Effect of a multicomponent intervention on achievement and improvements in quality-of-care indices among people with Type 2 diabetes in South Asia: the CARRS trial.

AIMS: To evaluate whether and what combinations of diabetes quality metrics were achieved in a multicentre trial in South Asia evaluating a multicomponent quality improvement intervention that included non-physician care coordinators to promote adherence and clinical decision-support software to enhance physician practices, in comparision with usual care. METHODS: Using data from the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, we evaluated the proportions of trial participants achieving specific and combinations of five diabetes care targets (HbA1c <53 mmol/mol [7%], blood pressure <130/80 mmHg, LDL cholesterol <2.6 mmol/L, non-smoking status, and aspirin use). Additionally, we examined the proportions of participants achieving the following risk factor improvements from baseline: ≥11-mmol/mol (1%) reduction in HbA1c , ≥10-mmHg reduction in systolic blood pressure, and/or ≥0.26-mmol/l reduction in LDL cholesterol. RESULTS: Baseline characteristics were similar in the intervention and usual care arms. Overall, 12.3%, 29.4%, 36.5%, 19.5% and 2.2% of participants in the intervention group and 16.2%, 38.3%, 31.6%, 11.3% and 0.8% of participants in the usual care group achieved any one, two, three, four or five targets, respectively. We noted sizeable improvements in HbA1c , blood pressure and cholesterol, and found that participants in the intervention group were twice as likely to achieve improvements in all three indices at 12 months that were sustained over 28 months of the study [relative risk 2.1 (95% CI 1.5,2.8) and 1.8 (95% CI 1.5,2.3), respectively]. CONCLUSIONS: The intervention was associated with significantly higher achievement of and greater improvements in composite diabetes quality care goals. However, among these higher-risk participants, very small proportions achieved the complete group of targets, which suggests that achievement of multiple quality-of-care goals is challenging and that other methods may be needed in closing care gaps.

Variation in growth and evaluation of cross-protection in Listeria monocytogenes under salt and bile stress.

AIMS: Exposure of Listeria monocytogenes to osmotic stress can induce increased resistance to subsequent lethal exposure to cell envelope stressors, such as nisin and bile salts. We wanted to determine if similar cross-protection phenotypes could occur when L. monocytogenes strains were treated with osmotic stress and exposed to sublethal levels of the cell envelope stressor, bile. METHOD AND RESULTS: Growth phenotypes were measured for six L. monocytogenes strains exposed to 6% NaCl, 0·3 and 1% bile in BHI. To evaluate cross-protection, cells were pre-exposed to 6% NaCl, followed by exposure to BHI+1% bile for 26 h and vice versa. Significant increases in λ (lag phase) and doubling time were observed under salt and bile stresses compared with BHI alone. Average λ and Nmax (maximum cell density) in 0·3 and 1% bile for all strains were significantly lower than that in 6% NaCl. Pre-exposure to 6% NaCl followed by exposure to 1% bile significantly increased λ (P < 0·05), whereas pre-exposure to 1% bile followed by exposure to 6% NaCl led to formation of filamentous cells, with no changes in cell density over 26 h. CONCLUSIONS: Variation in growth characteristics was observed among strains exposed to bile. Exposure to osmotic stress did not lead to increased resistance to bile. Exposure to bile significantly impacted the ability of L. monocytogenes to adapt to grow under osmotic stress, where cells did not multiply but formed filamentous cells. SIGNIFICANCE AND IMPACT OF THE STUDY: Pre-exposure to a cell envelope stress and subsequent exposure to an osmotic stress appears to pose a significant stress to L. monocytogenes cells.

Pathologies en-route of oral basaloid malignancies to basaloid squamous cell carcinoma.

Accurate histopathological diagnosis of any tumour is imperative because of variable prognostic and clinical implications. Basaloid squamous cell carcinoma (BSCC) is a rare distinctive histological variant of oral squamous cell carcinoma (OSCC) exhibiting an aggressive clinical course and poor prognosis. The advanced stage of presentation is speculatively responsible for this biological behaviour which is manifested by development of metastasis and subsequently poor survival. However, the non-specific clinical appearance and histopathological resemblance of BSCC with OSCC and other oral basaloid malignancies (OBM) especially in limited sample size poses diagnostic difficulties. The article emphasizes on the diagnostic criteria and pitfalls encountered in making the differential diagnosis of BSCC from OBMs along with report of a case presented at a dental college in January 2012.

Comparison of three videolaryngoscopes: Pentax Airway Scope, C-MAC, Glidescope vs the Macintosh laryngoscope for tracheal intubation.

We compared the intubating characteristics of the Pentax Airway Scope, the C-MAC and the Glidescope with those of the Macintosh laryngoscope in 400 patients without predictors of difficult intubation. We found shorter intubation times with the Airway Scope (mean (SD) 20.6 (11.5) s) compared with the C-MAC (31.9 (17.6) s) and Glidescope (31.2 (15.0) s), p < 0.001. The median (IQR [range]) score for ease of intubation was significantly lower (better) with the Airway Scope (0 (0-8.75 [0-60])) than with the C-MAC (10 (0-20 [0-90])) or Glidescope (0 (0-20 [0-80])), p < 0.001. Ease of blade insertion in the C-MAC (0 (0-0 [0-30])) was superior to that of the Airway Scope (0 (0-0 [0-70])), Macintosh (0 (0-0 [0-80])) or Glidescope (0 (0-10 [0-60])), p = 0.006. More patients had a grade 1 laryngeal view with the Airway Scope (97%) compared with the C-MAC (87%), Glidescope (78%), or Macintosh (58%), p < 0.001. There were no grade 3 laryngeal views with the Airway Scope. The three videolaryngoscopes had comparable first attempt successful intubation rates: 95% for the Airway Scope, 93% for the C-MAC and 91% for the Glidescope.

Substrate-dependent auxin production by Rhizobium phaseoli improves the growth and yield of Vigna radiata L. under salt stress conditions.

Rhizobium phaseoli strains were isolated from the mung bean nodules, and, the most salt tolerant and high auxin producing rhizobial isolate N20 was evaluated in the presence and absence of L-tryptophan (L-TRP) for improving growth and yield of mung bean under saline conditions in a pot experiment. Mung bean seeds were inoculated with peat-based inoculum and NP fertilizers were applied at 30-60 kg ha-1, respectively. Results revealed that imposition of salinity reduced the growth and yield of mung bean. On the contrary, separate application of L-TRP and rhizobium appeared to mitigate the adverse effects of salt stress. However, their combined application produced more pronounced effects and increased the plant height (28.2%), number of nodules plant-1 (71.4%), plant biomass (61.2%), grain yield (65.3%) and grain nitrogen concentration (22.4%) compared with untreated control. The growth promotion effect might be due to higher auxin production in the rhizosphere and improved mineral uptake that reduced adverse effects of salinity. The results imply that supplementing rhizobium inoculation with L-TRP could be a useful approach for improving growth and yield of mung bean under salt stressed conditions.

Randomised comparison of Pentax AirwayScope and Glidescope for tracheal intubation in patients with normal airway anatomy.

SUMMARY: We compared intubating characteristics of the Pentax AirwayScope and Glidescope in a randomised controlled trial involving 140 patients. We found significantly shorter intubation times with mean (SD) 21.3 (12.3) vs 30.2 (13.2) s, lower intubating difficulty scores 4.4 (10.4) vs 12.8 (16.3) p < 0.001, and better grade 1 laryngeal views with the Pentax AirwayScope (95.7 vs 81.4%, p = 0.015). Significantly more optimisation manoeuvres were needed to successfully intubate with the Glidescope, with significant inability to align the tip of the tracheal tube with the glottic opening with the Glidescope in 9 (13%) vs no patients, p = 0.013. There was more mucosal bleeding (4 (5.7%) vs 1 (1.4%), p = 0.366), more lip bleeding (3 (4.3%) vs 1 (1.4%), p = 0.620) and significantly more postoperative sorethroat, 13 (18.6%) vs 0, p < 0.001 associated with the Glidescope.

Inclusion of an S-nitrosylating agent in the insufflating gas does not alter gastric activity in rats following pneumoperitoneum.

BACKGROUND: We have previously shown that mixing the S-nitrosylating agent ethyl nitrite with carbon dioxide can attenuate pneumoperitoneum-induced decreases in splanchnic blood flow, but it was unclear if this agent would alter gastric function. This question was answered using rats by assessing gastric emptying and gastrointestinal transit times following gavage with radioactive chromium. METHODS: There were five experimental groups: absolute control, anesthesia control, and carbon dioxide alone or with 100 or 300 parts per million ethyl nitrite. The period of insufflation was 1 h, and all animals were euthanized 6.5 h after chromium administration. RESULTS: The mean amount of radioactivity remaining in the stomach ranged between 16% and 27% of the total administered; these differences were not statistically significant (p > 0.05). Modest differences in chromium distribution were identified in the gastrointestinal tract, but for all treatments, the peak amount of radioactivity was located in the distal portion. Location of the peak, expressed as a percentage of total tract length, varied between 70% and 85% (p = 0.366). CONCLUSIONS: This study found no adverse effect of ethyl nitrite on postoperative gastric emptying or gastrointestinal transit time following pneumoperitoneum. The findings support continued assessment of the clinical utility of ethyl nitrite in the setting of laparoscopic surgery.

De Novo Collapsing Glomerulopathy in Renal Allograft in Association with BK Virus Nephropathy in a Child and Stabilization of Renal Function by Elimination of Viremia.

Well-recognized association between HIV 1 infection and collapsing glomerulopathy (CG) raises the possibility that intrarenal infection by other viruses may also contribute to the development of this lesion in native or post-transplant kidneys. There is evidence in literature about association of these lesions with cytomegalovirus, Epstein-Barr virus, hepatitis C virus, and parvovirus B19 infections. Here, we present a case report of post-transplant BK virus nephropathy in a male child who was found to have CG in subsequent biopsy 2 months later. His renal function and proteinuria were stabilized on elimination of viremia.

Long-term behavioral assessment of guinea pigs following neonatal pneumoperitoneum.

BACKGROUND: Using guinea pigs, we previously demonstrated that pneumoperitoneum during pregnancy produces behavioral deficits in the offspring. In the current study, the purpose was to determine if CO(2) pneumoperitoneum during the early postnatal period also produced behavioral anomalies. METHODS: Following delivery, guinea pig pups were randomly assigned to one of three treatment groups: CO(2) pneumoperitoneum (P), laparotomy (L), or isolation control (I). Surgeries were performed on postnatal day (PND) 5 under isoflurane anesthesia; control pups were isolated from the dams for an equivalent period of time. On PNDs 10, 20, 40, and 60, behavior was assessed by monitoring locomotor and exploratory activity. RESULTS: A total of 29 animals were studied. We observed no immediate morbidity or mortality and the manipulations did not appear to affect postnatal growth. On PND 10, pups in group P exhibited lower levels of locomotor activity compared to L and I neonates, but this difference resolved as the animals got older. Histologic assessment of the adult offspring brains revealed no evidence of neurologic injury. CONCLUSION: These data suggest that unlike insufflation during pregnancy, neonatal pneumoperitoneum does not produce behavioral deficits.

Evaluation of surgical and anaesthesia response times for crash caesarean sections--an audit of a Singapore hospital.

INTRODUCTION: The Royal College of Obstetricians and Gynaecologists published the "Organisational Standards for Maternity Services" in 1995, in which they proposed that there be a maximum decision-to-delivery time of 30 minutes for urgent caesarean sections (CS). In 1997, our institution established a protocol for extremely urgent ("crash") CS to expedite delivery time and to conform to this standard. MATERIALS AND METHODS: The objective of this prospective audit was to determine the surgical and anaesthesia response times in our institution after the protocol had been implemented. The audit was conducted in KK Women's and Children's Hospital from February 2003 to January 2004, over a 12-month period. Upon activation of a "crash" CS, the attending anaesthetist was required to record the decision-to-anaesthesia time, decision-to-delivery time and the perinatal outcome. RESULTS: Ninety-eight cases of "crash" CS were identified from a total of 3629 elective and non-elective CS, with 80 cases having complete data. The mean decision-to-delivery interval was 7.7 min+/-3.0 (SD) with 100% of deliveries made within 17 minutes. The mean decision-to-anaesthesia time was 3.5 min+/-2.0 (SD) with all the patients anaesthetised within 10 minutes. The majority (88.8%) of the patients had general anaesthesia for "crash" CS while the rest had successful epidural block extension. There was no significant difference in the decision-to-delivery interval or mean cord blood pH with respect to the type of anaesthesia given. CONCLUSIONS: We achieved 100% deliveries within the proposed 30-minute decision-to-delivery time interval by implementing a protocol for "crash" CS. Both general anaesthesia and extension of existing epidural block are acceptable modes of anaesthesia and do not delay delivery of the fetus.

Treatment of symptomatic chronic adenotonsillar hypertrophy with amoxicillin/clavulanate potassium: short- and long-term results.

OBJECTIVE: To evaluate the short- and long-term effects of treatment of symptomatic chronic adenotonsillar hypertrophy (CATH) with a 30-day course of amoxicillin/clavulanate potassium (AMOX/CLAV). PATIENTS: Children 2 to 16 years of age with obstructive symptoms attributable to CATH, who did not have a history of recurrent adenotonsillitis. DESIGN: A prospective, randomized, double-blinded, placebo-controlled trial. SETTING: Ambulatory clinic of a tertiary care hospital. INTERVENTION: Patients were randomly treated with 30-day courses of either placebo (PLAC) or AMOX/CLAV (40 mg/kg in 3 divided doses daily). OUTCOME MEASURES: Patients' signs and symptoms were assessed by physical examination and by both physician and parental forced-choice questionnaires 1, 3, and 24 months after treatment. The decision to proceed to surgery or to continue expectant management was made for all patients by the same physician, based on reported symptoms and physical findings. RESULTS: Treatment with a 30-day course of AMOX/CLAV significantly reduced the need for surgery in the short term compared with PLAC (37.5% vs 62.7%) at 1-month follow-up). The reduced need for surgery in the AMOX/CLAV-treated group persisted at 3 months (AMOX/CLAV 54.5% vs PLAC 85.7%) and 24 months (AMOX/CLAV 83.3% vs PLAC 98.0%). CONCLUSIONS: A 30-day course of AMOX/CLAV significantly reduces the need for surgery in children with obstructive adenotonsillar hypertrophy at 1-month follow-up. This relative reduction persists at 3 and 24 months posttreatment, although the absolute percentages of patients requiring surgery increased in both groups as time after treatment increased. The reduction in symptoms in AMOX/CLAV-treated patients is modest but significant even in long-term follow-up. The precise role of this treatment for CATH is yet to be determined; however, our results suggest that a 30-day course of AMOX/CLAV can be used in situations when a temporary relief in symptoms is desirable or surgery would incur unacceptable risk.

Comparison of responses to rat and human adrenomedullin in the hindlimb vascular bed of the cat.

Responses to rat (r) adrenomedullin (ADM) and human (h) ADM were compared in the hindlimb vascular bed of the cat under conditions of controlled blood flow. Intra-arterial injections of rADM and hADM in doses of 0.03-1 nmol caused dose-related decreases in hindlimb perfusion pressure. In terms of relative vasodilator activity, rADM was similar to hADM. The time course of the vasodilator response and the recovery half times (T1/2) for the vasodilator response to rADM and hADM were not significantly different. Decreases in hindlimb perfusion pressure in response to rADM and hADM were not altered by the calcitonin gene-related peptide receptor antagonist, rCGRP(8-37), at the same time, vasodilator responses to calcitonin gene-related peptide (CGRP) were significantly reduced. The T1/2 of the vasodilator response to rADM and hADM were significantly greater after administration of the cAMP-selective, type IV phosphodiesterase inhibitor, rolipram. These data demonstrate that decreases in hindlimb perfusion pressure in response to rADM and hADM are similar and that vasodilator responses to rADM are not dependent on the activation of CGRP receptors in the hindlimb vascular bed of the cat. These data further suggest that decreases in hindlimb perfusion pressure in response to rADM are mediated by smooth muscle increases in cAMP levels.

Differential responses to ATPgammaS in the mesenteric and hindlimb vascular bed of the cat.

The mechanism by which the purinergic agonist adenosine 5'-O-(3 thiotriphosphate) (ATPgammaS) decreases vascular resistance was investigated in the mesenteric and hindlimb vascular beds of the cat. Injections of ATPgammaS into the hindlimb perfusion circuit elicited dose-dependent decreases in perfusion pressure while injections into the mesenteric circuit produced a biphasic response with an initial vasopressor response followed by a vasodepressor response. In the mesenteric vascular bed the pressor response to ATPgammaS was blocked by a P2X1 receptor antagonist. Also an inhibitor of nitric oxide synthase enhanced the vasoconstrictive responses to ATPgammaS. However, the vasodepressor response in the mesenteric bed was not altered by the adminstration of an alpha adrenergic receptor antagonist, a cyclooxygenase inhibitor, a P2Y1 receptor antagonist, or a K+ATP channel blocking agent. These data suggest that the vasopressor response to ATPgammaS in the mesenteric vascular bed of the cat is mediated via P2X1 receptor activation. The differential responses to ATPgammaS in the hindlimb and mesentery suggest differences in purinergic receptor distribution in the vascular system of the cat. In addition, the results suggest that prostaglandin synthesis, P2Y1 receptor activation, alpha receptor inhibition, and K+ATP channels activation play little to no role in mediating the vascular response to ATPgammaS in the mesentery of the cat.

A unique case of Cryptococcus laurentii keratitis spread by a rigid gas permeable contact lens in a patient with onychomycosis.

PURPOSE: We report the first case of fungal keratitis caused by Cryptococcus laurentii, a nonneoformans species. METHODS: A case of C. laurentii keratitis in a diabetic, gas permeable contact lens wearer was diagnosed after microbiologic evaluation of the corneal button after emergent keratoplasty. The excised cornea was also culture positive for Staphylococcus aureus and Fusarium solani. The medical history was significant for onychomycosis of the right great toe 2 months previously. Cultures of the toenail and of the contact lens case were also positive for C. laurentii and F. solani. RESULTS: An initial penetrating keratoplasty with histopathologically clear margins was unsuccessful in preventing intraocular spread of the fungal infection. Despite a repeat limbus-to-limbus therapeutic keratoplasty, pars plana vitrectomy, multiple anterior chamber washouts, intravitreal antifungal injections, and systemic antifungal treatment, the eye was ultimately lost due to ongoing inflammation, ocular hypotony, and a total retinal detachment. Histopathologic examination of the enucleated eye demonstrated filamentous fungi but no yeast forms. CONCLUSIONS: C. laurentii, a nonneoformans species, should be included in the differential diagnosis of fungal keratitis. This unique case also demonstrates the importance of a thorough clinical history and proper contact lens hygiene, particularly in a diabetic patient.

A devastating ocular pathogen: beta-streptococcus Group G.

PURPOSE: To report the clinical findings, treatment, and outcomes of four cases of beta-streptococcus Group G (BHS-G) ocular infection. METHODS: The medical and microbiologic records of four cases of BHS-G ocular infection were retrospectively reviewed. RESULTS: Two cases of BHS-G endophthalmitis and two cases of BHS-G keratitis were recorded. Three patients developed fulminant infection within 12 hours of the onset of symptoms. One patient's history was incomplete. One patient developed endophthalmitis from a contaminated donor button; another following cataract surgery. One developed keratitis in a keratoplasty suture tract; and another patient developed a corneal abscess after being struck with a tree branch. The patient with the contaminated donor button developed overwhelming endophthalmitis resulting in no light perception vision, severe pain, and evisceration. The postoperative cataract patient developed a purulent endophthalmitis and is still hypotonus with light perception vision. The second keratitis patient developed a significant suture abscess with marked stromal loss but eventually healed. The traumatic keratitis patient developed a large ulcer with hypopyon and descemetocele but was lost to follow-up. CONCLUSIONS: This is the first report of a series of BHS-G ocular infections. The ocular infections were characterized by rapid onset, extreme inflammation, and--despite in vitro antibiotic sensitivity--a poor or sluggish response to antibiotic therapy.

In vitro effectiveness of 13 agents in otomycosis and review of the literature.

Many agents have been recommended for treating otomycosis, but no preparation has been widely accepted. To compare the effectiveness of many recommended preparations, we performed an in vitro study using 15 species of fungi and yeast cultured from patients presenting with otomycosis during the past year. By measuring zones of inhibition, we assessed the effectiveness of aqueous Merthiolate, Burow's solution (2%), VoSol HC, VoSol plain, Cortisporin suspension, clotrimazole 1%, Mycostatin, amphotericin B, ethanol 95%, miconazole, tolnaftate 1%, natamycin, and flucytosine. Most otic preparations showed little or no growth inhibition. However, Merthiolate was very effective against all organisms tested, clotrimazole was very effective against most yeast and fungi tested, and nystatin had the widest spectrum of activity among the antifungals. Tolnaftate was ineffective. Vigorous cleaning of the external auditory canal remains the mainstay in treating otymycosis, but proper laboratory identification and suitable topical therapy are also important in dealing with this capricious infection.

Simultaneous bilateral quadriceps tendon rupture in renal patients.

AIMS: Simultaneous bilateral quadriceps tendon rupture occurs in patients with renal disease. It has been hypothesized that the length of renal disease and the length of dialysis may correlate with the development of tendon ruptures. This study aims to characterize the factors involved in patients with renal disease and simultaneous bilateral quadriceps tendon rupture. METHODS: All reported cases of simultaneous bilateral quadriceps tendon rupture were identified using MEDLINE. Each case was reviewed for information regarding this injury. RESULTS: Of the 65 cases reviewed, 24 cases involved patients with renal disease. Males were more often affected than females, almost a 2 : 1 ratio. The mean age of injury was 36 years. Most patients (63%) had signs of secondary hyperparathyroidism. The average length of renal disease was 13 years while the average length on dialysis was 6.5 years. Age, gender, mechanism of injury, time before diagnosis, location of rupture, method of repair, presence of hyperparathyroidism, length of renal disease or length on dialysis were not related to functional outcome. However, length on dialysis was related to mechanism of injury. CONCLUSIONS: Most patients with renal disease and simultaneous bilateral quadriceps tendon rupture have good functional recovery. Duration of dialysis is related to spontaneous tendon rupture and should be considered a complication of chronic renal failure.

Vasodilator responses to ATP and UTP are cAMP dependent in the mesenteric vascular bed of the cat.

BACKGROUND: This study was designed to examine the responses to and the mechanism by which purinergic agonists decrease vascular resistance in the mesenteric vascular bed of the cat. METHODS AND RESULTS: Injections of ATP, UTP, and 2-MethylThioATP (2-MetSATP) into the mesenteric perfusion circuit elicited dose-dependent decreases in perfusion pressure while injections of beta,gamma-MethylATP (beta,gamma-MetATP) produced a biphasic response with an initial vasopressor response followed by a vasodilator response. The order of potency of the vasodilator response was 2-MetSATP > ATP > UTP > beta,gamma-MetATP. The vasodilator responses to ATP, UTP, 2-MetSATP, and beta,gamma-MetATP were increased in duration by the cAMP phosphodiesterase inhibitor, rolipram. However, vasodilator responses were not altered by the adminstration of a nitric oxide synthase inhibitor, a cGMP phosphodiesterase inhibitor, or a cyclooxygenase inhibitor. Treatment with PPADS, a P2X(1), P2Y(1), and P2Y(4) receptor antagonist, did not alter vasodilator responses to the purinergic agonists; however, the vasopressor component of the response to beta,gamma-MetATP was decreased. CONCLUSIONS: These data suggest that ATP, UTP, 2-MetSATP, and beta,gamma-MetATP dilate the mesentary vascular bed in the cat by a cAMP dependent mechanism, and that nitric oxide or prostaglandin release, cGMP accumulation, or activation of P2X(1), P2Y(1), or P2Y(4) receptors play little or no role in mediating vasodilator responses to the purinergic agonists in this regional vascular bed. In addition, these results suggest that the pressor component of the response to beta,gamma-MetATP is mediated by the activation of P2X(1) receptors.

Community-acquired methicillin-resistant Staphylococcus aureus infections in otolaryngology.

Soon after the introduction of methicillin, strains of Staphylococcus aureus resistant to methicillin were reported. Methicillin-resistant Staphylococcus aureus (MRSA) has become a common hospital pathogen, often resistant to multiple antibiotics, while causing significant morbidity and mortality. Community-acquired MRSA infections have been infrequently documented. Most reports have been associated with intravenous drug abuse. This report reviews 15 patients with community-acquired MRSA infections of the head and neck. None admitted to intravenous drug use. Additionally, no patient was known to be a healthcare worker. The MRSA strains showed antibiotic susceptibility and resistance profiles different from typical hospital-acquired MRSA isolates. All but one infection resolved with adequate surgical or appropriate antibiotic therapy. Clinicians should become aware of the possibility of community-acquired MRSA in the patient who has had continued infection despite antibiotic therapy.

Creatine kinase and its isoenzyme MB in patients after open heart surgery.

Total serum creatine kinase (CK) and its isoenzyme MB (CKMB) were measured before and 4, 24, 48 and 72 hours after termination of cardiopulmonary bypass in patients undergoing (I) atriotomy, (II) ventriculotomy and (III) coronary artery bypass surgery. All patients were free of postoperative complications and myocardial infarction as defined by clinical course, 12 lead ECG and 2D echocardiography. Peak elevation of CK occurred at 24th hour and CKMB at 4th hour and then gradually declined. There was no relation between the peak level of rise of CK or CKMB with cross clamp time or bypass time. The 96th percentile values of absolute CKMB level at 4, 24, 48 and 72 hours may suggest perioperative myocardial infarction with specificity of 95%. In addition, the rising value of CKMB beyond 24 hours after the termination of bypass may also suggest occurrence of myocardial infarction.