Cutaneous manifestations of waterborne infections

Although waterborne pathogens are relatively uncommon causes of cutaneous infections, these agents are being recognized with increasing frequency. Humans are exposed to water through a variety of recreational and occupational activities. Poor sanitary conditions in developing nations place the human populations at constant risk. Some aquatically acquired skin infections respond well to therapy, whereas other diseases do not require a specific treatment. However, many of these infections are rare, and effective therapy has not been defined. Gram-negative bacilli constitute the largest group of aquatic pathogens that cause skin infections. Other agents include mycobacteria, fungi, viruses, and amoeba and other parasites. Toxins from aquatic animals and parasites are associated with cutaneous diseases. Because waterborne skin infections, which are caused by a wide variety of pathogens, occur infrequently, most of the literature on the topic are case reports. This paper reviews the aquatic pathogens associated with cutaneous infections in humans and the available treatments.     

Blastoschizomyces capitatus pneumonia in an immunocompetent male

Blastoschizomyces capitatus is an emerging fungal pathogen. It has been well characterized as a cause of local and disseminated disease in immunocompromised hosts, especially in the setting of neutropenia. We describe a case of B. capitatus pneumonia in an otherwise healthy man and review the clinical presentation, microbiologic characteristics, and treatment strategies for B. capitatus infections.     

The effect of treating bacterial vaginosis on preterm labor

OBJECTIVE: Multiple studies suggest that bacterial vaginosis (BV) causes preterm labor; yet its routine treatment remains controversial. In order to help to elucidate this controversy, we performed a thorough review of studies with levels of evidence ranging from I to II-II. METHODS: We searched for all of the studies from the years 1994 to 2001 via Medline's database, including MD Consult and Ovid Mednet. RESULTS: Several trials discovered a decrease in the incidence of preterm labor when BV was treated, but most of those trials were performed on women with a history of preterm labor. However, the majority of trials reviewed advise against treatment of a general low-risk obstetric population, as there was no significant decrease in preterm labor. CONCLUSIONS: Therefore, based on the above studies and the current guidelines of the Centers for Disease Control and Prevention (CDC), treating pregnant women in high-risk populations who are diagnosed with BV provides the clinician with an opportunity to possibly prevent preterm labor in this population. In nulliparous women without a history of preterm birth, treatment is recommended if other risk factors are present (e.g. gonorrhea or chlamydia). However, in the general low-risk populations, routine screening is not indicated.     

Depressive symptoms in advanced cancer. Part 2. Depression over time; the role of the palliative care professional

OBJECTIVE: To survey changes in depressive symptoms over time in patients with advanced cancer using the Mood Evaluation Questionnaire (MEQ), and explore how effective Palliative Care Professionals (PCPs) are at assessing this. METHOD: Forty-five advanced cancer patients were followed monthly for up to six interviews (108 interviews in total). Selected clinical variables were recorded. RESULTS: At first interview, 26 (58%) patients were depressed using MEQ, seven (16%) severely. Attrition rates were high, with 28, 13, nine, seven and six patients available for subsequent interviews. A > 12-point increase in MEQ over sequential interviews was associated with reduced survival (Hazard ratio 3.2, CI 1.2-8.4). PCPs recognized depressed mood, but underdiagnosed severe depression in 9% of patients (CI 3-16%, P = 0.002). A past history of depression was a strong indicator of current depressed mood on the MEQ. CONCLUSION: Change in depressive symptoms over time is related to mortality in this patient cohort, patients with marked deterioration in mood dying earlier. PCPs usually recognize patients' depression but underestimate the severity of depressed mood.     

Differential efficacy of intravenous lidocaine in alleviating ipsilateral versus contralateral neuropathic pain in the rat

In the this study we have investigated the threshold plasma concentration of lidocaine for reversal of mechanical ‘allodynia' in a neuropathic pain model in the rat, defined the concentration-dependent limits of that reversal and compared the acute reversal during intravenous drug infusion with the persistent relief of allodynia assayed 48 h later. Actions of i.v. lidocaine on ipsilateral and contralateral legs were also assessed. Forty rats were sorted into five groups (n=7–10) and underwent spinal root (L5–6) ligation to produce allodynia, as quantified by a lower force of von Frey hairs at the plantar hindpaw required to elicit paw withdrawal (PWT, paw withdrawal threshold). During surgery, intravenous catheters were placed for programmed lidocaine infusion and in some animals arterial catheters were also inserted for assaying lidocaine blood levels. PWTs were measured in ipsilateral and contralateral paws before and after ligation and during infusions which, beginning at 5 days after surgery, were conducted every other day to incrementing levels (1.1–9.7 μg/ml plasma). Ligation produced allodynia in ipsilateral paws (PWT=1.22±0.42 g (±SEM)) and in contralateral paws (PWT=4.99±0.61 g), both markedly lower than pre-operative control values for either paw (11.31±0.41 g). The ipsilateral allodynia was partially, but significantly and permanently reversed (to PWT=6–8 g) after a lidocaine infusion to 2.1 mg/ml in two separate groups (n=7, 8). Lower concentrations resulted in elevation of PWT during infusion but no sustained relief. The elevation of PWT during infusion at this threshold level among individual animals was positively correlated with the relief measured 48 h later, but higher lidocaine concentrations infused in subsequent dosings could exact no further sustained relief. The residual PWT level, after reversal by threshold lidocaine and greater, was constant for each individual rat tested over the next 14 days but varied substantially among individuals; some were restored to pre-operative PWTs and some were totally unresponsive to drug. Retrospective analysis revealed a significant and unanticipated correlation between the incidence of low pre-operative PWTs (<10 g) and a lack of sustained reversal of post-operative allodynia by lidocaine. Contralateral allodynia, despite its acute reversal during infusion to 2.1 μg/ml and higher, was not persistently relieved after infusion of lidocaine to any concentration. Repeated infusions to subthreshold levels (<2 μg/ml) did not provide persisting relief of allodynia on either side, and infusions of saline were impotent. These findings show that experimental allodynia results from multiple factors, only some of which are sensitive to lidocaine treatment, and that prolonged reversal of allodynia is limited in extent and likely influenced by pre-existing factors.     

An aid to the management of pediatric trauma in peripheral centers--a proposal for a pediatric trauma board.

In 1986, 630,000 children under the age of 15 were living in Queensland. This accounted for 17% of Australia's pediatric population. That year there were 39 pediatric deaths in Queensland resulting from road traffic incidents. Another 408 injured children were admitted to hospital. Less than 20% of these children were treated in an accident and emergency (A&E) department staffed by a qualified pediatrician. Only 35% of the A&E departments were staffed by a qualified emergency physician. A Pediatric Trauma Board is proposed, which will lead to improvement in the care of injured or critically ill pediatric patients. This board is made of pre-marked whiteboard and includes normal pediatric values and replacement fluid flow charts; it is approximately three feet in height and six feet in width. The Board is aimed primarily at nonpediatric clinicians who may or may not be specifically trained or interested in emergency medicine. It provides quick, easy access to the normal values of vital signs for children of different ages and sizes. It enables accurate calculation of the fluid requirements for resuscitation and provides a means for following the response to this therapy. Drug doses per weight are provided. A copy of the board can be made on size A4 photostats for inclusion in the hospital chart as part of the admission notes.     

Use of antibiotics during pregnancy

Pregnancy is occasionally complicated by infections that necessitate antibiotic therapy. When considering therapeutic options for pregnant women, both the physiologic changes of pregnancy and the prenatal effects of the drug must be weighed. Antibiotics should be selected with regard to the trimester of pregnancy. Some antibiotics are safe for use throughout pregnancy, while others are completely contraindicated. Choosing the proper antibiotic requires balancing the seriousness of the infection with the antibiotic's safety and antimicrobial activity.