Search

I. INTRODUCTION: THE GMENAC REPORT In 1976, the federal government took two major steps that were to have a major impact on public attitudes and policies toward the health professions. (1) Congress passed the Health Professions Educational Assistance Act of 1976, formally declaring an end to the notion that there was an overall shortage of physicians in the United States, and emphasizing geographic and primary care shortages instead. (2) Earlier, in April of the same year, the Department of Health, Education and Welfare (DHEW), now the Department of Health and Human Services (DHHS), established the Graduate Medical Education National Advisory Committee (GMENAC) to advise the Secretary of DHEW on a set of issues related to the health professions. The formal charge to GMENAC included five specific questions: (a) What number of physicians is required to meet the health care needs of the nation? (b) What is the most appropriate specialty distribution of these physicians? (c) How can a more favorable geographic distribution of physicians be achieved? (d) What are the appropriate ways to finance the graduate medical education of physicians? (e) What strategies can achieve the recommendations formulated by the Committee? After 4½ years of meetings, analysis, and developing and applying a complex methodology, GMENAC has now completed its work. Its recently published conclusions and recommendations are the subject of this policy statement. II. GMENAC's APPROACH GMENAC chose a ten-year span for its analysis, producing separate estimates for supply of and requirements for health professionals in 1990. Decisions on whether there would be a "shortage" or a "surplus" in a given field were based on a comparison of estimated supply with estimated requirements; the Panel's recommendations were, in turn, based on those decisions.

A randomized therapeutic trial of carbenicillin (CB) or ampicillin (AMP) in purulent meningitis was performed in 86 pediatric and adult patients (41 Haemophilus influenzae , 22 Streptococcus pneumoniae , 13 Neisseria meningitidis , and 10 of unknown etiology). All isolates, incuding H. influenzae , were susceptible to CB and AMP. Median cerebrospinal fluid (CSF) antibiotic concentrations were 0.85 and 1.60 μg/ml for CB and AMP, respectively, during administration of daily doses of 400 mg/kg and 0.65 and 0.45 μg/ml, respectively, on daily doses of 200 mg/kg. Higher CSF concentrations, up to a median concentration of 4.5 μg/ml, were observed in patients with CSF protein concentrations ≥75 mg/100 ml. Clinical responses were equivalent on either antibiotic regimen. Among AMP patients (45), 8 had significant residua and 3 died; among CB patients (41), 5 had residua and none died. However, 38% of H. influenzae patients treated with CB had positive CSF cultures on day 1 follow-up lumbar punctures, compared with only 5.8% of AMP patients with H. influenzae . The significance of a delay of CSF sterilization among CB-treated patients is unknown, since there was no correlation between persistence of hemophilus organisms and the frequency of adverse outcome. AMP and CB are equivalent for the treatment of bacterial meningitis due to susceptible organisms.

SINCE 1963 AMPICILLIN has been used extensively for treatment of meningitis and other infections due to Hemophilus influenzae, type b. Prior reports from this institution 1 have documented marked susceptibility of these organisms to ampicillin. Recently strains of H. influenzae, type b, resistant to ampicillin have been recognized.2. 3 Thes e reports prompted a review of the in vitro susceptibility to ampicillin and chloramphenicol of recently isolated strains compared to those isolated in earlier years. Susceptibility studies performed against groups of organisms isolated during 1971-1972 and 1974 were compared with results of similar studies 1 of strains to H. influenzae, type b, isolated ten years earlier during 1962-1964.

THE first known concentration of cases of meningitis due to sulfadiazine-resistant strains of meningococci occurred during the spring of 1963 at the United States Naval Training Center in San Diego, California.1 Most of the resistant organisms detected during the Naval Training Center outbreak belonged to serologic Group B, and some were resistant to more than 25 mg. of sulfadiazine per 100 ml.1 Because the patterns of sulfadiazine resistance of meningococci isolated from military recruits might be expected to reflect, perhaps in accentuated form, those in civilians in the region, it seemed desirable to assess the prevalence of resistant strains among . . .

Twenty-five patients with bacteriologically proved Listeria monocytogenes meningitis were studied. Twenty-one were male. Nine of the 25 were neonates, and 11 were 55 years of age or older. Twenty-four patients received either ampicillin or penicillin, at times in combination with other antibiotics. One of the ampicillin-treated patients, and six of the penicillin-treated patients died. Recovery of the patient from meningeal infection seemed to correlate best with an initial cerebrospinal-fluid glucose level over 30 mg per 100 ml. These data, like those already appearing in the literature, suggest that intravenous ampicillin may be the therapy of choice, from the standpoint of both superior efficacy and relative lack of toxicity.

Bacterial meningitis and "sepsis," confirmed by positive blood cultures when they occur during the first 30 days of life, present perhaps the greatest current challenges to the antimicrobial therapist. As detailed below for meningitis, case fatality rates are high, and the survivors frequently have crippling sequelae. This is true in spite of the fact that many of the patients have no obvious underlying severe disease and should be salvageable. Certainly, the infectious processes are not always promptly controlled by standard antimicrobials, and the over-all case fatality and residua rates leave ample scope for improvement in the results of therapy.

The presently available, effective antimicrobial therapy has substantially decreased the frequency of disability due to meningitis and has been even more effective in reducing mortality. Optimum therapeutic results are dependent upon prompt clinical recognition of disease, the specific identification of the infectious agent, the prompt administration of bactericidal drugs by the intravenous route, and proper monitoring of the patient during the acute illness. Indeed, rapid diagnosis, monitoring the patient for shock with prompt restoration of effective circulation, early detection of complications, and proper concern toward rehabilitative measures are features of therapy which may be as important as choosing the right antimicrobial.

The purpose of this study was to evaluate gentamicin as a therapy for neonatal meningitis. Neonatal patients received intramuscular gentamicin plus intravenous ampicillin as treatment. Also, according to a prospective study protocol, alternate patients received intracisternal gentamicin daily for three days. Six of eighteen patients died, a lower percentage than with previous therapeutic study groups. Bacterial isolates from spinal fluid generally had a lower minimal bactericidal concentration for gentamicin than for other antibiotics tested. The data is encouraging, but the number of patients is too small to allow firm conclusions. Further evaluation with larger numbers of neonatal patients is indicated.

MANY authorities1 , 2 have recognized chloramphenicol as the preferred drug for the treatment of clinical typhoid fever. During the early months of 1972, an epidemic strain of Salmonella lyphosa resistant to chloramphenicol, tetracycline, streptomycin and sulfadiazine was identified in the area of Mexico City.3 , 4 Since June, 1972, a small number of cases among American citizens who had traveled to endemic areas of Mexico have been reported to the Center for Disease Control.5 , 6 The drug resistance is mediated in a degraded Vi(A) phage type of typhoid bacillus by an R-factor,7 , 8 and it is currently postulated that this same pattern of antibiotic resistance . . .

To investigate the maternal-fetal transfer of tobramycin (TBM) and its distribution in the fetus, a single dose of 2 mg/kg was administered intramuscularly to 35 pregnant patients (13 first trimester, 22 second trimester) 0.5 to 34 h before hysterectomy. TBM concentration was assayed microbiologically in maternal serum, fetal tissues (placenta, brain, lung, liver, and kidney), and fluids (amniotic, cerebrospinal fluid [CSF], urine, and serum). Mean maternal serum half-life (1.54 h) and mean peak serum concentration of TBM were within ranges reported for nonpregnant adults. In fetal serum, half-life was 5.2 h, and TBM levels did not exceed 0.58 μg/ml. For intervals up to 34 h, the mean TBM concentration in placental tissues was 1.4 μg/g. Concentration differences related to fetal maturation were found for fetal CSF, amniotic fluid, and fetal kidney. No antimicrobial activity was found in the fetal CSF of >16 weeks' gestation. TBM was present predominantly in the second trimester amniotic fluid specimens. Fetal kidney concentrations reached 7.2 μg/g at 34 h after maternal drug administration. Higher TBM concentrations were related to advanced maturation of the fetal kidney. Second trimester fetal urine concentrations for TBM ranged from 0.1 to 3.4 μg/ml, and the fetal urinary half-life was 3.7 h. Knowledge of fetal pharmacology is essential for weighing the fetal benefits or risks of antimicrobial therapy for the infected gravid patient.

CONGENITAL DEFECT of the scalp presents diagnostic problems in the neonate, where it appears as a superficially ulcerated lesion which may be associated with a defect in the underlying bone. The observation of scalp defects in identical twin girls at birth afforded an opportunity to document the natural course of this condition. Report of Cases RK (L.A.G.H. 226-73-07), a 5 lb 4 oz (2,380 gm) female, was born the first of twins, at 42 weeks gestation, of a 20-year-old Caucasian mother and a 22-year-old Caucasian father. The mother had no prenatal care and the pregnancy was complicated by preeclampsia. The mother, maternal grandfather, and maternal great-grandfather were each one of fraternal twins. There was no family history of skin defects or other congenital anomalies. At the time of delivery, the patient was noted to have three small circumscribed raw areas in the scalp at the vertex. She was admitted to

1. 1. The sex of the host has a modifying influence upon the intensity of infection with A. tetraptera . 2. 2. Gonadectomy of the host significantly lowers the worm burden. 3. 3. Estradiol in male mice is detrimental to the establishment of a heavy infection, whereas testosterone seems to have little or no effect on the worm burden in either males or females.

The frequency of cranial bruits in 55 patients with purulent meningitis as compared to that of 653 afebrile and 155 febrile patients without meningitis showed that 82 per cent of the patients with purulent meningitis between the ages of three months and five years had cranial bruits whereas bruits were heard in 22 per cent in the febrile control group and 16 per cent in the afebrile control group. The bruits associated with purulent meningitis are usually transitory, lasting one to four days after initiation of therapy. In three of the patients with purulent meningitis cranial bruits recurred in association with the development of subdural effusions. These bruits disappeared as the subdural effusions cleared. Cranial bruits may be another diagnostic point in the recognition of purulent meningitis, subdural effusions and other conditions associated with increased intracranial pressure.

In August 1970, an 18-month-old girl, who had never been outside of Los Angeles County, was found to have shiga bacillus dysentery. Consequently, we established a surveillance of all cases of this disease in the county. Twenty cases occurred between 1966 and 1971; 19 of them in the last three years. Two patients died. Three had never traveled out of the county. Of 47 family contacts, 5 had evidence of asymptomatic infection. The sudden rise in incidence of this disease and the documented spread within the county are a warning for the future.

Introduction Enterobius vermicularis, the pinworm of man, is probably the most cosmopolitan of all the helminthic parasites. Fortunately, it is relatively innocuous. It is, however, enough of a pathogen to cause irritating symptoms in a great number of those persons infected. In spite of its prevalence, relatively little is known of the host-parasite relationship. Many studies have been initiated toward finding a good chemotherapeutic agent for this infection. Unfortunately, the human pinworm has a narrow host range, and will not infect the usual laboratory animals. As a result, the mouse pinworms, Syphacia obvelata and Aspiculuris tetraptera, have been utilized in drug screening.1-5My studies6,7of the host-parasite relationship of the mouse pinworm have shown differences in infection rate and worm burden associated with the sex and age of the host. These results prompted the present study. This report is directed toward answering 2 questions about the relationships of

Intensive immunization efforts in the United States have significantly reduced the incidence of reported rubeola; consequently, the report of an outbreak of rubeola among adolescent boys in one gym class in a Los Angeles high school was regarded as highly unusual. When all the boys had been seen and the spectrum of disease reviewed, rubella was considered the most likely diagnosis. A prodrome characterized by upper-respiratory tract symptoms was present in 65% of the ill students. The rash lasted more than five days in 32%. Recognition of the atypical manifestations of rubella in older age groups may serve to alert physicians to the presence of rubella in the community. With this knowledge, immunization efforts can be directed where they are most needed in an attempt to lessen the impact of the predicted rubella epidemic.

of the "hypersensitivity syndromes" has improved the prognosis of these diseases. Their usefulness, however, has been tempered by the observations that steroids may mask acquired infectious processes, and may depress the normal host resistance to such a degree that normal enteric commensals become pathogenic in nature. Kass and Finland (1953), in their review, have summarized the results of studies in laboratory animals as follows: Cortisone usually depresses the resistance of laboratory animals to a wide variety of bacterial, viral, protozoal, and fungal agents. Cortisone may activate latent infections. Depression of resistance occurs whether the resistance is acquired or native. The use of these hormones is usually associated with evidence of increased multi

NEONATAL herpesvirus hominis (simplex) (HV) infection is generally belived to result in fatal systemic disease. Since the first description of neonatal HV infection in 1935, 1 we are aware of 66 reported patients, eight of whom have survived. 2-8 This report describes three infants who, at birth, had nonvesicular cutaneous lesions which may have represented the first manifestation of their HV infection. All three survived and had recurrent crops of vesicular lesions during the period of observation. Herpesvirus hominis was isolated from vesicular fluid on one occasion in each patient. Report of Cases Case1.— Hospital Course. —A female infant (LACGH PF# 242-04-92) weighing 1,943 gm (4 lb 1 ounce) was born after 33 weeks of gestation to a gravida 1, Rh negative white woman. The only abnormality noted during pregnancy was mild intermittent vaginal bleeding for one month prior to delivery. Small red patches were reported on the

Excerpt INTRODUCTION Although trichostrongyliasis of humans is commonly found in such areas as Turkey, Iran, India, Japan, Korea and China, very few cases have been reported in the United States.1-...