and the critical need to formulate sound principles of disease containment. These lessons should provoke consideration of future directions for bioterrorism planning and preparedness at all levels of government and among the many communities and practitioners with responsibilities for national security and public health.
Assuntos
Bioterrorismo/prevenção & controle , Doenças Transmissíveis Emergentes/prevenção & controle , Planejamento em Desastres/organização & administração , Saúde Pública , Doenças Transmissíveis Emergentes/epidemiologia , Tomada de Decisões , Surtos de Doenças/prevenção & controle , Previsões , Humanos , Liderança , Prática de Saúde Pública , Estados UnidosRESUMO
This article presents an overview of the nature and scope of the challenges posed by biological weapons, and offers ways by which the infectious diseases professional community might address the challenges of biological weapons and bioterrorism.
Assuntos
Guerra Biológica/prevenção & controle , Controle de Doenças Transmissíveis , Doenças Transmissíveis/diagnóstico , Doenças Transmissíveis/tratamento farmacológico , Surtos de Doenças/prevenção & controle , Educação Médica , Humanos , Papel do MédicoRESUMO
At intraoperative testing of defibrillation thresholds during implantation of internal cardioverter defibrillators, standard step-down approaches of energy outputs are used. If relatively high energy outputs are not successful at defibrillating the heart, the electrodes are frequently reconfigured. When attempting implantation of a nonthoracotomy lead system, high defibrillation thresholds may warrant opening of the chest cavity to place one or more epicardial electrodes. A case is presented where a nonthoracotomy system was able to be implanted using relatively low energy outputs which were reproducibly successful at terminating ventricular fibrillation when higher energy outputs were unsuccessful. Mechanisms for this phenomenon and alternate recommendations for defibrillation testing are presented.
Assuntos
Desfibriladores Implantáveis , Cardioversão Elétrica/métodos , Idoso , Eletrodos Implantados , Humanos , Masculino , Fibrilação Ventricular/terapiaRESUMO
Serum alanine transaminase (ALT) levels are used to select hepatitis C virus (HCV)-infected patients for treatment and liver biopsy. However, the natural history of these measurements is poorly understood. To examine the hypothesis that ALT levels vary over time in HCV-infected patients, serial serum ALT levels were prospectively measured in a cohort of 1,235 persons with a history of prior illicit drug use. Over 25 months of follow-up, there was a median of four evaluations per patient. ALT values were higher in 1,164 (94%) HCV-infected individuals than in 71 (6%) HCV-uninfected individuals. The remainder of the analysis focused on these HCV-infected individuals, 647 (62%) of whom had normal ALT values at their initial visit. However, 323 (49%) of these had at least one elevated ALT over the next 25 months. Of the 395 patients whose ALT was initially abnormal, 332 (84%) had at least one normal value over the next 25 months. Overall, among individuals with four or more visits, ALT values were persistently normal in 42%, persistently elevated in 15%, and intermittently elevated in 43%. Because serum ALT levels have high visit-to-visit variability, single assessments should not be used to manage HCV-infected individuals. Further investigation is needed to ascertain the correlation of serial ALT trends with important disease outcomes.
Assuntos
Serviços de Saúde Comunitária , Hepatite C/enzimologia , Fígado/enzimologia , Abuso de Substâncias por Via Intravenosa/virologia , Adulto , Alanina Transaminase/sangue , Biópsia , Feminino , Infecções por HIV/enzimologia , Hepacivirus/genética , Humanos , Fígado/patologia , Masculino , Estudos Prospectivos , RNA Viral/sangueRESUMO
CONTEXT: Self-prescription is common among practicing physicians, but little is known about the practice among resident physicians. OBJECTIVE: To determine prescription drug use and self-prescription among US resident physicians. DESIGN AND SETTING: Anonymous mail survey of all resident physicians in 4 US categorical internal medicine training programs in February 1997. MAIN OUTCOME MEASURES: Self-reported use of health care services and prescription medications and how they were obtained. RESULTS: A total of 316 (83%) of 381 residents responded; 244 residents (78%) reported using at least 1 prescription medicine and 162 residents (52%) reported self-prescribing medications. Twenty-five percent of all medications and 42% of self-prescribed medications were obtained from a sample cabinet; 7% of all medications and 11% of self-prescribed medications were obtained directly from a pharmaceutical company representative. CONCLUSIONS: Self-prescription is common among resident physicians. Although self-prescription is difficult to evaluate, the source of these medications and the lack of oversight of medication use raise questions about the practice.
Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Internato e Residência/estatística & dados numéricos , Automedicação/estatística & dados numéricos , Humanos , Medicina Interna/educação , Inquéritos e Questionários , Estados Unidos , Recursos HumanosRESUMO
OBJECTIVE: The Working Group on Civilian Biodefense has developed consensus-based recommendations for measures to be taken by medical and public health professionals if botulinum toxin is used as a biological weapon against a civilian population. PARTICIPANTS: The working group included 23 representatives from academic, government, and private institutions with expertise in public health, emergency management, and clinical medicine. EVIDENCE: The primary authors (S.S.A. and R.S.) searched OLDMEDLINE and MEDLINE (1960-March 1999) and their professional collections for literature concerning use of botulinum toxin as a bioweapon. The literature was reviewed, and opinions were sought from the working group and other experts on diagnosis and management of botulism. Additional MEDLINE searches were conducted through April 2000 during the review and revisions of the consensus statement. CONSENSUS PROCESS: The first draft of the working group's consensus statement was a synthesis of information obtained in the formal evidence-gathering process. The working group convened to review the first draft in May 1999. Working group members reviewed subsequent drafts and suggested additional revisions. The final statement incorporates all relevant evidence obtained in the literature search in conjunction with final consensus recommendations supported by all working group members. CONCLUSIONS: An aerosolized or foodborne botulinum toxin weapon would cause acute symmetric, descending flaccid paralysis with prominent bulbar palsies such as diplopia, dysarthria, dysphonia, and dysphagia that would typically present 12 to 72 hours after exposure. Effective response to a deliberate release of botulinum toxin will depend on timely clinical diagnosis, case reporting, and epidemiological investigation. Persons potentially exposed to botulinum toxin should be closely observed, and those with signs of botulism require prompt treatment with antitoxin and supportive care that may include assisted ventilation for weeks or months. Treatment with antitoxin should not be delayed for microbiological testing.
Assuntos
Guerra Biológica , Bioterrorismo , Toxinas Botulínicas , Botulismo , Antitoxinas/uso terapêutico , Botulismo/diagnóstico , Botulismo/epidemiologia , Botulismo/etiologia , Botulismo/prevenção & controle , Botulismo/terapia , Defesa Civil , Clostridium/patogenicidade , Descontaminação , Diagnóstico Diferencial , Humanos , Controle de Infecções , Saúde Pública , Estados Unidos , VirulênciaRESUMO
OBJECTIVE: The Working Group on Civilian Biodefense has developed consensus-based recommendations for measures to be taken by medical and public health professionals if tularemia is used as a biological weapon against a civilian population. PARTICIPANTS: The working group included 25 representatives from academic medical centers, civilian and military governmental agencies, and other public health and emergency management institutions and agencies. EVIDENCE: MEDLINE databases were searched from January 1966 to October 2000, using the Medical Subject Headings Francisella tularensis, Pasteurella tularensis, biological weapon, biological terrorism, bioterrorism, biological warfare, and biowarfare. Review of these references led to identification of relevant materials published prior to 1966. In addition, participants identified other references and sources. CONSENSUS PROCESS: Three formal drafts of the statement that synthesized information obtained in the formal evidence-gathering process were reviewed by members of the working group. Consensus was achieved on the final draft. CONCLUSIONS: A weapon using airborne tularemia would likely result 3 to 5 days later in an outbreak of acute, undifferentiated febrile illness with incipient pneumonia, pleuritis, and hilar lymphadenopathy. Specific epidemiological, clinical, and microbiological findings should lead to early suspicion of intentional tularemia in an alert health system; laboratory confirmation of agent could be delayed. Without treatment, the clinical course could progress to respiratory failure, shock, and death. Prompt treatment with streptomycin, gentamicin, doxycycline, or ciprofloxacin is recommended. Prophylactic use of doxycycline or ciprofloxacin may be useful in the early postexposure period.
Assuntos
Guerra Biológica , Defesa Civil/normas , Surtos de Doenças/prevenção & controle , Tularemia/prevenção & controle , Antibacterianos/uso terapêutico , Vacinas Bacterianas , Bioterrorismo , Descontaminação , Francisella tularensis/patogenicidade , Humanos , Controle de Infecções , Tularemia/diagnóstico , Tularemia/epidemiologia , Tularemia/etiologia , Estados Unidos/epidemiologia , Vacinação , Vacinas Atenuadas , VirulênciaRESUMO
OBJECTIVE: The Working Group on Civilian Biodefense has developed consensus-based recommendations for measures to be taken by medical and public health professionals following the use of plague as a biological weapon against a civilian population. PARTICIPANTS: The working group included 25 representatives from major academic medical centers and research, government, military, public health, and emergency management institutions and agencies. EVIDENCE: MEDLINE databases were searched from January 1966 to June 1998 for the Medical Subject Headings plague, Yersinia pestis, biological weapon, biological terrorism, biological warfare, and biowarfare. Review of the bibliographies of the references identified by this search led to subsequent identification of relevant references published prior to 1966. In addition, participants identified other unpublished references and sources. Additional MEDLINE searches were conducted through January 2000. CONSENSUS PROCESS: The first draft of the consensus statement was a synthesis of information obtained in the formal evidence-gathering process. The working group was convened to review drafts of the document in October 1998 and May 1999. The final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members. CONCLUSIONS: An aerosolized plague weapon could cause fever, cough, chest pain, and hemoptysis with signs consistent with severe pneumonia 1 to 6 days after exposure. Rapid evolution of disease would occur in the 2 to 4 days after symptom onset and would lead to septic shock with high mortality without early treatment. Early treatment and prophylaxis with streptomycin or gentamicin or the tetracycline or fluoroquinolone classes of antimicrobials would be advised.
Assuntos
Guerra Biológica/prevenção & controle , Peste/prevenção & controle , Yersinia pestis , Antibacterianos/uso terapêutico , Defesa Civil , Descontaminação , Planejamento em Desastres , Humanos , Controle de Infecções , Peste/epidemiologia , Peste/fisiopatologia , Vacina contra a Peste , Violência , Virulência , Yersinia pestis/patogenicidadeRESUMO
OBJECTIVE: To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of anthrax as a biological weapon against a civilian population. PARTICIPANTS: The working group included 21 representatives from staff of major academic medical centers and research, government, military, public health, and emergency management institutions and agencies. EVIDENCE: MEDLINE databases were searched from January 1966 to April 1998, using the Medical Subject Headings anthrax, Bacillus anthracis, biological weapon, biological terrorism, biological warfare, and biowarfare. Review of references identified by this search led to identification of relevant references published prior to 1966. In addition, participants identified other unpublished references and sources. CONSENSUS PROCESS: The first draft of the consensus statement was a synthesis of information obtained in the formal evidence-gathering process. Members of the working group provided formal written comments which were incorporated into the second draft of the statement. The working group reviewed the second draft on June 12, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members. CONCLUSIONS: Specific consensus recommendations are made regarding the diagnosis of anthrax, indications for vaccination, therapy for those exposed, postexposure prophylaxis, decontamination of the environment, and additional research needs.
Assuntos
Antraz , Guerra Biológica , Saúde Pública , Adolescente , Adulto , Antraz/diagnóstico , Antraz/tratamento farmacológico , Antraz/prevenção & controle , Bacillus anthracis/imunologia , Vacinas Bacterianas , Criança , Pré-Escolar , Descontaminação , Exposição Ambiental , Feminino , Humanos , Hospedeiro Imunocomprometido , Lactente , Controle de Infecções , Masculino , Gravidez , Estados Unidos , Vacinação , Vacinas de Produtos InativadosRESUMO
OBJECTIVE: To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of smallpox as a biological weapon against a civilian population. PARTICIPANTS: The working group included 21 representatives from staff of major medical centers and research, government, military, public health, and emergency management institutions and agencies. Evidence The first author (D.A.H.) conducted a literature search in conjunction with the preparation of another publication on smallpox as well as this article. The literature identified was reviewed and opinions were sought from experts in the diagnosis and management of smallpox, including members of the working group. CONSENSUS PROCESS: The first draft of the consensus statement was a synthesis of information obtained in the evidence-gathering process. Members of the working group provided formal written comments that were incorporated into the second draft of the statement. The working group reviewed the second draft on October 30, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members. CONCLUSIONS: Specific recommendations are made regarding smallpox vaccination, therapy, postexposure isolation and infection control, hospital epidemiology and infection control, home care, decontamination of the environment, and additional research needs. In the event of an actual release of smallpox and subsequent epidemic, early detection, isolation of infected individuals, surveillance of contacts, and a focused selective vaccination program will be the essential items of an effective control program.