J Am Dent Assoc, 1997 Aug, 128(8), 1142 - 51 Prevention of bacterial endocarditis: recommendations by the American Heart Association; Dajani AS et al.; OBJECTIVE: To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease . PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the infectious Diseases Society of America, the American Academy of Pediatrics and the American Society for Gastrointestinal Endoscopy . EVIDENCE: The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures . MEDLINE database searches from 1936 through 1996 were done using root words endocarditis, bacteremia and antibiotic prophylaxis . Recommendations in this document fall into evidence level III of the U.S . Preventive Services Task Force categories of evidence . CONSENSUS PROCESS: The recommendations were formulated by the writing group after specific therapeutic regimens were discussed . The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association . These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment . CONCLUSIONS: Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate- and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered. J Pediatr Hematol Oncol, 1997 Jul-Aug, 19(4), 339 - 44 The use of implantable venous access devices (IVADs) in children with hemophilia; Perkins JL et al.; PURPOSE: Implantable venous access devices (IVADs), either centrally or peripherally implanted, have become increasingly popular in children with hemophilia to assist in the early treatment of bleeding episodes and in the prevention of arthropathy . Their use has been associated with complications including thrombosis, thrombophlebitis, and infection . We attempted to better define whether the benefits associated with IVADs in this population outweight the associated risks . PATIENTS AND METHODS: We studied the medical records of 35 children from the University of Minnesota's Comprehensive Hemophilia Center who received IVADs between 1992 and 1996 . RESULTS: There was no bleeding or thrombophlebitis associated with IVADs in our population . One patient required removal of a central IVAD due to thrombosis . The central IVADs were associated with local infection and bacteremia rates of 3% and 33%, respectively . The rates of local infection and bacteremia associated with peripheral IVADs were both 25% . The majority of infections were cleared with antibiotics, and ports remained intact . Both types of IVADs were associated with a high patient/parent satisfaction . CONCLUSION: Despite being associated with a significant incidence of infection, we believe the benefits of IVADs for children with hemophilia and their families outweigh the risks . Possible explanations for the observed infection rates are discussed. J Pediatr Hematol Oncol, 1997 Jul-Aug, 19(4), 309 - 12 High dose cyclophosphamide with carboplatin: a tolerable regimen suitable for dose intensification in children with solid tumors; Kreissman SG et al.; PURPOSE: To determine the hematopoietic and nonhematopoietic toxicity of a novel dose-intensive chemotherapy regimen for the treatment of children with relapsed solid tumors . PATIENTS AND METHODS: The time to hematopoietic recovery and toxicity experienced during 46 courses of high-dose cyclophosphamide (4.0 g/m2), MESNA, and carboplatin (400 mg/m2) with granulocyte colony stimulating factor (G-CSF) support in 14 children with recurrent solid tumors was reviewed . RESULTS: All patients developed grade 4 neutropenia and thrombocytopenia . Recovery to an absolute neutrophil count (ANC) of 500/microliter and platelet count of 50,000/microliter occurred at a median of 15 days and 23 days respectively . Median time to ANC > 1,000/microliter and platelets > 100,000/microliter was 27 days . Hospitalization for fever and neutropenia occurred during 35 of 46 courses, with documented bacteremia in six courses . There was no grade II or greater nonhematopoietic organ toxicity . Responses (CR + PR) were observed in 6 of 11 evaluable patients . CONCLUSIONS: These data suggest that this regimen is tolerable in heavily pretreated children with solid tumors with myelosuppression as the primary toxicity . Due to the lack of significant nonhematopoietic toxicity, this is a good candidate regimen for dose escalation using peripheral blood progenitor cell infusions and deserves further evaluation for efficacy in children with both recurrent and newly diagnosed high-risk solid tumors. Circulation, 1997 Jul 1, 96(1), 358 - 66 Prevention of bacterial endocarditis . Recommendations by the American Heart Association; Dajani AS et al.; OBJECTIVE: To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease . PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the Infectious Diseases Society of America, the American Academy of Pediatrics, and the American Society for Gastrointestinal Endoscopy . EVIDENCE: The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis, and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures . MEDLINE database searches from 1936 through 1996 were done using the root words endocarditis, bacteremia, and antibiotic prophylaxis . Recommendations in this document fall into evidence level III of the US Preventive Services Task Force categories of evidence . CONSENSUS PROCESS: The recommendations were formulated by the writing group after specific therapeutic regimens were discussed . The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association . These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment . CONCLUSIONS: Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered; and (6) for gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified . These changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations. Arch Surg, 1997 Jul, 132(7), 744 - 7; discussion 748 Safety, efficacy, and cost of pancreaticoduodenal resection in a specialized center based at a community hospital; Cooperman AM et al.; OBJECTIVE: To determine whether pancreaticoduodenal resection (PDR) for benign and malignant disease can be performed safely, efficiently, and economically at a 50-bed community hospital . DESIGN: Retrospective review of 39 consecutive PDRs performed in an 18-month period . Indications for surgery, length of hospital stay, complications, and patient charges were analyzed . SETTING: A suburban 50-bed community hospital . PATIENTS: Thirty-nine patients (15 male and 24 female) referred for PDR for benign and malignant disease . MAIN OUTCOME MEASURES: Mortality and morbidity rates, length of hospital stay, care, and cost . RESULTS: Of 39 patients who underwent PDRs, 1 patient (2.6%) died of myocardial infarct . Intraoperative blood transfusions were required by 3 patients (8%) . The mean postoperative hospital stay was 11 days . Twenty-four patients (62%) were discharged by day 11 . Fifteen patients (38%) were hospitalized 11 to 24 days . Complications in 10 patients (28%) included pancreatic or biliary fistula (n = 6), upper gastrointestinal tract bleeding (n = 1), partial wound dehiscence (n = 1), bacteremia (n = 1), and pneumonia (n = 1) . No patient required reoperation . Three patients were rehospitalized within 1 month . Mean patient charges were $21,864, and mean reimbursements were $19,669 . CONCLUSIONS: Pancreaticoduodenal resection can be accomplished with low morbidity and mortality rates and a short stay at a community hospital . Thorough preoperative investigations to exclude unresectable lesions must precede every PDR for malignant disease . Mortality and morbidity rates in this series were similar to those for patients with similar diagnoses who were operated on in academic centers . Cost for and length of hospital stay of these 39 patients were significantly lower than those in other reported series. Acad Emerg Med, 1997 Jul, 4(7), 679 - 83 The use of antibiotics to prevent serious sequelae in children at risk for occult bacteremia: a meta-analysis; Bulloch B et al.; OBJECTIVE: To determine whether antibiotics prevent serious bacterial infections in children at risk for occult bacteremia . METHODS: Meta-analysis of randomized controlled trials involving children aged 3 months to 36 months without a focus of infection and randomized into 2 treatment groups: 1) no antibiotic vs antibiotic or 2) IM ceftriaxone vs oral antibiotic . RESULTS: The use of either an oral antibiotic or IM ceftriaxone did trend toward a reduced risk of serious infection, although neither reached statistical significance (OR = 0.60; 95% CI 0.10, 3.49; and OR = 0.38; 95% CI 0.12, 1.17, respectively) . It would be necessary to treat 414 patients to prevent 1 serious bacterial infection . When only children with proven occult bacteremia were analyzed, the use of IM ceftriaxone was statistically significant in preventing serious bacterial infections (OR = 0.25; 95% CI 0.07, 0.89) . CONCLUSIONS: Clinical judgment should not be replaced by widespread antibiotic use in the approach to a child with fever . If rapid methods to identify children with occult bacteremia, such as polymerase chain reaction, could be improved and become widely available, then antibiotics could be used judiciously on initial visits . Antibiotic use in all children at risk for occult bacteremia implies the treatment of many children unlikely to benefit from such therapy. Neurosurgery, 1997 Jul, 41(1), 101 - 7; discussion 107-9 Thrombotic, infectious, and procedural complications of the jugular bulb catheter in the intensive care unit; Coplin WM et al.; OBJECTIVE: An assessment of the thrombotic, infectious, and technical complications of continuous jugular bulb catheter monitoring in the intensive care unit (ICU) was made . METHODS: Over a 1-year period, 44 patients suffering from traumatic brain injury, subarachnoid hemorrhage, or stroke received jugular bulb catheter monitoring in the ICU . They were followed for catheter insertion complications and the development of bacteremia . In 20 patients chosen randomly, an ultrasonographic evaluation was performed after removal of the catheter for an assessment of internal jugular vein thrombosis . RESULTS: Of the 44 patients, 1 became bacteremic; the source was identified as a thoracostomy site . Among the complications related to the 44 catheter insertions, there were 2 instances of carotid artery puncture (4.5%), 1 misplaced catheter (thoracic placement), and 1 clinically insignificant hematoma . Of the 20 patients investigated with ultrasonography, 8 (40%) had nonobstructive, subclinical internal jugular vein thrombi after jugular bulb catheter monitoring (95% confidence interval, 19-61%) . The median monitoring duration was 3 days (range, 1-6 d) . No clinical factor was identified to be associated with thrombus formation . CONCLUSION: We conclude the following: 1) the risk of bacteremia related to the jugular bulb catheter was negligible; 2) complications related to catheter insertion were rare and clinically insignificant; and 3) the incidence of subclinical internal jugular vein thrombosis after jugular bulb catheter monitoring is considerable . Although it is worthy to note this complication, no patient with a thrombus became symptomatic in the present series . The risk-benefit assessment of this monitoring technique must include consideration of subclinical thrombosis. Am J Med Sci, 1997 Jul, 314(1), 44 - 6 Spontaneous healing of pancreatic abscess after fistulization to the duodenal bulb; Kawachi S et al.; A 70-year-old man was admitted to the hospital because of sudden, upper abdominal and back pain . Laboratory and image data indicated acute pancreatitis . Shortly after the admission, pancreatic and liver abscess with bacteremia developed . Antibiotic therapy seemed effective . A month later, spontaneous fistulization of the pancreatic abscess to the duodenal bulb was found by gastroduodenal fiberscopy . Injection of contrast medium into the duodenal orifice showed that the fistula was draining the abscess and that no other fistula formed from the abscess . Endoscopic retrograde cholangiopancreatogram indicated no fistula formation to the pancreatic duct . The pancreatic abscess became smaller and was not visible using computerized tomography and ultrasonography 3 months later and thereafter . Closure of the duodenal orifice was ascertained by the endoscopy . It is suggested that retrograde infection from the fistula was prevented by the single fistulization to the acidic duodenal bulb, which is not supposed to allow most bacterial growth . Pancreatic abscess usually necessitates operative treatment, even with fistulization to the alimentary tract . It seems likely that the single, small fistulization to the bulb, in addition to the lack of underlying disease and medical and nutritional support, facilitated the spontaneous healing process. J Infect Dis, 1997 Jul, 176(1), 296 - 9 Pretreatment with a 55-kDa tumor necrosis factor receptor-immunoglobulin fusion protein attenuates activation of coagulation, but not of fibrinolysis, during lethal bacteremia in baboons; van der Poll T et al.; Baboons (Papio anubis) receiving a lethal intravenous infusion with live Escherichia coli were pretreated with either a 55-kDa tumor necrosis factor (TNF) receptor-IgG fusion protein (TNFR55:IgG) (n = 4, 4.6 mg/kg) or placebo (n = 4) . Neutralization of TNF activity in TNFR55:IgG-treated animals was associated with a complete prevention of mortality and a strong attenuation of coagulation activation as reflected by the plasma concentrations of thrombin-antithrombin III complexes (P < .05) . Activation of fibrinolysis was not influenced by TNFR55:IgG (plasma tissue-type plasminogen activator and plasmin-alpha2-antiplasmin complexes), whereas TNFR55:IgG did inhibit the release of plasminogen activator inhibitor type I (P < .05) . Furthermore, TNFR55:IgG inhibited neutrophil degranulation (plasma levels of elastase-alpha1-antitrypsin complexes, P < .05) and modestly reduced release of secretory phospholipase A2 . These data suggest that endogenous TNF contributes to activation of coagulation, but not to stimulation of fibrinolysis, during severe bacteremia. J Infect Dis, 1997 Jul, 176(1), 206 - 16 Experimental infection of young specific pathogen-free cats with Bartonella henselae; Guptill L et al.; Eighteen 12-week-old specific pathogen-free cats, blood culture- and serum antibody-negative for Bartonella henselae, were randomly allocated to groups and were intravenously inoculated with 10(10) (group 1), 10(8) (group 2), or 10(6) (group 3) B . henselae or with saline (group 4) or were not inoculated (group 5) . Cats were humanely killed at 2, 4, 8, 16, and 32 weeks after inoculation . All B . henselae-inoculated cats were bacteremic by 2 weeks after infection . Bacteremia persisted until 32 weeks after infection in 1 cat . Cats in groups 1 and 2 had fever (>39.7 degrees C) and partial anorexia by 2 weeks after infection that lasted 2-7 days . All infected cats had Bartonella-specific IgM and IgG serum antibodies and lymphocyte blastogenic responses . Histopathologic lesions were observed in multiple organs of infected cats through 8 weeks after infection . Cats were readily infected with B . henselae by intravenous inoculation, developed histopathologic lesions that apparently resolved, and developed B and T lymphocyte responses to infection. J Infect Dis, 1997 Jul, 176(1), 126 - 32 Early manifestations of disseminated Mycobacterium avium complex disease: a prospective evaluation; Gordin FM et al.; A nested case-control study was conducted in two trials of prophylaxis for Mycobacterium avium complex (MAC) infection to describe the specific signs, symptoms, and laboratory abnormalities of MAC disease in AIDS . Patients had < or =200/mm3 CD4 cells and a prior AIDS-defining illness . Of 571 patients, 102 (17.9%) developed MAC bacteremia during a mean follow-up of 256 days . Among cases of MAC disease, 90 were compared with 180 matched controls . Patients with MAC disease were more likely than controls to have lower weights (66.3 vs . 71.1 kg, P = .001) and Karnofsky scores (74.3 vs . 84.4, P < .001); a higher proportion had fever (48% vs . 26%, P = .003), abdominal pain (23% vs . 13%, P =.05), decreased hemoglobin levels (10.9 vs . 12.1 g/dL, P < .001), and elevated alkaline phosphatase (203 vs . 138 U/L, P=.04) and lactate dehydrogenase (334 vs . 280 U/L, P = .02) levels . Characteristics of MAC disease that occurred before bacteremia were weight loss (3 months prior), fever (2 months), and anemia and elevated lactate dehydrogenase (1 month) . These data suggest that patients have symptomatic MAC disease for several months prior to the occurrence of bacteremia. J Clin Microbiol, 1997 Jul, 35(7), 1784 - 90 Serial surveillance cultures of skin and catheter hub specimens from critically ill patients with central venous catheters: molecular epidemiology of infection and implications for clinical management and research; Atela I et al.; A prospective study of 45 central venous catheters was conducted to assess, by strain delineation, the turnover of skin and catheter hub (superficial) colonization and the relative contributions of catheter hub and skin colonization to catheter tip colonization . Serial quantitative cultures of skin and catheter hub were performed . Catheter tip, blood, and specimens for culture from targeted superficial sites (TSSs) were also collected at the time of catheter removal . Strains from 17 tip-positive catheters were delineated by pulsed-field gel electrophoresis . Only 12 (28.6%) of 42 skin strains and 14 (31.1%) of 45 catheter hub strains were found to be present at the time of catheter removal . In addition, only 9 (29.0%) of the 31 tip-colonizing strains were present on TSSs . Moreover, 15 (48.4%) of the 31 tip-colonizing strains had a superficial origin, and the other 16 (51.6%) were of unknown origin . In catheters suspected of infection, cultures of TSSs had a negative predictive value for catheter-related bacteremia of 94.4% but a positive predictive value of 44.4% . When the causative agent was identified (to the strain level) these values dropped to 80.9 and 18.7%, respectively . The study shows that skin and catheter hub colonization is a common, dynamic phenomenon . Strains recovered from TSSs showed a low level of correlation with strains from previous cultures of specimens from superficial sites and catheter tip isolates . Consequently, TSSs cannot be recommended for use in determining the therapy . However, catheter-related bacteremia is uncommon when cultures of TSSs are negative. Transplantation, 1997 Jun 15, 63(11), 1595 - 601 Cytomegalovirus disease is associated with increased cost and hospital length of stay among orthotopic liver transplant recipients; Falagas ME et al.; Cytomegalovirus (CMV) is a cause of considerable morbidity and mortality among orthotopic liver transplant (OLT) recipients . To study the impact of CMV on cost and hospital length of stay in this population, we undertook an analysis of a cohort of OLT recipients from four transplant centers in Boston who participated in a CMV prophylaxis trial . First posttransplant year hospital length of stay (including the hospital stay after transplantation and readmissions within 1 year after transplantation) was available for all 141 patients included in the study . In a multiple linear regression model bacteremia (P=0.0001), CMV disease (P=0.0007), abdominal reexploration (excluding retransplantation) (P=0.0070), recipient age < or = 16 years (P=0.0352), and the number of units of blood products (red blood cells, platelets, or fresh frozen plasma) administered during transplantation (P=0.0523) were shown to be independently associated with longer first posttransplant year hospital length of stay . Cost data for in-hospital care for the year beginning with admission for liver transplantation were available for 66 OLT recipients . Using a multiple linear regression model, development of CMV disease (P=0.0001), the number of units of blood products administered during transplantation (P=0.0001), bacteremia (P=0.0002), decreased pretransplant renal function (estimated by creatinine clearance) (P=0.0109), and need for retransplantation (P=0.0619) were shown to be independently associated with higher cost . These data strongly suggest that CMV disease has a direct impact on cost and hospital length of stay in liver transplantation. JAMA, 1997 Jun 11, 277(22), 1794 - 801 Prevention of bacterial endocarditis . Recommendations by the American Heart Association; Dajani AS et al.; OBJECTIVE: To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease . PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the Infectious Diseases Society of America, the American Academy of Pediatrics, and the American Society for Gastrointestinal Endoscopy . EVIDENCE: The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis, and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures . MEDLINE database searches from 1936 through 1996 were done using the root words endocarditis, bacteremia, and antibiotic prophylaxis . Recommendations in this document fall into evidence level III of the US Preventive Services Task Force categories of evidence . CONSENSUS PROCESS: The recommendations were formulated by the writing group after specific therapeutic regimens were discussed . The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association . These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment . CONCLUSIONS: Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered; and (6) for gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified . These changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations. Acta Paediatr Jpn, 1997 Jun, 39(3), 312 - 6 Percutaneous central venous catheterization via the great saphenous vein in neonates; Ohki Y et al.; In 44 neonates (mean birthweight 1207 g and mean gestational age 30.0 weeks), very small central venous catheters were percutaneously inserted via the great saphenous vein on 46 occasions . Catheter-related complications such as catheter blockages in 17 (37%), edema in a unilateral leg in three (6%), and mechanical disruption in two (4%) were noted . Although two of the neonates were found to have bacteremia and five neonates died, none were catheter related . The optimal length of catheter insertion (Y) from the great saphenous vein at the level of the medial maleollus to the inferior vena cava at T9 and L3 was calculated by regression equations utilizing total body length (X) . Radiographs taken with extended and flexed leg postures revealed that the catheter tips were retracted with extension of the lower extremities and the degree of displacement ranged from 1 to 4 (mean 2.7) vertebral levels . Because this movement might cause migration into veins that connect to the inferior vena cava, the catheter tip should be located between T9 and L3, except at the renal vein junction . Percutaneous central venous catheterization via the great saphenous vein is safe and useful . Regression equations provided for rapid estimation of the optimal length of insertion. Crit Care Med, 1997 Jun, 25(6), 989 - 94 Utilization and diagnostic yield of blood cultures in a surgical intensive care unit; Darby JM et al.; OBJECTIVE: To evaluate the diagnostic yield of blood cultures obtained in a surgical intensive care unit (ICU) and to assess factors potentially influencing yield . DESIGN: Retrospective, descriptive study . SETTING: Surgical ICU in a university hospital . SUBJECTS: All patients who had a blood culture obtained during their admission to the trauma/neurosurgical ICU of Presbyterian University Hospital from January 1, 1993 to December 31, 1993 . MEASUREMENTS AND MAIN RESULTS: Blood culture isolates were categorized as pathogens or contaminants and overall diagnostic yield was determined . Blood cultures were positive for pathogens in 4.6% of all culture episodes, while contaminants were isolated in 5.5% of all culture episodes . A total of 23 true bacteremias were identified in 21 patients, for an overall rate of bacteremia of 3.6 per 100 admissions (5.9 per 1,000 patient days) . Concurrent antibiotics were being used at the time of blood culture in 65.3% of all culture episodes . The yield for pathogens was significantly lower (2.2%) when cultures were obtained on antibiotics compared with culture episodes obtained off antibiotics (6.4%) (p < .05) . Single-set blood culture episodes were obtained in approximately 32% of all culturing episodes with the overall yield for pathogens of these culturing episodes lower (2.9%) than that of multiple-set culture episodes (5.3%) (p = NS) . CONCLUSIONS: Blood culture yield in this surgical ICU was relatively low in comparison with other published studies . The data further suggest that concurrent use of systemic antibiotics and inappropriate or excessive culturing may negatively influence blood culture yield. Am J Med Sci, 1997 Jun, 313(6), 341 - 5 Geographic and seasonal variation in Mycobacterium avium bacteremia among North American patients with AIDS; Horsburgh CR Jr et al.; Analysis of geographic risk was performed for Mycobacterium avium complex (MAC) bacteremia among North American patients with AIDS . Monthly mycobacterial blood cultures were taken from patients who were placebo recipients in a prospective evaluation of MAC prophylaxis . Of 571 patients, 102 (17.9%) acquired MAC bacteremia during an average follow-up of 256 days . The area with the highest risk for MAC was the South Central region (27.9%; P < 0.02), whereas the area with the lowest risk was Canada (11.3%; P = 0.12) . When the southern states were combined and compared with the northern states and Canada, the incidence of MAC bacteremia was higher in the southern states (21.6% versus 14.0%, P < 0.03) . Proportional hazards analysis was performed for the difference between the North and South and controlled for baseline CD4 cell count . In this analysis, time to MAC was significantly longer in the North (hazard ratio = 0.587, 95% confidence interval 0.390 to 0.883, P = 0.01) . Although overall variation in seasonality was not marked, there was a significant decrease in cases in the North during the summer months (P < 0.01) . We conclude that geographic location is a risk factor for MAC bacteremia in patients with advanced AIDS, with decreased risk in northern North America. Shock, 1997 Jun, 7(6), 432 - 8 Modulation of skeletal muscle lactate metabolism following bacteremia by insulin or insulin-like growth factor-I: effects of pentoxifylline; Vary TC et al.; Hyperlactatemia is a frequent complication of sepsis . We investigated the effect of pentoxifylline on plasma lactate concentrations and lactate release by epitrochlearis incubated in vitro following intravenous injection of Escherichia coli . Plasma lactate concentrations were elevated on day 2 postinfection and remained elevated for at least another 4 days . Lactate production by incubated epitrochlearis was not increased in septic rats on day 2 postinfection, and lactate production from muscles incubated with insulin (2 nM) or insulin-like growth factor-I, (10 nM) was similar in control and septic rats . On day 6 postinfection, lactate production was augmented 1.8-fold in muscles from septic rats and both insulin and IGF-I caused an exaggerated stimulation of lactate production compared with control . Pentoxifylline decreased plasma TNF concentrations 100-fold following injection of bacteria and prevented the sepsis-induced hyperlactatemia and increase in lactate production by incubated muscles in presence or absence of insulin or IGF-I . Thus, pentoxifylline prevented the sepsis-induced abnormalities in skeletal muscle lactate production and plasma lactate concentrations. Infect Immun, 1997 Jun, 65(6), 2153 - 9 Characteristics and prevalence within serogroup O4 of a J96-like clonal group of uropathogenic Escherichia coli O4:H5 containing the class I and class III alleles of papG; Johnson JR et al.; The recent discovery of a geographically dispersed clonal group of Escherichia coli O4:H5 that includes prototypic uropathogenic strain J96 prompted us to determine the prevalence of J96-like strains within serogroup O4 and to further assess the characteristics of such strains . We used O:K:H;F serotyping, PCR-based genomic fingerprinting, pulsed-field gel electrophoresis (PFGE), multilocus enzyme electrophoresis (MLEE), and PCR detection of the three papG alleles and of the cytotoxic necrotizing factor 1 (cnf1) and aerobactin (aer) gene sequences to characterize the 15 O4 strains among 336 E . coli isolates from three clinical collections (187 from mixed-source bacteremia, 75 from urosepsis, and 74 from acute cystitis) . J96-like strains constituted approximately half of the O4 strains, or 2% of the total population . In contrast to other O4 strains, the J96-like strains characteristically exhibited specific group III capsular antigens, the H5 flagellar and F13 fimbrial antigens, a distinctive PCR genomic fingerprint, the class III papG allele (plus, in 50% of strains, the enigmatic class I papG allele), and cnf1 but lacked aer . A subset of these strains was remarkably homogeneous with respect to all these characteristics and exhibited a distinctive PFGE fingerprint and MLEE pattern . These findings clarify the epidemiological relevance of J96 as a model extraintestinal pathogen, provide further evidence of the class I papG allele outside of strain J96, and offer insights into the evolution of E . coli serogroup O4. Nutrition, 1997 May, 13(5), 431 - 7 Contrasting effects of identical nutrients given parenterally or enterally after 70% hepatectomy: bacterial translocation; Qiu JG et al.; High mortality occurs in rats with 70% hepatectomy fed intravenous (IV) total parenteral nutrition (TPN; 13.9% glucose, 4.17% amino acids, 1.46% fat, electrolytes, trace minerals, and vitamins providing 216 kcal.kg-1.d-1) but not when the identical nutrients are given at the same rate enterally (gastrostomy) . We hypothesized that a difference in bacterial translocation (BT) was a contributing factor to this phenomenon . Forty-five male Sprague-Dawley rats (300-360 g) were divided into five groups and underwent the following: control (no operation), sham (intraperitoneal {IP} pentobarbital anesthesia, central venous and gastrostomy catheters, laparotomy, sham hepatectomy), standard oral feeding (SOF), TPN (IV nutrients), and total enteral nutrition (TEN; gastrostomy) . The SOF, TPN, and TEN groups had IP pentobarbital anesthesia, central venous and gastrostomy catheters, and 70% hepatectomy . Postoperatively, control and SOF (both catheters plugged) rats ate a commercial rat chow and drank tap water ad libitum pre- and postoperatively . The sham, TPN, and TEN groups were given the identical infusate composition as above, but the nutrient concentrations were cut in half (110 kcal/kg) and three-quarters (165 kcal/kg) on postoperative days 1 and 2, respectively . At the end of postoperative day 2, all rats were euthanized . BT to mesenteric lymph nodes (MLNs), liver, spleen, and lungs was significantly higher in the TPN rats compared with all other groups, except that BT to the MLNs was similar in the TPN and TEN groups . Bacteremia was found only in the TPN rats . BT in TPN rats with 70% hepatectomy was significantly greater 48 h after operation than in those fed the identical nutrients enterally at the same rate; this correlates with the previously reported significantly greater mortality in rats with 70% hepatectomy receiving TPN. Diagn Microbiol Infect Dis, 1997 May, 28(1), 45 - 8 Comparison of BACTEC 12B vs solid media for the recovery of Mycobacterium avium complex from blood cultures in AIDS patients; Morgan MB et al.; We compared liquid (BACTEC 12B) and solid culture media for the diagnosis of Mycobacterium avian complex (MAC) bacteremia among 258 AIDS patients with a positive blood culture . Neither culture media alone had adequate sensitivity; BACTEC 12B detected growth earlier . Use of both liquid and solid media may improve the yield of mycobacterial blood culture. J Pediatr Hematol Oncol, 1997 May-Jun, 19(3), 208 - 11 Early hospital discharge of children with fever and neutropenia: a prospective study; Wacker P et al.; PURPOSE: We report a prospective study on brief IV antibiotic therapy in selected children with cancer experiencing fever and neutropenia (FN) after chemotherapy . PATIENTS AND METHODS: All children with FN (T degree > or = 38 degrees C; ANC < 0.5 x 10(9)/L) were hospitalized for treatment with broad spectrum IV antibiotics . They were divided into three groups: group A (no infection), group B (clinically documented infection), and group C (bacteremia) . Children in group A (and some children in group B) were discharged before recovery of neutropenia, if afebrile and in good condition . RESULTS: Eighty-eight consecutive episodes of FN occurred in 30 children . Children in group A (44 episodes; 50%) received IV antibiotics for a median of 3 days; on 25 occasions (57%), IV antibiotics were stopped before recovery of neutropenia . In children in group B (30 episodes; 34%), early discharge was allowed in eight cases of minor infections (27%); six received oral antibiotics . Two children (group A) were rehospitalized for recurrent FN but recovered without complications . CONCLUSION: In chemotherapy-induced neutropenia, children hospitalized for fever but without documented infections and some children with minor infections can cautiously be discharged before evidence of bone marrow recovery if afebrile and in good general condition. Am J Physiol, 1997 May, 272(5 Pt 2), R1562 - 70 Role of endotoxin in the response to experimentally induced bacteremia in chronically prepared rats; Carlson DE et al.; Chronically prepared rats were injected intravenously with live Escherichia coli in doses from approximately 10(5) to approximately 10(9) colony-forming units (CFU) . Significant dose-related increase in plasma adrenocorticotropin and corticosterone occurred after approximately 10(7) CFU . Fever occurred after approximately 10(7) CFU but not after approximately 10(9) CFU . These responses changed significantly but were not blocked completely when > 94% of the viable E . coli was removed from the inoculates . The remaining endotoxin activity in the inoculates resembled lipopolysaccharide (LPS) extracted from the same strain of E . coli on electrophoretic gels . Plasma endotoxin increased for > or = 240 min to 5.1 +/- 0.9 endotoxin units (EU)/ml after approximately 10(7) CFU and to 440 +/- 59 EU/ml after approximately 10(9) CFU . Endotoxin at approximately 10(9) CFU caused death within 24 h that was not predicted by the total activity of endotoxin that was injected . In contrast, extracted LPS with its strain and total activity matched to approximately 10(7) CFU mimicked the responses to this nonfatal dose . The total endotoxin activity of the injected bacteria appears to account for the effects of nonfatal doses of E . coli but not for the effects of fatal doses. Nutrition, 1997 Apr, 13(4 Suppl), 10S - 14S Current laboratory techniques in the diagnosis of catheter-related infections; Linares J et al.; The unspecificity of the clinical manifestations of catheter-related infections (CRIs) makes laboratory confirmation necessary, and many diagnostic techniques have been developed . Semiquantitative culture of catheter tips has been accepted by most laboratories for its simplicity and is currently the reference technique . It discriminates between catheters producing infection (when > or = 15 colony forming units grow on the culture) and insignificant colonization . Nonquantitative methods improve the sensitivity of diagnosis of CRI but are less specific . Quantitative methods improve the specificity and can identify and quantify colonization of both the internal and external surfaces of the catheter; however, these are time-consuming techniques . The high rate of unnecessary catheter removal has promoted interest in in situ staining methods such as gram staining of the skin entry site and hub . These methods are simple to perform and have shown a high negative predictive value . Quantitative blood culture methods allow the diagnosis of CRI, but their sensitivity decreases in the absence of associated bacteremia . Finally, the introduction of molecular techniques has helped to explain the pathogenesis of CRI and could help to improve the management of nosocomial CRI. Rev Esp Enferm Dig, 1997 Apr, 89(4), 289 - 95 Bacteremia following liver biopsy in transplant recipients with Roux-en-Y choledochojejunostomy; de Diego Lorenzo A et al.; Between 1990 and 1995, 666 percutaneous liver biopsies were performed in 196 patients at Gregorio Maranon General Hospital (mean 3.4 biopsies/patient); 533 biopsies (80.03%) were carried out in patients with choledochostomy biliary anastomosis and 133 (19.97%) in patients with choledochojejunostomy . Infectious complications, in the form of sepsis, occurred in two patients, who recovered favorably with antibiotic therapy . These two patients had undergone Roux-en-Y choledochojejunostomy (1.5%, not significant) . Our findings suggest that the incidence of infectious complications after liver biopsy in transplant recipients is very low . Antibiotic prophylaxis at the time of liver biopsy in patients with Roux-en-Y choledochojejunostomy may decrease the frequency of infectious complications. J Trauma, 1997 Apr, 42(4), 602 - 6; discussion 606-7 Hypertonic saline resuscitation decreases susceptibility to sepsis after hemorrhagic shock; Coimbra R et al.; BACKGROUND: We hypothesized that improvements in cellular immune function after hypertonic saline (HTS) resuscitation will alter the outcome of sepsis after hemorrhage . METHODS: To test this hypothesis, a two-hit model was used . Hemorrhage was induced in BALB/c mice by catheterizing the femoral artery and bleeding until a mean arterial pressure = 35 mm Hg was reached and maintained for 1 hour . Resuscitation was performed with HTS (NaCl 7.5%, 4 mL/kg) or lactated Ringer's (LR, twice the shed blood volume), plus the shed blood . Cecal ligation and puncture (CLP) was performed 24 hours after hemorrhage . Mortality was assessed for 72 hours, comparing HTS (n = 14) and LR (n = 13) resuscitation . Another set of animals (n = 10 in each group at each time point) were killed at 2 and 24 hours after blood collection . Liver and blood were cultured for the presence of bacteria, and lung and liver samples were scored on a scale from 0 (normal) to 4 (most severe) in a blind fashion by a pathologist . RESULTS: Mortality 72 hours after CLP was 14.3% in HTS and 76.9% in LR treated animals (p < 0.002) . At 24 hours after CLP, 44% of HTS, but 77% of LR treated animals had > 1,000 colony forming units/mL of blood . Positive liver cultures (> 100,000 colony forming units/g) also showed the same trend (HTS = 30%, LR = 60%) . Autopsies revealed a better containment of the infection (abscess formation) in the HTS group . At 2 hours, lung scores were 1.2 +/- 0.25 and 2.6 +/- 0.31 for HTS and LR, respectively (p < 0.002) . At 24 hours, HTS treated animals showed marked improvement of lung injury, while the scores in the LR group remained high . A significant difference was also observed regarding liver injury . At 2 hours, scores were 0.4 +/- 0.22 and 2.3 +/- 0.16 for HTS and LR, respectively (p < 0.002) . At 24 hours, HTS treated animals showed normal hepatic architecture, although mild injury was still observed in the LR group . CONCLUSION: HTS resuscitation leads to increased survival after hemorrhage and CLP . Marked improvements were observed in lung and liver injury compared with isotonic resuscitation . The better containment of the infection observed with HTS resuscitation corresponds to a marked decreased in bacteremia . HTS resuscitation stands as an alternative resuscitation regimen with immunomodulatory potential. J Gastroenterol, 1997 Apr, 32(2), 264 - 7 Liver cirrhosis with synchronous gas gangrene and spontaneous bacterial peritonitis due to E . coli; Murata K et al.; We report a case of synchronous gas gangrene and spontaneous bacterial peritonitis associated with liver cirrhosis . The patient was a 52-year-old man who was being followed for decompensated liver cirrhosis . He experienced sudden onset lower abdominal pain with distension and pain in the left leg . A bullous lesion, with crepitation, later appeared in the thigh and showed air-bubbles on X-ray . Eschericia coli was cultured from ascites and the bullous lesions; there was associated gas gangrene . The patient died of bacteremia with disseminated intravascular coagulopathy 26 h after admission, despite receiving intensive care . We discuss the route of bacteria causing the spontaneous bacterial peritonitis and simultaneous gas gangrene. Bull Acad Natl Med, 1997 Mar 18, 181(3), 441 - 50; discussion 451-4 {Cat scratch disease and associated infections}; Chomel BB et al.; Cat scratch disease (CSD) was first described in France by Debre et al . in 1950, yet the causative bacterial agent of CSD remained obscure until 1992, when Bartonella (formerly Rochalimaea) henselae was implicated in CSD by serological and microbiologic studies . B . henselae had been linked initially to bacillary angiomatosis (BA), but also bacillary peliosis, relapsing bacteremia and endocarditis . Cats are healthy carriers of B . henselae and B . clarridgeiae, and can be bacteremic for months to years . Cat to cat transmission of the organism involves the cat flea in absence of direct contact transmission . Present knowledge on the etiology, clinical features and epidemiological characteristics of cat scratch disease/bacillary angiomatosis are presented. Ann Trop Paediatr, 1997 Mar, 17(1), 49 - 55 The epidemiology and clinical features of paraffin (kerosene) poisoning in rural African children; Reed RP et al.; One hundred and eleven children under 5 years of age admitted with a diagnosis of paraffin ingestion, constituting 9.1% of total ward admissions in this age group, were studied prospectively . The majority were between 13 and 36 months old . One-fifth of the children were in the care of another child at the same time of ingestion . Fourteen families had a past history of paraffin ingestion . Only 22% of households normally stored in paraffin above ground level and in only 15% of cases was paraffin stored in a container specified for that purpose . Emesis was attempted using home remedies in 72% of cases and was associated with a significant increase in vomiting . Vomiting had an impact on the exacerbation of the clinical features of paraffin poisoning, particularly fever . Clinical criteria laid down for suspected superadded bacterial lung infection resulted in half of the study group having blood cultures performed on day 1 and another 17 on day 4 . Only two yielded isolates which possibly could have been indicative of bacteremia secondary to infective pneumonia . No child in the suspected group was treated with antibiotics and all recovered uneventfully . Admission chest X-rays contributed little to the management of the illness . Paraffin ingestion remains a serious contributor to child morbidity in rural South Africa and there appears to be room for further preventive education at community level . Specific measures could include storage of paraffin in designated containers above ground level and emphasis on adult supervision of children . Superadded bacterial pneumonia is uncommon and antibiotics in the management of suspected cases are not routinely indicated. AIDS, 1997 Mar, 11(3), 311 - 7 Clarithromycin and ethambutol with or without clofazimine for the treatment of bacteremic Mycobacterium avium complex disease in patients with HIV infection; Chaisson RE et al.; OBJECTIVE: To compare the efficacy of two- and three-drug regimens for treating Mycobacterium avium complex (MAC) bacteremia in patients with AIDS . DESIGN: Randomized open-label clinical trial . SETTING: Outpatient HIV specialty centers' clinics . PATIENTS: A total of 106 adults with AIDS and MAC bacteremia . INTERVENTIONS: Patients were treated with clarithromycin 500 mg twice daily and ethambutol 800-1,000 mg daily and were randomized to receive clofazimine 100 mg daily or no clofazimine . MAIN OUTCOME MEASURES: Quantitative blood MAC cultures, symptoms, adverse reactions and survival . RESULTS: Patients randomly assigned to three drugs had significantly higher baseline colony counts of MAC in blood than patients receiving two drugs . The proportion of patients becoming culture-negative was 65% in the two-drug group and 54% in the three-drug group . The median time to negative culture was 58 days for patients in the two-drug and 63 days for the three-drug group . At the last visit during treatment, the mean reduction in colony forming units/ml of MAC in blood was 1.8 log10 for the two-drug group and 2.3 log10 for the three-drug group . Improvement in fever and night sweats was reported by 87 and 89% of the two-drug patients and 84 and 86% of the three-drug patients . During the study, 38% of two-drug patients and 61% of three-drug patients died (P = 0.032), and time to death was shorter in patients treated with three drugs (P = 0.012) . In a multivariate analysis, both assignment to clofazimine and high baseline colony counts of MAC bacteremia were significantly associated with death (P < 0.05) . CONCLUSION: The addition of clofazimine to a regimen of clarithromycin and ethambutol for MAC bacteremia in AIDS patients does not contribute to clinical response and is associated with higher mortality. Presse Med, 1997 Mar 1, 26(6), 262 - 4 {Percutaneous hepatic puncture biopsy in ambulatory care . 231 patients}; Bourgaux JF et al.; OBJECTIVES: The aim of this study was to verify that percutaneous liver biopsy does not require prolonged hospitalization over 24 hours and can be performed in a day care clinic without increased morbidity . PATIENTS AND METHODS: Two hundred thirty-one outpatients underwent percutaneous liver biopsies in a day care clinic from November 1, 1994 to June 30, 1996 . There were 136 men and 95 women, mean age 39.5 years, age range 16-72 years . Liver biopsy was performed as part of the work-up for hepatitis C in 183 patients . The biopsy was a repeat procedure in 43 patients . RESULTS: The procedure was uneventful in 230 patients . Hospitalization for 24 hours was required in one patient with a biliodigestive anastomosis who developed chills and fever due to Eschericia coli bacteremia . Two procedures were unsuccessful . CONCLUSION: This series confirms that when performed in compliance with standard rules for strictly controlled indications, morbidity after percutaneous liver biopsy is not greater in an outpatient than a classical inpatient setting. Infect Control Hosp Epidemiol, 1997 Mar, 18(3), 183 - 8 Infection risk and cost-effectiveness of commercial bags or glass bottles for total parenteral nutrition; Durand-Zaleski I et al.; OBJECTIVE: To determine whether the greater daily expense of administering total parenteral nutrition (TPN) via plastic bags changed once daily, compared to glass bottles changed thrice daily, could be offset by savings from a reduction in nosocomial infections . DESIGN: The costs and potential benefits of commercially available TPN bags and TPN in glass containers were compared . Costs were computed from the viewpoint of the hospital, first in a general model and then for two specific examples, Crohn's disease and intensive-care unit (ICU) patients . The extra cost of using bags was $20 per day . The total cost of nosocomial bacteremia was estimated at $6,000 . The monetary benefits of using TPN bags were $6,000XT, where XT was the percentage of nosocomial infections averted . We also considered that reduction in intravenous (IV)-line manipulation could reduce bacteremia-related mortality and computed a cost-per-life-saved ratio . RESULTS: Modeling showed that TPN in bags could yield a net benefit when the absolute reduction in the daily risk of nosocomial bacteremia reached the threshold value of 0.3% . Such a reduction could not be attained in patients with Crohn's disease, and corresponded to a 50% to 60% reduction of infection rates in ICU patients . Varying the risk of mortality attributable to IV-line-related infection from 1% to 13% resulted in a cost effectiveness of using TPN bags ranging from $90,000 to $7,000 per life saved in ICU, assuming a two-thirds reduction in IV-line infections, and from $180,000 to $14,000 if the infection rate was reduced by one third . CONCLUSION: The baseline cost-minimization analysis concluded that the extra cost of TPN bags was not justified by the extra savings . The cost-effectiveness analysis, however, found that the cost per life saved fell within the accepted range of public health interventions, provided a large fraction of infections are averted using TPN bags. Blood, 1997 Mar 1, 89(5), 1787 - 92 Acute chest syndrome in sickle cell disease: clinical presentation and course . Cooperative Study of Sickle Cell Disease; Vichinsky EP et al.; Acute chest syndrome (ACS) is an important cause of morbidity and mortality in sickle cell disease (SCD) . Previous studies reported conflicting pictures of ACS making therapeutic interventions difficult . The Cooperative Study of Sickle Cell Disease prospectively followed 3,751 patients enrolled from birth to 66 years of age for ACS . Data on presenting signs and symptoms, laboratory findings, and hospital course were collected . There were 1,722 ACS episodes in 939 patients . Young children (age 2 to 4 years) presented with fever and cough, a negative physical exam, and rarely had pain . Adults were often afebrile and complained of shortness of breath, chills, and severe pain . Upper lobe disease was more common in children; multilobe and lower lobe disease affected adults more often . Severe hypoxia occurred in 18% of adults tested and could not be predicted by examination or laboratory findings . Bacteremia was documented in 3.5% of episodes, but was strongly influenced by age (14% of infants and 1.8% of patients > 10 years) . ACS was most common in winter with children having the most striking increase . Transfusion was used less frequently, but earlier in children . Young children were hospitalized for 5.4 days versus 9 days for adults . Fifty percent of adults had a pain event in the 2 weeks preceding ACS and children were more likely to have febrile events . The death rate was four times higher in adults than in children . Fatal cases generally developed rapid pulmonary failure and one third were associated with bacteremia . Age has a striking effect on the clinical picture of ACS . In children, ACS was milder and more likely due to infection, whereas in adults ACS was severe, associated with pain and had a higher mortality rate. J Clin Microbiol, 1997 Mar, 35(3), 641 - 6 Diagnosis of triple-lumen catheter infection: comparison of roll plate, sonication, and flushing methodologies; Sherertz RJ et al.; In a recent clinical trial, 248 triple-lumen catheters were removed from patients in an intensive care unit, and their tip and subcutaneous segments were cultured by both the sonication and roll plate methods; for 191 of these catheters, flush cultures of all three catheter lumens were also performed . Previously published quantitative endpoints were used to define significant catheter colonization . By using a composite index as a definition of colonization (any of the seven types of cultures meeting quantitative criteria), sonication of the subcutaneous segment was the most sensitive at detecting colonization (58%), followed by sonication of the catheter tip (53%) . Sonication of both the subcutaneous and tip segments was 20% more sensitive than sonication of an adjacent catheter segment by the roll plate method (P < 0.05) . The greater sensitivity of the sonication method could be attributed to its greater ability than the roll plate method to detect catheter lumen colonization (82 versus 57%, respectively; P = 0.01) . A greater number of positive catheter segment cultures were found for colonized catheters from patients with associated bacteremia than for colonized catheters from patients without bacteremia (57 versus 37%; P = 0.004), making any culture method more likely to identify them . For catheters with significant colonization of only one site, the localization was as follows: 36.7% subcutaneous segment, 36.7% catheter lumen, and 26.6% tip segment . These findings suggest that the current practice of culturing a single segment of a central vascular catheter is inadequate and needs to be reexamined . They further suggest that initial colonization of the catheter lumen and tip segments may be more important than previously thought and may require a change in thinking of strategies designed to prevent catheter infection. J Clin Microbiol, 1997 Mar, 35(3), 563 - 5 Doing it right the first time: quality improvement and the contaminant blood culture; Weinbaum FI et al.; The aim of the project was to determine whether the rate of contaminant blood cultures could be reduced by using a team of dedicated phlebotomists . Comparisons were made between adult patients requiring blood cultures for suspected bacteremia on medical and surgical units before and after the introduction and withdrawal of a dedicated blood culture team . The results showed that a significant reduction in the contaminant blood culture rate was achieved by the blood culture team (P < 0.001; chi(2) test) . Therefore, in our experience, the rate of contaminant blood cultures can be reduced in a teaching hospital by using a team of dedicated phlebotomists . Calculations made with our data and those published by others suggest that cost savings from reducing false-positive blood cultures are greater than the cost of the blood culture team. Med Pediatr Oncol, 1997 Mar, 28(3), 196 - 200 Efficacy of a vancomycin solution to prevent bacteremia associated with an indwelling central venous catheter in neutropenic and non-neutropenic cancer patients; Barriga FJ et al.; We evaluated the efficacy of a vancomycin solution in the prevention of bacteremia caused by vancomycin-sensitive organisms (VSO) in cancer patients with a tunneled central venous catheter (CVC) . Eighty-three patients who had a single lumen CVC were randomized to use a heparin solution (25 U/ml) for daily catheter flush with (HepVan) or without (Hep) vancomycin, 25 mcg/ml . Febrile episodes were recorded, and central and peripheral blood cultures were drawn before beginning antibiotic therapy . Patients participated in follow-up to 16,677 catheter days (8,666 Hep and 8,011 HepVan), and 143 febrile episodes were recorded (82 Hep and 61 HepVan) . Forty-four episodes of bacteremia occurred, 23 of them due to VSO (16 occurred in the Hep group and 7 in the HepVan group (P = 0.19) . VSO bacteremia occurred in 14 neutropenic (absolute neutrophil count < 500 x 10(9)/l) episodes (7 Hep vs . 7 HepVan) and in 9 non-neutropenic episodes (9 Hep vs . O HepVan; P = 0.013) . Vancomycin effectively prevented bacteremia by VSO in non-neutropenic patients, supporting the idea that intraluminal colonization of indwelling CVCs contributes to bacteremia only in these patients. Ann Intern Med, 1997 Feb 15, 126(4), 275 - 9 Effect of cytomegalovirus infection status on first-year mortality rates among orthotopic liver transplant recipients . The Boston Center for Liver Transplantation CMVIG Study Group; Falagas ME et al.; BACKGROUND: To reduce the mortality rate associated with liver transplantation, it is important to identify the risk factors for increased mortality among liver transplant recipients . It has been suggested that cytomegalovirus (CMV) infection is one such risk factor, but no studies have examined mortality rates associated with the CMV serologic status of the donor and recipient by using multivariate techniques . OBJECTIVE: To study the effect of CMV on 1-year mortality rates in orthotopic liver transplant recipients . DESIGN: Intention-to-treat analysis of a cohort . PATIENTS: 146 liver transplant recipients who were enrolled in a multicenter, randomized, placebo-controlled intervention trial . SETTING: Four university-affiliated transplantation centers . RESULTS: 1-year mortality rates for the four strata of donor and recipient CMV serologic status before transplantation were as follows: seronegative donor and recipient, 11%; seronegative donor and seropositive recipient, 22%; seropositive donor and recipient, 30%; and seropositive donor and seronegative recipient, 44% (P = 0.0091) . Multivariate analysis using a time-dependent Cox proportional hazards model showed that retransplantation (relative risk, 4.6 {95% CI, 1.9 to 10.7}; P < 0.001); total number of units of blood products administered during transplantation (relative risk, 1.006 per unit {CI, 1.003 to 1.010}; P < 0.001); and presence of CMV disease (relative risk, 3.9 {CI, 1.8 to 8.5}; P < 0.001), invasive fungal disease (relative risk, 3.3 {CI, 1.5 to 7.1}; P = 0.0020), and bacteremia (relative risk, 2.5 {CI, 1.2 to 5.2}; P = 0.0136) were independently associated with higher mortality rates . If post-transplantation variables that were highly correlated with donor and recipient CMV serologic status were restricted from the model, donor and recipient CMV serologic status was the only pretransplantation variable independently associated with higher mortality rates (P = 0.002) . CONCLUSION: Donor and recipient CMV serologic status is a significant pretransplantation determinant for death in liver transplant recipients. Zhonghua Yi Xue Za Zhi (Taipei), 1997 Feb, 59(2), 88 - 94 The outcome of terminal liver cirrhosis patients requiring mechanical ventilation; Lee KC et al.; BACKGROUND: Liver cirrhosis is a common problem in Taiwan . Without liver transplantation, patients with end-stage liver cirrhosis frequently die of various complications and often require mechanical ventilatory support prior to their death . The purpose of this study was to investigate the in-hospital and short-term outcome of such patients . METHODS: A retrospective review of 47 medical records of mechanically ventilated patients with primary diagnosis of liver cirrhosis, admitted from November 1990 to September 1993, allowed analysis of disease course and outcome for these patients . RESULTS: Among the 47 patients, a Child-Pugh's class A patient receiving temporary mechanical ventilation (MV) after elective devascularization surgery was excluded from analysis . Among the remaining medically treated 46 patients, there were 33 Child-Pugh's class C patients, 9 class B patients and 4 unclassified patients . Primary reasons for endotracheal intubation and MV included airway protection, acute respiratory distress and shock . Of these patients, shock was present in 39 cases, upper gastrointestinal bleeding in 34, systemic inflammatory response syndrome in 32, renal insufficiency with creatinine greater than 1.3 mg/dl in 32, bacteremia in 14, parenchymal lung disease in 16, spontaneous bacterial peritonitis in 10, and intracerebral hemorrhage in 1 during their hospital courses . Thirty-eight patients (83%) died within 72 hours after being placed on mechanical ventilation . Patients requiring MV with complications of bacteremia, parenchymal lung disease or renal insufficiency during hospitalization were found to have a 100% mortality rate . Successful weaning occurred in only 3 of 46 patients (8.7%) . Of these three, two (4.3%) went home alive and had survived over six months after discharge . CONCLUSIONS: It was concluded that cirrhotic patients requiring MV have an extremely poor prognosis . Patients and their families should be fully informed of the prognosis, and routine use of MV should not be encouraged in patients with terminal stage liver disease. Clin Infect Dis, 1997 Feb, 24(2), 148 - 52 Treatment of penicillin-resistant pneumococcal bacteremia in neutropenic patients with cancer; Carratala J et al.; We identified 17 cases of pneumococcal bacteremia among 340 neutropenic cancer patients with bacteremia . Pneumonia was more frequent in patients with pneumococcal bacteremia than in those with bacteremia due to other organisms: 12 (71%) of 17 patients with pneumococcal bacteremia had pneumonia, whereas only 23 (7%) of 323 patients with nonpneumococcal bacteremia had pneumonia (P < .001) . Eight (47%) of the 17 episodes of pneumococcal bacteremia were caused by penicillin-resistant strains (MICs ranged from 0.12 microg/mL to 4 microg/mL); these penicillin-resistant pneumococci showed varying degrees of diminished susceptibility to all beta-lactams studied, especially ceftazidime (MICs of this drug ranged from 1 microg/mL to 64 microg/mL) . Imipenem was the beta-lactam agent most active against these organisms (MICs ranged from 0.03 microg/mL to 0.25 microg/mL) . Patients with penicillin-resistant pneumococcal bacteremia received inappropriate empirical antibiotic therapy more often than did patients with bacteremia due to susceptible strains (i.e., 4 (50%) of 8 patients vs . 0 of 9, respectively; P < .05) . Eight (47%) of the 17 patients with pneumococcal bacteremia died . In areas where penicillin-resistant pneumococci are highly endemic, these findings should be considered in selecting empirical antibiotic therapy for neutropenic patients with cancer who are suspected of having pneumonia. Clin Infect Dis, 1997 Feb, 24(2), 140 - 3 Pneumonia and bacteremia due to Mycobacterium celatum masquerading as Mycobacterium xenopi in patients with AIDS: an underdiagnosed problem? Zurawski CA, Cage GD, Rimland D, Blumberg HM. A newly described species of mycobacteria, Mycobacterium celatum, has rarely been reported as a cause of localized and disseminated human disease and can easily be misidentified as Mycobacterium xenopi when identification is based on biochemical testing alone . We report two cases of pneumonia and bacteremia due to M . celatum in patients with AIDS . In one case, diagnosis and initiation of therapy were delayed by misidentification of the infecting organism as M . xenopi . Genomic analysis or high-performance liquid chromatography is necessary to distinguish the two species . The finding in our two cases and a review of existing literature indicate that pulmonary disease may be an important manifestation of infection with M . celatum, especially in patients with AIDS . Further studies are needed to determine the incidence and clinical relevance of this organism in patients with AIDS and the optimal treatment regimens. Eur J Clin Microbiol Infect Dis, 1997 Feb, 16(2), 125 - 34 Prognostic factors associated with improved outcome of Escherichia coli bacteremia in a Finnish university hospital; Kuikka A et al.; All cases of bacteremia caused solely by Escherichia coli in 1977-1979, 1987-1989, and 1993-1994 in a Finnish university hospital were reviewed retrospectively to determine the clinical manifestations, the outcome, and the prognostic factors . In 332 episodes, mortality during the month after the first positive blood culture was 17% . This figure diminished during the study period from 23% in the 1970s to 9% in the 1990s (p = 0.028) . Mortality was lowest among patients treated with a combination of antibiotics, 7% versus 18% among those treated otherwise (p = 0.034) . The use of acetaminophen increased during the study period from 18 to 55% . Mortality among patients who received acetaminophen within a period < 24 h to 48 h of the first positive blood culture was 10% versus 22% among others (p = 0.002) . Logistic regression analysis showed six factors predictive of a fatal outcome: pneumonia, no known focus, shock, CNS disorder, thromboembolism, and rapidly fatal underlying disease . Appropriate antibiotic therapy predicted survival . In the analysis, replacement of appropriate antibiotic therapy by acetaminophen revealed that this drug was significantly associated with survival. Pediatrics . 1997 Feb;99(2):E2. Meta-analyses of the effectiveness of intravenous immune globulin for prevention and treatment of neonatal sepsis; Jenson HB et al.; OBJECTIVE: To determine the effectiveness of intravenous immune globulin (IVIG) in the prevention and treatment of neonatal sepsis . DESIGN: All published studies of IVIG for the prevention or treatment of neonatal sepsis were reviewed . Peer-reviewed, prospective, randomized trials with high merit were analyzed by two meta-analyses . The effect of prophylactic IVIG was evaluated by comparison of the numbers of cases of sepsis (bacteremia in the presence of systemic manifestations of sepsis), and of therapeutic IVIG by comparison of the numbers of deaths resulting from early-onset sepsis . RESULTS: Meta-analysis of 4933 evaluable newborns in 12 studies of IVIG prophylaxis showed a statistically significant negative association with the incidence of sepsis in premature low birth weight newborns given IVIG shortly after birth (P = .0193, two-sided) . The heterogeneity across these studies precluded estimation of a common odds ratio . Meta-analysis of 110 evaluable cases of neonatal sepsis in three studies of IVIG treatment of neonatal sepsis showed a significant decrease in the mortality rate for neonates with sepsis given IVIG (P = .007, two-sided) . The common odds ratio was .173 (95% confidence interval = .031 to .735) . CONCLUSIONS: Using conservative and objective outcome rating criteria, the addition of IVIG to standard therapies is of minimal but demonstrable benefit in preventing sepsis when administered prophylactically to premature low birth weight newborns, and of unequivocal benefit in preventing death when administered therapeutically for early-onset neonatal sepsis . The likelihood of newborns with sepsis living past the neonatal period was improved nearly sixfold when IVIG was administered in addition to standard therapies. Curr Opin Pediatr, 1997 Feb, 9(1), 9 - 13 Epidemiology and prevention of pneumococcal infections; McIntyre P; There are comparatively few data on the incidence and morbidity from pneumococcal disease, which is greatly underestimated by case ascertainment from sterile site isolates alone . New diagnostic methods, such as serology and polymerase chain reaction, to detect components of the pneumococcal cell wall promise to significantly enhance detection of pneumococci causing childhood pneumonia . There is increasing evidence that excessive antibiotic use in children is a major factor promoting antibiotic resistance in pneumococci . Resistance is a problem worldwide and has focused attention on vaccine prevention . Fortunately, antibiotic-resistant pneumococci appear to belong to a limited range of serotypes, those commonly colonizing children, in all areas so far studied . If conjugate pneumococcal vaccines prove to eradicate carriage, immunization may be the major weapon against the spread of antibiotic-resistant pneumococcal infection . Conjugate pneumococcal vaccines are now being studied in large-scale efficacy trials with outcomes of bacteremia and otitis media, the results of which are eagerly awaited. Eur J Pediatr Surg, 1997 Feb, 7(1), 42 - 3 A case of brain abscess as complication of esophageal dilation for caustic stenosis; Appignani A et al.; The authors report a case of a two-year-old child with esophageal stricture -- caused first by caustic ingestion and by the end-to-end anastomosis, performed after the excision of the stenotic esophageal segment-- that required repeated dilations . These manouvres unfortunately led to bacteremia and a serious complication of a brain abscess, in the right fronto-parietal area, that was promptly removed . A few months later the child was subjected to an esophageal substitution with a colonic transposition . At present he is in good condition and the follow-up showed normal function of the neo-esophagus. Int J STD AIDS, 1997 Feb, 8(2), 118 - 23 A study of Malaysian drug addicts with human immunodeficiency virus infection; Yoong KY et al.; A cross-sectional study was undertaken to determine the clinical profile, haematological and biochemical changes, seroprevalence of common opportunistic pathogens, and AIDS-defining events in 49 Malaysian male drug addicts with HIV infection . Their mean age was 33.2 years, the majority had been injecting drugs for more than 5 years and 88% reporting sharing needles . Fatigue, weight loss and night sweats were common presenting symptoms and the most frequent physical findings were hepatomegaly (57%), lymphadenopathy (35%) and thrush (29%) . Pulmonary infections were the commonest complications seen (61%) and of these, 13 had septic pulmonary emboli, 7 had bacterial pneumonias, 7 had pulmonary tuberculosis, and 4 had Pneumocystis carinii pneumonia . Eight patients had infective endocarditis and 5 had infected pseudoaneurysm in the groin . Anaemia (82%), leucocytosis (53%), hypoalbuminaemia (43%), hyperglobulinaemia (88%), elevated liver enzymes and hyponatraemia (57%) were frequent laboratory findings . The prevalence of HCV, HBV, cytomegalovirus and toxoplasma infection (by serology) were 100%, 12.2%, 72.7% and 59% respectively . All 7 patients with AIDS (4 P . carinii pneumonia, 2 extrapulmonary tuberculosis, and one oesophageal candidiasis) presented with their AIDS-defining illness, suggesting that HIV-infected intravenous drug user (IVDU) patients present late in the course of the diseasePIP: A cross-sectional study of a cohort of 49 male human immunodeficiency virus (HIV)-infected intravenous drug users attending the Infectious Diseases Unit of the National University of Malaysia during 1991-94 yielded a clinical profile of these patients . The mean age of respondents was 33.2 years and the mean duration of intravenous drug use was 12.7 years . On average, these men had known of their HIV-positivity for 53.2 weeks . Intravenous drug use was the only reported HIV risk factor in 34 men (69%) . Clinical symptoms at intake included fatigue (49%), weight loss (47%), night sweats (31%), fever (14%), and diarrhea (6%), while clinical findings included hepatomegaly (57%), lymphadenopathy (35%), and oral thrush (29%) . Anemia (82%), leucocytosis (53%), hypoalbuminemia (43%), hyperglobulinemia (88%), elevated liver enzymes and hyponatremia (57%) were frequent laboratory findings . The prevalences of hepatitis B virus, cytomegalovirus, and toxoplasma infection were 12.1%, 72.7%, and 59%, respectively . A total of 91 diagnoses were made in these 49 patients: most common were pneumonia, tuberculosis, bacteremia, infective endocardiditis, mycotic aneurysm, and psychiatric disorders . The mean duration of known progression to acquired immunodeficiency syndrome (AIDS) in the 7 patients at this stage was 391 days . Pneumocystis carinii pneumonia was the most common AIDS-defining illness . Three months into the study, 19 men (57%) had defaulted, reflecting the difficulties of involving drug addicts in research and intervention projects . Moreover, 16 patients (33%) were first confirmed HIV-positive at presentation to the hospital, suggesting that many drug users' HIV status remains unknown until they develop symptoms requiring hospital care . Crit Care Med, 1997 Feb, 25(2), 249 - 52 Randomized, double-blind study of intravenous human albumin in hypoalbuminemic patients receiving total parenteral nutrition; Rubin H et al.; OBJECTIVE: To determine whether replacement of human albumin will improve a patient's prognosis . DESIGN: A randomized, double-blind, controlled study in which 25 g of human albumin vs . placebo was administered intravenously daily . SETTING: A university-affiliated hospital . PATIENTS: Thirty-six patients with hypoalbuminemia (serum albumin of <2.5 g/dL), receiving total parenteral nutrition . None of the patients had known cancer, cirrhosis, or nephrotic syndrome . INTERVENTIONS: Each patient received at least 6 days of therapy (6 to 24 days of albumin; 7 to 32 days of placebo) . Four subjects were excluded from the study since they received therapy for <6 days . One patient was excluded from the study after nephrotic syndrome was identified . Albumin metabolic rates for those patients receiving albumin were estimated using the formula: Metabolism of albumin = 25 g/day + (albumin 1 - albumin 2)(Vd)/days, where albumin 1 and 2 are the serum albumin concentrations (g/L) at the beginning and end of the serum sampling intervals, respectively; Vd is the volume of distribution (L); and days relates to the number of days of the sampling interval . MEASUREMENTS AND MAIN RESULTS: Sixteen patients received albumin; 15 patients received placebo . One patient receiving placebo and two patients receiving albumin died within 30 days . One patient who received placebo and three patients who received albumin developed sepsis or bacteremia; four patients who received placebo and seven patients who received albumin developed pneumonia during the study (NS) . The serum albumin increased in all patients receiving intravenous albumin, but one patient received intravenous albumin for only 6 days . The mean serum albumin concentration increased by 1.42 g/dL in the albumin patients, and increased by 0.29 in the placebo patients (p < .0001 by unpaired t-test) . Mean initial albumin metabolism was 17.4 g/day (0.3 g/kg/day) . At the end of therapy, albumin metabolism was 20.5 g/day (0.36 g/kg/day) (paired t-test, p = .4, NS) . CONCLUSIONS: a) The administration of intravenous albumin to hypoalbuminemic patients receiving total parenteral nutrition does not improve morbidity or mortality . b) Albumin metabolic rates, initially related to the catabolic state, are high; later, these rates are high related to filling of the albumin space and gluconeogenesis . c) On the basis of the high albumin catabolic rates at the end of the infusion, doses of albumin of <25 g/day might be sufficient to replace albumin stores. Am Surg, 1997 Feb, 63(2), 170 - 7 Primary repair of 58 consecutive penetrating injuries of the colon: should colostomy be abandoned? Jacobson LE, Gomez GA, Broadie TA. Although primary repair of penetrating colon injuries in patients with low injury severity is now widely accepted, several "risk factors" continue to be viewed as relative contraindications to this method of management . The purpose of this study was to evaluate the septic complications and leak rate in a series of consecutive penetrating colon injuries managed exclusively with primary repair . The records of 58 consecutive patients with penetrating intra-abdominal colon injuries managed at an urban Level I trauma center from July 1991 to December 1995 were reviewed . Patients were stratified for injury severity using the Penetrating Abdominal Trauma Index (PATI), and the presence of "risk factors" and septic abdominal and wound complications were recorded . All 58 patients were managed with primary repair . There were 48 gunshot wounds (72%), 7 shotgun wounds (12%), and 9 stab wounds (16%) with a mean PATI of 26.7 +/- 15.2 standard deviation . Seven patients (12.1%) developed intra-abdominal abscess, and all were managed by CT-guided percutaneous drainage . Five patients (8.6%) developed bacteremia, and eight patients (13.8%) developed fascial dehiscence . Three patients (5.2%) underwent abdominal re-exploration in the postoperative period, but none of these was related to failure of the colonic repair . There were no clinically apparent leaks or fistulae and no deaths . The presence of "risk factors" appeared to identify more severely injured patients as indicated by a higher mean PATI score and a higher incidence of intra-abdominal abscess, when compared to patients in whom the "risk factor" was absent . Primary repair can safely be used for virtually all penetrating colon injuries, as clinical leaks are rare, even in patients with "risk factors" . Intra-abdominal abscess and other septic complications are dependent on the overall severity of the intra-abdominal injuries and probably result from contamination occurring at the time of injury rather than from postoperative leak from the primary repair. Infect Immun, 1997 Feb, 65(2), 811 - 4 Similarities and disparities between core-specific and O-side-chain-specific antilipopolysaccharide monoclonal antibodies in models of endotoxemia and bacteremia in mice; Bailat S et al.; We have previously described cross-reactive antilipopolysaccharide (anti-LPS), or anti-endotoxin, monoclonal antibodies (MAbs) which provide cross-protection in several systems of endotoxin bioactivity . The protective effects of the murine cross-reactive MAb WN1 222-5 (immunoglobulin G2a(kappa) {IgG/2a(kappa)}) and of its chimerized version, SDZ 219-800 {human IgG1(kappa)}, have now been evaluated in lethality models against LPS from three different serotypes and in bacterial infection models . We confirmed the protective activity of the two MAbs in D-galactosamine-sensitized mice challenged with LPS of other E . coli serotypes (O18, O127, and O111) . The protective effect correlated with the suppression of tumor necrosis factor formation . Furthermore, WN1 222-5 enhanced bacterial clearance of intravenously administered E . coli O111 bacteria, thus protecting mice from death . However, the MAbs were unable to provide protection in a peritonitis model (intraperitoneal inoculation) . Our study, therefore, shows that LPS cross-reactive antibodies are capable of mediating cross-protection against LPS and bacteria but that the selected models have a clear influence on the results. MMWR Morb Mortal Wkly Rep, 1997 Jan 24, 46(3), 60 - 2 Outbreaks of pneumococcal pneumonia among unvaccinated residents of chronic-care facilities--Massachusetts, October 1995, Oklahoma, February, 1996, and Maryland, May-June 1996; 3'-Azido 3'-deoxythymidine + methotrexate as a novel antineoplastic combination in the treatment of human immunodeficiency virus-related non-Hodgkin's lymphomas; Istituto di Ematologia 'L . e A . Seragnoli', Policlinico S . Orsola, Bologna, ItalyWe have previously reported that 3'-azido 3'-deoxythymidine (AZT) can possess a significant antineoplastic activity when combined with drugs that disrupt de novo thymidylate synthesis, such as 5-fluorouracil and methotrexate (MTX) . The aim of the present study was to evaluate the efficacy and the tolerance of the combination AZT + MTX in human immunodeficiency virus (HIV)-related non-Hodgkin's lymphoma (NHL) . Twenty-nine patients (22 men and 7 women), either newly diagnosed or pretreated, have been enrolled in the trial; the median age was 34 years, 45% had acquired immunodeficiency syndrome before lymphoma and 19 patients had less than 100 CD4 lymphocytes/microL . Histologic diagnoses were mainly Burkitt (27%) and diffuse large B-cell lymphoma (45%); extranodal involvement was present in 20 patients . The treatment plan included three weekly courses of MTX at 1 g/m2 (days 1, 8, and 15) plus oral AZT at 2 g/m2 (days 1, 2, and 3), 4 g/m2 (days 8, 9, and 10), and 6 g/m2 (days 15, 16, and 17), plus leucovorin rescue . From the eleventh patient on, in case of complete or partial remission, the treatment was continued with three additional courses, using AZT at the maximum dose . In 26 evaluable patients, the total (complete + partial) response rate was 77% (95% confidence interval, 58% to 89%), with complete remission (CR) in 46% of the patients (95% confidence interval, 29% to 65%) . The median CR duration was 12.8 months . Grade III-IV neutropenia and anemia were observed in 52% and 31% of the courses, respectively . There was one therapy-related death due to bacteremia followed by septic shock; the only other recorded infection was a herpes vaginalis . In conclusion, we suggest that AZT + MTX is an effective and well-tolerated regimen in HIV-related NHL. Avian Dis, 1997 Jan-Mar, 41(1), 234 - 40 Experimental reproduction of Escherichia coli cellulitis and septicemia in broiler chickens; Gomis SM et al.; Experimental reproduction of avian cellulitis was conducted by subcutaneous inoculation of 25-day-old broiler chickens with a field isolate of serogroup O78 Escherichia coli . Development of the cellulitis lesion occurred as early as 24 h post-infection . Reproduction of cellulitis occurred in 98% of inoculated birds, and E . coli was isolated from > 75% of cellulitis lesions . In addition to cellulitis, other lesions, including pericarditis, airsacculitis, osteomyelitis, arthritis, and perihepatitis, occurred in > 80% of birds inoculated with E . coli . Bacteremia occurred as early as 6 h post-infection and dramatically declined by 5 days post-infection . Seventeen of 59 (29%) birds inoculated with E . coli developed a fatal infection between 1 and 6 days post-infection, and bacteria were isolated from lesions in 98% birds . In contrast, E . coli was not isolated from lesions in birds that survived until days 7-14 post-infection . Birds that survived with cellulitis and other lesions until day 14 post-infection had a significantly lower body weight compared with the control group . This avian model of cellulitis and other lesions will be useful for studying the development of vaccination strategies for E . coli in broilers. J Surg Res, 1997 Jan, 67(1), 67 - 71 Differential intestinal microvascular dysfunction occurs during bacteremia; Spain DA et al.; Altered vascular responsiveness is the hallmark of septic shock . Recently, these changes have frequently been attributed to increased production of nitric oxide (NO) . Continued exposure to high levels of NO may alter both endothelial and vascular smooth muscle cell function . Although ex vivo studies demonstrate hyporeactivity of large conduit arteries during established sepsis, it is unclear if the same phenomena exist during early sepsis . This is especially true in the small resistance arterioles of the viscera . We used in vivo microscopy of the rat small intestine to assess (1) endothelial-dependent relaxation and vasomotion (periodic contraction and relaxation of blood vessels) in response to acetylcholine (ACH; 10(-8) to 10(-5) M), (2) endothelial-independent relaxation to nitroprusside (NTP; 10(-5) M), and (3) vascular smooth muscle response to norepinephrine (NE; 10(-10) to 10(-7) M) in normal and bacteremic rats (Escherichia coli) . There were no alterations in endothelial-dependent or -independent relaxation during bacteremia as measured by mean diameters . However, acute E . coli bacteremia severely impaired vasomotion in A1 (inflow) and A3 (premucosal) arterioles . Vasomotion was returned to baseline levels in A1 with low-dose ACH (10(-8) M) but only partially improved in A3 arterioles (P < 0.05) . A1 response to NE was impaired, while A3 were minimally altered despite being more sensitive to E . coli-induced vasoconstriction . These data suggest that bacteremia causes a rapid, differential impairment of both endothelial-dependent (A3 vasomotion) and vascular smooth muscle cell (A1 constriction) functions . These microvascular impairments occur much earlier than previously described and may contribute to sepsis-induced mucosal ischemia of the intestines. Comp Immunol Microbiol Infect Dis, 1997 Jan, 20(1), 41 - 51 Experimental and natural infection with Bartonella henselae in domestic cats; Abbott RC et al.; Domestic cats were experimentally infected with culture propagated Bartonella henselae by intradermal (i.d.) and intravenous (i.v.) routes . Cats were more efficiently infected by the i.d . (8/8 cats) than by the i.v . (2/16) route . Bacteremia was detected 1-3 weeks following inoculation and lasted for most cats for 1-8 months . However, one naturally infected cat was observed for 24 months and was found to be cyclically bacteremic, with bacterial levels varying one hundred fold or more from one period to another . No clinical or hematologic abnormalities were observed in any of the infected cats, even at the peak of bacteremia . Two cats that had become abacteremic were resistant to reinfection when inoculated with B . henselae a second time . Horizontal transmission through intimate contact between bacteremic and susceptible cats did not occur, and antibody positive bacteremic queens did not transmit the infection to their kittens in utero, peri-partum or post-partum . Only four of the 18 kittens acquired detectable levels of maternal antibody following nursing, which disappeared by 6 weeks of age . These studies indicate that B . henselae exists in an almost perfect host-parasite relationship with its feline host, but that most cats can ultimately rid themselves of the infection . The susceptibility of cats to intradermal infection and the lack of direct cat-cat transmission are compatible with possible arthropod vectors. Infect Control Hosp Epidemiol, 1997 Jan, 18(1), 38 - 41 Implementation of consensus guidelines for the follow-up of positive blood cultures; Herchline T et al.; OBJECTIVE: Assess the effect and use of resources associated with implementation of a program for the systematic follow-up of positive blood cultures . DESIGN: Prospective epidemiologic study . SETTING: Tertiary-care military medical center . INTERVENTION: All positive blood cultures (BC) were reported via E-mail to an infectious disease specialist as soon as growth was noted . This individual reviewed all Gram stains, clinical data, and antibiotic information on these patients . RESULTS: From June 26, 1994, through January 25, 1995, there were 3,121 BCs drawn, of which 199 (6.4%) were positive from 145 episodes . Sixty-three episodes involved probable contaminants, and 82 episodes were considered true bacteremias . Six patients with true bacteremia died, two were transferred, and three were discharged within 24 hours of drawing the positive BC . Of the remaining 71 true bacteremias, 9 patients were on inadequate empiric therapy, as judged by the final organism susceptibilities . Changes in empiric therapy were recommended for five of the nine episodes and were implemented by the primary physicians in each case . Each of the changes resulted in improved coverage (as judged by the final identification and susceptibilities) . CONCLUSIONS: This program has improved the quality of care at Keesler Medical Center at the cost of one additional hour of consultant time per week. J Am Geriatr Soc, 1997 Jan, 45(1), 50 - 5 A comparison of nursing home-acquired pneumonia patients with patients with community-acquired pneumonia and nursing home patients without pneumonia; Marrie TJ et al.; OBJECTIVES: To determine the factors responsible for mortality and characteristics unique to patients with nursing home acquired pneumonia (NHAP) . DESIGN: A prospective study of 71 patients with NHAP, 79 patients admitted from nursing homes for conditions other than pneumonia (NP), and 93 patients with community-acquired pneumonia (CAP) . SETTING: A teaching hospital that serves as the community hospital for the City of Halifax . RESULTS: The 32% in-hospital mortality rate for NHAP was higher than the 14% rate for CAP (P < .05) but not significantly higher than the 23% mortality rate for NP patients . The most important determinants for long-term (52 weeks) outcome were complications during hospital stay, odds ratio for mortality 3.55, and self sufficiency at time of admission, odds ratio for mortality 0.306 . While bacteremia rates were similar at 8% for NHAP, 13% for CAP, and 17% for NP, there was a trend toward a higher rate of pneumococcal bacteremia in the CAP group . CAP patients were more likely to receive ventilatory support, 13% versus 3% for NHAP and 4% for no pneumonia patients despite similar levels of hypoxemia in the two pneumonia groups . CONCLUSIONS: The in-hospital mortality rate for NHAP is higher than that for CAP . The 1-year survival rate is determined by self-sufficiency at time of admission and absence of complications during hospital stay and is not group (e.g., nursing home) dependent. Clin Chest Med, 1996 Dec, 17(4), 713 - 23 Bacterial pneumonia associated with HIV-1 infection; Noskin GA et al.; Bacterial pneumonia remains an important cause of treatable morbidity among HIV-1-infected persons . These pneumonias occur at all CD4 counts but are especially common as the HIV-1 infection progresses . Bronchopneumonia should be considered particularly in the setting of segmental or lobar consolidation associated with productive cough and fever . S . pneumoniae remains the most common pathogen causing bronchopneumonia . Because of the high rate of bacteremia, diagnosis may be facilitated by blood cultures . Treatment is similar to management of HIV-1-seronegative persons, although drug resistance against some bacteria may be an emerging problem . Several opportunities exist for prevention, and these should be pursued vigorously. J Pediatr, 1996 Dec, 129(6), 828 - 35 Serotype-specific immunoglobulin G antibody responses to pneumococcal polysaccharide vaccine in children with sickle cell anemia: effects of continued penicillin prophylaxis; Bjornson AB et al.; OBJECTIVES: (1) To determine serotype-specific IgG antibody responses to reimmunization with pneumococcal polysaccharide vaccine at age 5 years in children with sickle cell anemia and (2) to determine whether continued penicillin prophylaxis had any adverse effects on these responses . STUDY DESIGN: Children with sickle cell anemia, who had been treated with prophylactic penicillin for at least 2 years before their fifth birthday, were randomly selected at age 5 years to continue penicillin prophylaxis or to receive placebo treatment . These children had been immunized once or twice in early childhood with pneumococcal polysaccharide vaccine and were reimmunized at the time of randomization . RESULTS: Serotype-specific IgG antibody responses to reimmunization varied according to pneumococcal serotype but in general were mediocre or poor; the poorest response was to serotype 6B . The antibody responses were similar in subjects with continued penicillin prophylaxis or placebo treatment, and in subjects who received one or two pneumococcal vaccinations before reimmunization . The occurrence of pneumococcal bacteremia was associated with low IgG antibody concentrations to the infecting serotype . CONCLUSIONS: Reimmunization of children with sickle cell anemia who received pneumococcal polysaccharide vaccine at age 5 years induces limited production of serotype-specific IgG antibodies, regardless of previous pneumococcal vaccine history . Continued penicillin prophylaxis does not interfere with serotype-specific IgG antibody responses to reimmunization. Shock, 1996 Dec, 6(6), 442 - 51 A porcine model of peritonitis and bacteremia simulates human septic shock; Goldfarb RD et al.; Cardiovascular responses to systemic bacteremia were evaluated in a pre-instrumented, conscious pigs . Basal observations were obtained 5-7 days after instrumentation . On the next day, Escherichia coli 0111.B4 (1.1 to 33 x 10(9) CFU/kg)-laden fibrin clots were implanted intraperitoneally . Nonsurvivors (9/18) demonstrated rapid cardiovascular decompensation . Survivors (9/18) demonstrated significant cardiovascular injury, which was reversed by 5-7 days postimplant . Cardiac inotropicity was significantly reduced in this period, but recovered by day 7 . Circulating myocardial depressant substance activity (assayed by serum-induced depression of beating neonatal rat myocytes) was present on days 1-4 of bacteremia and recovered to basal values on day 6 . No clinical or cardiovascular changes were seen in pigs implanted with sterile clots (n = 4) . These data demonstrate that implantation of bacteria-laden fibrin clots in pigs induces cardiovascular alterations that mimic responses seen in human sepsis. Surg Endosc, 1996 Dec, 10(12), 1176 - 9 Does pneumoperitoneum during laparoscopy increase bacterial translocation? Evasovich MR, Clark TC, Horattas MC, Holda S, Treen L. BACKGROUND: To evaluate the impact of laparoscopy in the presence of peritonitis, this study was designed to assess bacteremia caused by E . coli-induced peritonitis with a carbon dioxide pneumoperitoneum in a rat model . METHODS: Sixty Sprague-Dawley rats were divided into inoculum groups (no E . coli, 10(6) colony-forming units {CFU} E . coli, and 10(8) CFU E . coli), followed by induction of a carbon dioxide pneumoperitoneum or no pneumoperitoneum . Fifteen-minute-interval blood cultures were obtained to determine time of bacteremia development . Statistical assessment to determine significant differences among groups was done using ANOVA and t-test analysis . RESULTS: A total of 20 animals with E . coli introduced into the peritoneum and a carbon-dioxide-induced pneumoperitoneum had more frequent positive blood cultures at all time intervals compared to identical inoculum subgroups without a pneumoperitoneum . ANOVA revealed a significant difference in bacteremia within the same concentration inoculum groups in animals receiving a pneumoperitoneum vs none (p < 0.01) . Bacteremia increased significantly as inoculum concentrations increased (25% with 10(6) E . coli inoculum vs 80% with 10(8) E . coli), especially among the insufflated subgroups (45% with 10(6) E . coli vs 100% with 10(8) E . coli) over 180 min (p < 0.01) . CONCLUSION: Carbon dioxide pneumoperitoneum increases the incidence of E . coli bacterial translocation from the peritoneum into the bloodstream in this rat model. Nutr Hosp, 1996 Nov-Dec, 11(6), 317 - 20 The small intestine as the origin of bacteremia in acute diffuse peritonitis; Peregudov SI et al.; Studies have demonstrated the failure of gut barrier function in all cases of experimental acute diffuse peritonitis . Histobacterioscopy and electron microscopy showed the occurrence of bacteria under the basal membrane, in lymphatic and blood capillaries of the small intestinal villi . Experimental and clinical trials with blood sampling from different regions of the circulation have demonstrated the gut origin polymicrobial bacteremia in 66% of patients and in 75% of experimental animals with acute diffuse peritonitis. Am J Physiol, 1996 Nov, 271(5 Pt 2), R1193 - 8 Endogenous modulators of TNF and IL-1 response are under partial control of TNF in baboon bacteremia; Redl H et al.; Tumor necrosis factor (TNF) and interleukin (IL)-1 are two cytokines for which naturally occurring inhibitors have been identified . The present study was undertaken to evaluate the extent to which scavenging of TNF in bacteremia attenuates the plasma levels of IL-1 receptor antagonist (IL-1ra) and soluble TNF receptors (sTNFR) . Ten male baboons received 2 x 10(9) colony-forming units/kg live Escherichia coli over 2 h and were subjected to either placebo or anti-TNF antibody (anti-TNF Ab) treatment (1 mg/kg CDP571, Celltech, UK) 2 h before E . coli infusion (observation time: 72h) . IL-1ra (range: 50-100 ng/ml) and sTNFR (range: 55kDa, 20-25 ng/ml; 75 kDa, 30-35 ng/ml) release was more sustained than that of IL-1 and TNF and was significantly attenuated by anti-TNF treatment, as were the circulating levels of IL-1, IL-8, and monocyte chemotactic peptide-1 (MCP-1) in the anti-TNF Ab group . We conclude that the increase in circulating natural cytokine modulators observed in nonhuman primate bacteremia is under the partial control of endogenous TNF because it was influenced by anti-TNF pretreatment . This attenuation is comparable to the anti-TNF effect on the chemokine MCP-1. Bone Marrow Transplant, 1996 Nov, 18(5), 879 - 84 Mobilization of peripheral stem cells with intensive chemotherapy (ICE regimen) and G-CSF in chronic myeloid leukemia; Boque C et al.; Seventeen patients with Philadelphia (Ph) chromosome-positive chronic myeloid leukemia (CML) were treated with the ICE regimen plus G-CSF with the aim of mobilizing and collecting Ph-negative peripheral stem cells (PSC) in the setting of an autotransplant program . Fifteen patients had CML in first chronic phase (CP), and two in accelerated phase (AP) . Three patients had been previously treated with interferon alpha 2a (IFN) . Twelve patients underwent leukaphereses and a mean of 4.7 x 10(8)/kg mononuclear cells were obtained . Four CP patients did not show a significant mobilization peak of CD34+ cells and leukapheresis was not performed; finally, one patient died before apheresis could be performed . Six of the 12 who underwent leukaphereses obtained more than 1.0 x 10(6)/kg CD34+ cells . Eight of the 12 mobilized patients (67%) obtained a major cytogenetic response, including two complete and six partial; in the remaining four patients minimal or absent cytogenetic responses were observed . A higher rate of Ph purging was obtained in patients mobilized early or showing residual Ph-negative cells before mobilization, even if they were in AP . Infectious complications were frequent with a 38% rate of bacteremia recorded and one case of pulmonary aspergillosis resulting in a toxicity similar to that occurring in acute myeloid leukemia-induction chemotherapy . The ICE regimen can promote 'in vivo' purging of the Ph+ cells in 67% of CML mobilized patients (8/12) . Failure of mobilization occurs in 65% of patients (11/17), mainly because of poor CD34+ cell yield. Crit Care Med, 1996 Nov, 24(11), 1775 - 81 Plasma proinflammatory cytokine concentrations, Acute Physiology and Chronic Health Evaluation (APACHE) III scores and survival in patients in an intensive care unit; Friedland JS et al.; OBJECTIVE: To more clearly define the relationships between plasma proinflammatory cytokine concentrations, physiologic disturbance, and survival in severely ill patients . DESIGN: Prospective, longitudinal, cohort analytic study . SETTING: Teaching hospital intensive care unit (ICU) . PATIENTS: Two hundred fifty-one consecutive nonselected patients admitted to the ICU . INTERVENTIONS: None . MEASUREMENTS AND MAIN RESULTS: Daily Acute Physiology and Chronic Health Evaluation (APACHE) III scores were calculated from clinical and laboratory data . In concurrent blood samples, plasma concentrations were measured of four proinflammatory cytokines (tumor necrosis factor-{TNF} alpha, interleukin {IL}-1 beta, IL-6, and IL-8), all of which are believed to be of central importance in host proinflammatory and immune responses . Plasma TNF concentrations were increased in 42 patients, plasma IL-1 beta in 15 patients, IL-6 in 194 patients, and IL-8 in 52 patients at presentation . Although admission plasma IL-1 beta, IL-6, and IL-8 concentrations were higher in patients who died in the ICU compared with survivors (n = 33; p < .02, p < .01, p < .02, respectively), only admission plasma IL-8 concentrations were higher in patients with a fatal outcome if all in-hospital deaths were considered (n = 53; p = .05) . APACHE III score was the best predictor of mortality (odds ratio 11.41; p = .003) . Detection, but not the absolute level, of TNF bioactivity in plasma was a weak independent predictor of death (odds ratio 3.17; p = .02) . There was no relationship between bacteremia or presence of the systemic inflammatory response syndrome and plasma cytokine concentrations . Nineteen patients were in the ICU for > or = 10 days, and of these 19 patients, 16 patients had prolonged increases of plasma cytokines . Two patients with persistently increased plasma TNF concentrations died . Otherwise, persistently increased plasma cytokine concentrations had a variable relation to daily APACHE scores and to mortality . CONCLUSIONS: Plasma cytokine concentrations fluctuate in serious illness and have a poor correlation with derangement of whole body physiology in seriously ill patients . Only the presence of bioactive TNF in plasma was an independent predictor of mortality . Daily measurement of plasma proinflammatory cytokine concentrations is unlikely to have clinical application in the ICU setting, except possibly in specific subgroups of patients. Arch Ophthalmol, 1996 Nov, 114(11), 1348 - 56 Chemotherapy plus local treatment in the management of intraocular retinoblastoma; Murphree AL et al.; OBJECTIVE: To describe platinum-based chemotherapy combined with local treatment modalities as an alternative to external beam radiotherapy for intraocular retinoblastoma . DESIGN: Platinum levels were measured by atomic absorption analysis in the tumors of 2 patients with retinoblastoma given carboplatin 5 or 2.5 hours before enucleation . Platinum levels in heated vs nonheated Greene melanoma tumors in rabbits were compared . A retrospective review of 172 affected eyes in 136 consecutive patients treated for retinoblastoma between January 1990 and December 1995 was performed . From 1990 to 1992, all treatable eyes initially received systemic carboplatin, 560 mg/m2, followed by 15 to 30 minutes of continuous diode laser hyperthermia (thermochemotherapy) . Since 1992, larger tumors were treated initially with 3 monthly cycles of carboplatin, etoposide, and vincristine sulfate to reduce tumor volume (chemoreduction) followed by sequential aggressive local therapy (SALT) during examinations under anesthesia every 2 to 3 weeks . OUTCOME MEASURE: Treatment success was defined as eradication of tumor without enucleation or external beam radiotherapy . RESULTS: Significant therapeutic platinum levels were measured in the human tumors 2.5 and 5 hours after carboplatin administration . Increasing the temperature by 9 degrees C for 15 minutes doubled platinum levels in the rabbit model . Of the 38 eyes with Reese-Ellsworth group 1 through 5b tumors that were treated primarily with thermochemotherapy, all 24 eyes with group 1 and 2 tumors were treated successfully and two of the 4 eyes with group 3 tumors and all 10 eyes with group 5b tumors were treated unsuccessfully . Chemoreduction plus SALT was the primary treatment in 35 eyes and was successful in all 10 eyes with group 1 through 4 tumors and unsuccessful in all 7 eyes with extensive subretinal seeding and all 18 eyes with group 5b tumors with vitreous seeding . Seventy patients received carboplatin or carboplatin, vincristine, and etoposide, with myelosuppression, occasionally associated with bacteremia, being the main side effect . Transfusions were required in 15% of patients . Radiation retinopathy occurred in all 6 eyes treated with iodine 125 plaques . CONCLUSIONS: Thermochemotherapy is successful primary treatment for Reese-Ellsworth group 1 and 2 retinoblastomas . For larger tumors in the absence of vitreous or extensive subretinal seeding, 3 cycles of chemoreduction followed by SALT eradicates residual viable tumor . Chemoreduction plus SALT was not successful in eyes with diffuse vitreous or extensive subretinal seeding . Prior chemotherapy increases the risk for radiation retinopathy following 125I plaque therapy . External beam radiotherapy can safely be avoided in the primary treatment of Reese-Ellsworth groups 1 through 4 nondispersed retinoblastoma. J Am Soc Nephrol, 1996 Oct, 7(10), 2264 - 7 A clustering of epidural abscesses in chronic hemodialysis patients: risks of salvaging access catheters in cases of infection; Kovalik EC et al.; The objective of this study was to investigate factors that might increase the risk of epidural abscesses in hemodialysis patients . The charts of all hemodialysis patients presenting with an epidural abscess over a period of 5 yr at Duke University Hospital and the Durham Veterans Administration Medical Center were reviewed for patient demographics, months on dialysis, vascular access, recently treated infections, signs and symptoms at presentation, and results of any surgical intervention . Ten patients developed an epidural abscess during a 5-yr period . Severe, debilitating back pain was the only consistent initial complaint . Eight patients had dual-lumen intravenous catheters for hemodialysis access, and five patients had or were receiving parenteral antibiotics for catheter salvage . There were no consistent physical, clinical, or laboratory findings . Surgical drainage of the abscess with removal of the hemodialysis catheters and parenteral antibiotics were required for cure in six patients . It was concluded that attempts at catheter salvage with parenteral antibiotics has significant risks for complications . Hemodialysis patients with recently treated or ongoing bacteremia who complain about severe and debilitating back pain with or without neurologic findings should raise the suspicion of an occult epidural abscess. Med Decis Making, 1996 Oct-Dec, 16(4), 357 - 66 The discrepancy between daily practice and the policy of a decision-analytic model: the management of fever of unknown origin; Timmermans DR et al.; The optimal treatment of children with fever of unknown origin is controversial, in spite of two decision analyses that advise treatment with antibiotics for all such children . The aim of this study was to analyze the differences between pediatricians' diagnostic and therapeutic decisions and the outcomes of the decision-analytic models . Thirty-six pediatricians were asked to evaluate 30 patient cases and to give their diagnostic and therapeutic judgments . In addition, the pediatricians were asked questions about the epidemiology of fever of unknown origin . Analyses showed that the differences in policy between pediatricians and the models could not be explained by the reasons mentioned in the literature, i.e., 1) differences in epidemiologic data used, 2) differences in the weighting of clinical information, and 3) differences in the evaluation of outcomes . The differences in policy might be due to a difference between the objective of the models and pediatricians' aim . In a curative setting, pediatricians are not trying to prevent meningitis (or another serious disease) by treating possible occult bacteremia, but rather aim to detect meningitis in an early stage . A decision analysis determining the most cost-effective strategy for early detection of meningitis might therefore be more easily accepted by pediatricians. Gastrointest Endosc, 1996 Oct, 44(4), 378 - 81 Absence of bacteremia after gastrointestinal procedures in children; el-Baba M et al.; BACKGROUND: Transient bacteremia after certain gastrointestinal endoscopies is well documented in adult patients; however, experience in pediatric patients is very limited . We conducted a prospective study to determine the frequency of bacteremia after common endoscopic procedures in children . METHODS: A total of 108 endoscopies were performed in 95 patients (age range 8 months to 17 years; mean age 10.2 years) . Procedures included 68 esophagogastroduodenoscopies (EGDs), 29 colonoscopies, and 11 flexible sigmoidoscopies . Most procedures (88) were performed with patients under conscious sedation; 20 were under general anesthesia with endotracheal intubation . Biopsy specimens were obtained from all patients . Blood samples for aerobic and anaerobic cultures were obtained prior to, and within 5 minutes of, completion of the procedure . In patients who underwent general ane