Pseudo-outbreak of Acinetobacter lwoffii infection in a tertiary care center in Thailand.

We describe a pseudo-outbreak of Acinetobacter lwoffii infection that was recognized early. The pseudo-outbreak involved 16 patients and occurred 3.5 months after the GNS-506 Vitek automated system was introduced in the microbiology laboratory. Prompt confirmation of incomplete use of the automated system's algorithm as the point source of the misidentified A. lwoffii clinical isolates averted a full outbreak investigation and excess use of infection control resources.     

Stamey-Martius procedure for severe genuine stress incontinence.

There are few options now available to treat patients with severe genuine stress incontinence caused by urethral failure. These patients usually have a low maximum urethral closure pressure (less than 20 cm of water) and anterior vaginal wall scarring caused by previous surgery. In 32 such patients we used the Martius fat pad insertion procedure, in addition to the Stamey procedure, and achieved a 91% symptomatic success rate over a mean 13-month follow-up period. Because of its simplicity, reliability and low morbidity, we recommend this procedure in this difficult group of patients before performing a sling procedure or insertion of an artificial urinary sphincter.     

Risk factors and outcomes of influenza A (H3N2) pneumonia in an area where avian influenza (H5N1) is endemic.

We conducted a cohort study to identify the risks and outcomes of influenza A (H3N2) pneumonia. Of the 145 patients studied, 10 (7%) had influenza A pneumonia. Logistic regression identified multiple comorbidities (P<.001) and diarrhea at the initial presentation (P=.001) as associated risks. Infection with influenza A (P=.01) and receipt of inadequate antimicrobial therapy (P=.005) were predictors of mortality.     

Inflammatory mediators and the destruction of bone

Bone is remodelled by the coordinated actions of osteoclasts and osteoblasts. Cellular remodelling occurs in discrete packets of bone, and is regulated by local cytokines produced in the environment of the remodelling cells. These cytokines are secreted by immune cells and by bone cells. In addition, some growth regulatory factors are incorporated into the noncollagenous bone matrix and are released in an active form when bone is stimulated to resorb. Complex interactions between these cytokines and their target cells are responsible for the normal delicate balance between bone resorption and bone formation, and disorders of bone loss are due to imbalances between the rates of resorption and formation.     

A preliminary report on a new hydraulic sphincter for controlling urinary incontinence

A new pressure-regulated artificial urinary sphincter (AUS) has been developed which overcomes many of the deficiencies of earlier devices. This implantable AUS comprises a circular occluder cuff and the means to inflate and deflate through a pressure-regulated valve. The device is made from medical-grade silicone rubber and filled with radio-opaque isotonic fluid. A few days before surgery the implant is coated on the outside with an antibiotic-loaded silicone rubber solution. Tests have shown that the regulated pressure was very easily adjusted in situ by injecting or withdrawing the hydraulic fluid through a hypodermic needle penetrating a self-sealing filling port. When set, the regulated pressure remained very stable. The mechanism by which cuff pressure was increased to overcome stress incontinence worked well. Of the five earlier devices (AUS Mk I) implanted, none has survived without mechanical failure. The two latest implants (Mk II), which were rigorously tested for defects before implantation, have been more successful.     

A technique for total substitution of the lower urinary tract without the use of a prosthesis

A technique is described for total replacement of the lower urinary tract in women in which a pedicled labial skin tube is created and anastomosed to a substitution cystoplasty with a submucosal tunnelled type of "anti-reflux" anastomosis which provides a continence mechanism. The patients thereafter void by intermittent self-catheterisation. This technique has been used in 6 women as part of total pelvic reconstruction for vesico-vagino-rectal fistula following radical radiotherapy, with or without a Wertheim's hysterectomy, for carcinoma of the cervix. A similar technique using a pedicled preputial/penile skin tube has been used in 2 men following a cystoprostato-urethrectomy for transitional cell carcinoma of the bladder.     

The treatment of sphincter strictures

A group of 25 patients with strictures of the membranous urethra following transurethral resection of the prostate (TURP) were investigated and treated initially by careful urethral dilatation. This controlled the stricture in 14 patients, 6 of whom continued with occasional dilatation or self-catheterisation to maintain control; 8 required an artificial urinary sphincter (AUS) and 2 required a "clam" ileocystoplasty for detrusor instability. Eleven had persistent or recurrent strictures requiring urethroplasty. Nine underwent bulbo-prostatic anastomotic urethroplasty, 4 with simultaneous bladder neck reconstruction and 5 with subsequent implantation of an AUS; 2 had a preputial patch urethroplasty with subsequent implantation of an AUS. Four of the 9 patients with a urethroplasty and an AUS are satisfactory, 1 developed a recurrent stricture and 2 developed erosions. Two of those with a bulbo-prostatic anastomosis and bladder neck reconstruction are satisfactory and 2 are incontinent. These results were compared with those of 18 other patients who underwent bladder neck reconstruction and 12 who had a urethroplasty in conjunction with an AUS for reasons other than a post-TURP sphincter stricture. The success rate of bladder neck reconstruction was 55% and the success rate of urethroplasty in conjunction with an AUS was 83%, but the main complication of AUS implantation, erosion, was a more serious problem than failure of bladder neck reconstruction. However, the much higher success rate makes AUS implantation a more satisfactory procedure. Surgery should be avoided if at all possible and reliance placed on urethral dilatation.     

Serum concentrations of oestradiol-17beta, progesterone, relaxin and chorionic gonadotrophin during blastocyst implantation in natural pregnancy cycle and in embryo transfer cycle in the rhesus monkey

The present study was undertaken to assess the temporal association between the profiles of serum concentrations of oestradiol-17beta, progesterone, chorionic gonadotrophin (CG) and relaxin in pregnancies established naturally, and after embryo transfer, as well as in failed pregnancies in rhesus monkeys. In naturally mated cycles (group 1) a conception rate of 75% was obtained. In group 1, the mean day of CG detection in serum was 11.5 +/- 1.9 day post-ovulation, and for relaxin, 9.0 +/- 2.5 day post-ovulation. In group 2, embryo transfer to synchronous, non-mated surrogate recipients was performed; seven embryo transfer cycles yielded three pregnancies which were allowed to continue to term and normal infants were delivered. In embryo transfer cycles the mean day of CG detection was 14.8 +/- 1.8 day post- ovulation, and for relaxin, 11.4 +/- 2.6 day post-ovulation. A delay of about 3 days was observed in the appearance in circulation of CG (P < 0.05) and also of relaxin (P < 0.05) between natural mated and embryo transfer conception cycles. Significant differences (P < 0.05 for progesterone and P < 0.03 for oestradiol) were obtained for the areas under the curves for progesterone and oestradiol between days 12 and 16 in conception cycles compared with failed pregnancies. These data provide the first observation of the normal hormonal signals associated with maternal recognition of transferred embryos during the peri- implantation period, and suggest that the use of such an experimental primate embryo transfer model may help to elucidate components of maternal and embryonic signal-response mechanisms during embryo implantation.      

Evaluation of a latex agglutination test for Clostridium difficile in two nursing home outbreaks.

The Culturette Brand Clostridium difficile test (CDT; Marion Laboratories, Inc., Kansas City, Mo.) is a latex agglutination test for C. difficile. The recent controversy involving the identity of antigens detected by CDT has made decisions on its use difficult. We compared the test results with those of selective culture and stool cytotoxin assays in investigations of two nursing home outbreaks of C. difficile-associated disease in order to formulate usage recommendations. Selective culture for C. difficile identified 27 (19%) of 142 subjects as carriers. CDT and the stool cytotoxin assay identified only 52 and 48% of these carriers, respectively. Compared with the stool cytotoxin assay, CDT had a high sensitivity (92%) and specificity (89%) for the detection of C. difficile disease, but the positive predictive value of the test was only 17% when the prevalence of disease was 2%. We conclude that the CDT should not be used to identify carriers but that it is a sufficiently sensitive and specific screening test for diagnosing C. difficile disease. However, since the positive predictive value of the CDT is low when the prevalence of disease is low, positive test results should be confirmed by the stool cytotoxin assay.     

Tourniquet inflation after intra-articular morphine and bupivacaine administration following knee arthroscopy

We performed a randomized doubled-blind study to evaluate whether there was a benefit in delay in tourniquet deflation with intra-articular administration of morphine and bupivacaine following operative arthroscopic surgery. In 34 patients the tourniquet was deflated immediately and in 38 patients the tourniquet remained inflated for 10 min following injection. The analgesic efficacy was assessed using pain scores and the amount of supplementary analgesia required. The results demonstrate no benefit in delay in tourniquet deflation.