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Objectives: To examine how perceptions of parental responsibility for diabetes management are associated with age, pubertal status, adolescents' self-efficacy, and parental perceptions of adolescents' efficacy, and if parental responsibility is associated with better metabolic control as a function of adolescents' self-efficacy and parental perceptions of adolescents' efficacy.Methods: Questionnaires assessing parental responsibility, pubertal status, adolescents' self-efficacy, and parental perceptions of adolescents' efficacy were given to 185 adolescents with type 1 diabetes, 185 mothers, and 145 fathers.Results: Greater parental responsibility was negatively associated with age, perceptions of pubertal status, and efficacy for all reporters. Interactions between parental responsibility and parental perceptions of adolescents' efficacy indicated that parental responsibility was associated with better metabolic control when adolescents were perceived to have lower efficacy.Conclusions: Adolescents' and parents' perceptions of parental responsibility are related to multiple factors. Metabolic control is best when high parental responsibility is maintained among adolescents with lower efficacy. [ABSTRACT FROM AUTHOR]

Developing individuals and their families benefit from a warm and supportive relationship that fosters the development of good self-regulatory skills in the child needed for a host of positive developmental outcomes. Children and parents face special challenges to self-regulation when faced with a child's chronic illness. A developmental model is presented that traces how positive parental involvement is coordinated with a child's self-regulation skills (regulation of cognition, emotion, and behavior) that are essential for positive health management. This involves different temporal patterns of coordination of child and parent (and other close relationships) that lead to accumulating regulatory developments that afford benefits for managing illness. This process begins early in infancy through attachment and develops into childhood and adolescence to involve the coordination of parental monitoring and child disclosure that serves as a training ground for the expansion of social relationships beyond the family during emerging adulthood. The specific case of families dealing with type 1 diabetes is used to illustrate the transactional and dynamic nature of parent-child coordination across development. We conclude that a developmental model of parent-child coordination holds promise for understanding positive health outcomes and offers new methodological and statistical tools for the examination of development of both child and parent.

Background: To describe 2 cases of melanocytic matricoma with malignant histological features and systematically review previously reported cases of malignant melanocytic matricoma., Methods: Two cases of malignant melanocytic matricoma were identified from the practice of the authors. Additional 3 cases were identified in the literature. The clinical and pathological features of these 5 cases are described., Results: Malignant melanocytic matricoma occurs predominantly in sun-damaged skin of elderly individuals. The tumor is composed of atypical epithelial cells with brisk mitotic activity showing evidence of matrical keratinization and widespread positivity with beta-catenin. There is an admixed cytologically bland dendritic melanocytic component. To date, local recurrence has occurred in one case, but no cases of disseminated disease or death have been reported., Conclusions: Recognition of this rare tumor and separation from a range of diagnostic mimics is important to ensure adequate treatment by local excision and to allow further cases to be identified to better define the biological potential of this lesion.

Objective: To identify whether changes in pubertal status and self-efficacy for diabetes management are associated with longitudinal declines in parental responsibility for diabetes, and to determine whether these factors moderate associations between declining parental responsibility and deteriorating adherence across adolescence., Methods: Adolescents (N = 252; 53.6% females) with type 1 diabetes, mothers, and 188 fathers participated in a 2.5-year longitudinal study. Self-reports of pubertal status, adolescent efficacy, parental responsibility, and adherence were completed every 6 months (6 time points)., Results: Latent growth curve modeling revealed that longitudinal increases in efficacy and pubertal maturation were uniquely associated with longitudinal declines in parental responsibility. Declines in parental responsibility were related to deterioration in adherence especially when adolescents did not report concomitant growth in self-efficacy., Conclusions: Transfer of responsibility for diabetes management across adolescence may be more optimal when adolescents' increased independence is titrated to their changing self-efficacy beliefs., (© The Author 2014. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To test structural models of parental involvement in type 1 diabetes and to examine associations of parental involvement with adherence and metabolic control., Methods: Two hundred and fifty-two young adolescents (10-14 years) completed reports of adherence and parents' involvement: acceptance, independence encouragement, communication, general and diabetes-specific monitoring, frequency of help, and intrusive support. HbA(1c) values came from medical records., Results: A model of relationship quality, behavioral involvement, and monitoring as three separate yet interrelated factors best fit the data. Higher reports of mothers' and fathers' monitoring and fathers' relationship quality uniquely related to better adherence, whereas higher reports of fathers' behavioral involvement uniquely related to poorer adherence. Higher reports of paternal monitoring were related to lower HbA(1c)., Conclusions: Adolescent perceptions of components of parental involvement are interrelated, yet separate constructs for both mothers and fathers. Parental monitoring was an important predictor of management of type 1 diabetes during adolescence.

This study examined whether perceived coping effectiveness (PCE) was associated with better diabetes management and was higher when adolescents' dyadic coping was matched to shared stress appraisals. There were 252 adolescents with Type 1 diabetes who completed stress and coping interviews where they appraised mothers' and fathers' involvement in stress ownership (mine, indirectly shared, directly shared with parent), in coping (uninvolved, supportive, collaborative, or controlling), and rated their effectiveness in coping. Adolescents completed assessments of depressive symptoms (Children's Depression Inventory), self-care behaviors (Self-Care Inventory), and efficacy of disease management (Diabetes Self-Efficacy). Glycosylated hemoglobin levels were obtained from medical records. Higher PCE was associated with fewer depressive symptoms, self-care behaviors, and efficacy across age and, more strongly for older adolescents' metabolic control. Appraisals of support or collaboration from parents were more frequent when stressors were appraised as shared. PCE was enhanced when dyadic coping with mothers (but not fathers) was consistent with stress appraisals (e.g., shared stressors together with collaborative coping). Stress and coping is embedded within a relational context and this context is useful in understanding the coping effectiveness of adolescents., ((PsycINFO Database Record (c) 2009 APA, all rights reserved).)

Objective: This study examined 1) whether the benefits of mothers' and fathers' accepting relationships with their adolescents regarding diabetes control were due to parental monitoring and 2) how parents together may provide sufficient acceptance and monitoring for diabetes management., Research Design and Methods: Adolescents aged 10-14 years with type 1 diabetes (n = 185) and their mothers (n = 185) and fathers (n = 145) completed assessments of parental acceptance and monitoring of diabetes tasks. Adolescents completed a modified version of the Self-Care Inventory (1) to measure adherence. A1C scores were used as a marker of glycemic control., Results: Mediational analyses revealed that the benefits of adolescents' reports of fathers' acceptance on A1C and mothers' and fathers' acceptance on better adherence were partially mediated by monitoring. Both mothers' and fathers' monitoring and fathers' acceptance had independent effects in predicting adherence. However, only fathers' monitoring had an independent effect on A1C. The effect of fathers' monitoring on A1C occurred as fathers were monitoring at a lower level than mothers. Mothers' and fathers' reports of their own acceptance and monitoring were not associated with A1C or adherence., Conclusions: Results reveal the importance of fathers' acceptance and monitoring in diabetes management, a role that should be encouraged, despite the little attention it has received.

Objective: To examine how children's and mother's appraisals of each other's involvement in coping with diabetes events are associated with emotional adjustment., Methods: One hundred and twenty-seven children (ages 10-15 years) with type 1 diabetes and their mothers reported on their own emotional adjustment and how each other was involved in coping strategies surrounding diabetes stressful events., Results: Appraisals that mothers and children were uninvolved with each other's stressors were associated with greater depressive symptoms and less positive mood; children's appraisals of mother's supportive involvement with children's less depressive symptoms, and appraisals of collaborative involvement with less depressive symptoms and more positive mood for both mothers and children. Appraised control was most detrimental for children for older females and for mothers of younger children., Conclusions: Collaborative involvement in coping efforts may be an important resource for addressing negative emotions that both children and mothers experience surrounding type 1 diabetes, especially across adolescence.

Objective: To examine how children's appraisals of maternal involvement in coping with diabetes are associated with adherence, metabolic control, and quality of life across adolescence., Methods: Children (N = 127, ages 10-15 years) with type 1 diabetes completed measures of adherence, quality of life, and appraisals of mothers' involvement in dealing with diabetes problems (i.e., mother appraised as uninvolved, controlling, or collaborative). Metabolic control was indexed through medical records., Results: Regardless of age or sex of child, appraised maternal uninvolvement was associated with poorer adherence and quality of life, while appraised collaboration was associated with better adherence and metabolic control. There was evidence that the association between appraised collaboration and metabolic control was partially mediated by adherence. Appraised control was associated with poorer adherence among older, but not younger, children and with poorer quality of life among older females but not among older males or younger children of either sex., Conclusions: Maintaining maternal involvement in diabetes care is important across ages 10 to 15, but the optimal form of this involvement may need to be adjusted to be consistent with the child's level of development. The present findings suggest that better adherence is seen across age when mothers are viewed as collaborating with, as opposed to controlling, their child when dealing with diabetes problems.

Objective: To examine how autonomy and pubertal status explain age decreases in maternal involvement in type 1 diabetes management across adolescence, how they relate to metabolic control, and the reasons that guide declines in maternal involvement., Methods: One hundred twenty-seven children ages 10-15 years with type 1 diabetes and their mothers participated. Data included maternal and child report of diabetes management, child report of autonomy level, maternal report of pubertal status, maternal reports of reasons for transfer of diabetes responsibility, and glycosylated hemoglobin (Hba(1c)) values., Results: Autonomy and pubertal status partially mediated age effects on reports of maternal involvement. Mothers' reasons for transferring responsibility included responding to the child's competence, promoting competence and maturity in their child, and minimizing hassles and conflict. The transfer of diabetes responsibility from mother to child without sufficient autonomy and when pubertal status was low was related to higher Hba(1c) values., Conclusions: The importance of chronological age for changes in maternal involvement suggests the need to examine mothers' and adolescents' developmental expectations for diabetes management. The reasons for transferring responsibility from mother to child suggest many avenues for intervention.

Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) are currently hyperendemic in sub-Saharan Africa. HIV and AIDS have a special impact on working-age populations, economic resources, certain illnesses, and health care facilities. Assessment of HIV serostatus of hospitalized patients is rarely performed, however, because of a reluctance to intrude on patient confidentiality, a perceived lack of benefit (no antiretroviral therapy is available), and societal denial. We evaluated the effect on health care of HIV testing of patients routinely admitted to medical wards in the 2 major city hospitals in Harare, Zimbabwe. Of 196 patients tested, 58% were HIV positive with strong associations with infectious diseases, and with youth and weight loss, but not with cardiac, pulmonary, endocrinologic, or renal diagnoses, and not with rural versus urban location, occupation, sex, mortality, or cost of hospitalization. The clinical estimate of patients' HIV serostatus was largely inaccurate. Mandatory HIV testing of all hospitalized patients would improve diagnosis of infectious diseases, clarify patient prognosis, allow for individual counseling with regard to HIV prevention, and focus national health efforts by providing alarming, realistic statistics.

Effects of sex and competition on receptive attention and Stroop task performance of 59 college students were investigated, 33 participants in a competitive condition were informed that performance would be ranked by sex; 36 in a noncompetitive condition were given no information regarding competition. Consistent with previous research, no significant main effects or interactions were found for scores on the receptive attention task. Contrary to previous findings, though, the Stroop task also yielded no significant main effects; however, a significant interaction was found. Men experienced more interference in the competitive condition, whereas women showed no significant effects of competition. Women did experience more interference than men in the Noncompetitive condition. Conclusions suggest that men may be more sensitive to sex-based performance comparisons.

Incessant supraventricular tachycardia can cause a dilated cardiomyopathy. This article discusses the case of a 55-year-old woman whose cardiomyopathy was reversed when she underwent successful radiofrequency catheter ablation of a unifocal atrial tachycardia.

Objective: To quantify inorganic pyrophosphate (PPi) production from extracellular adenosine triphosphate (ATP) by human synovial fluids (SF)., Methods: Serial measurements of ATP hydrolysis rate (t1/2) were performed by the luciferase method from a starting concentration of 500 nM in 21 pathologic and one normal cell-free SF samples incubated under physiologic conditions. ATP was then pumped into a sample of each fluid, using the rate constant derived from the t1/2 of that fluid, to provide steady state levels simulating those reported in SF. Trace [32P] gamma ATP was added at the start of the infusion; conversion to [32P] Pi and to [32P] PPi was determined by precipitation of Pi as reduced phosphomolybdate before and after treatment with yeast inorganic pyrophosphatase. Finally, the pumping experiment was repeated and PPi production was calculated from direct measurement of PPi at time zero and at 60 min. PPi hydrolysis was measured in each fluid by [32P] Pi precipitation from [32P] PPi tracer added at time zero., Results: ATP was hydrolyzed by all SF. The mean t1/2 (seconds) in 8 osteoarthritis (OA) samples was 72 s, in 5 calcium pyrophosphate dihydrate (CPPD) 30 s (p < 0.02), in 3 rheumatoid arthritis (RA) 1160 s, in normal 86 s, in 3 olecranon bursal (OB) 54 s, and in 2 total knee replacement fluid samples 17 and 121 s. The major product of ATP hydrolysis was PPi in all but 2 fluids (1 RA, 1 OB), even at lower than steady state levels. At simulated in vivo steady state ATP levels, mean conversion of APT to PPi was stoichiometric in OA and CPPD fluids. PPi hydrolysis was < 4% in all noninflammatory fluids., Conclusion: PPi is the major product of extracellular ATP catabolism in most SF. Hydrolysis rates were significantly faster in SF containing CPPD crystals. Mean PPi production by these fluids at simulated in vivo steady state levels was 6-fold that of OA SF (p < 0.01). Hydrolysis of extracellular ATP by ectonucleotide pyrophosphohydrolases can account for all PPi produced by joint issues previously estimated from [32P] PPi pool and turnover studies in human knee joints.

Broad-spectrum versus narrow-spectrum antibiotic prophylaxis for patients who undergo cardiac operations is variously advocated to reduce the incidence of all infections or, conversely, to prevent resistant superinfections. Previous studies of prophylaxis have shown a reduction in the incidence of staphylococcal infections with some increased resistance. We studied preoperative and postoperative wound colonization as a surrogate for infection. Among 78 patients undergoing cardiac procedures, the type of prophylaxis was allocated as follows: narrow-spectrum (nafcillin), 24 patients; midspectrum (cephapirin), 26 patients; and broad-spectrum (ceftriaxone), 28 patients. Seventeen patients who underwent other procedures received no antibiotics and served as controls. Cultures of the operative site were done preoperatively, and 3 and 6 days postoperatively. The incidence of preoperative skin colonization with staphylococci was identical (95%) in all groups. Postoperatively, more patients receiving nafcillin (48%) were culture-negative for all organisms than were either of the other groups receiving antibiotics (27% and 22%) (p < 0.05). Gram-negative bacilli were infrequent colonizers and neither did the incidence of infection with these organisms increase nor did resistance develop in any group. The infection rates were not different among the treatment groups. Thus, a narrow-spectrum antistaphylococcal penicillin may offer an advantage in terms of both prophylaxis for cardiac operations and hospital costs.

We present a sixth human case in which primary human immunodeficiency virus (HIV-1) infection occurred, despite antiretroviral prophylaxis, after accidental inoculation of infected blood. In the prior five instances, variables such as large virus dose, late administration of antivirals, viral resistance to zidovudine, and pre-existent immunosuppression, may have played a role in the treatment failure. In this case, high-dosage oral zidovudine was given within minutes of the accident and replaced 2 1/2 days later with interferon alpha and dideoxyinosine (ddl). Despite aggressive treatment, HIV-1 infection was demonstrated in blood, spleen, and brain tissue at autopsy 16 days later. Of the tissues studied, detection of HIV-1 was most prominent in the spleen. Double-label immunocytochemistry confirmed the morphologic impression that while some of the infected spleen cells were CD3-positive T cells, the majority were macrophages. Thus, current single or dual (zidovudine, ddl-interferon) therapies for accidental HIV-1 inoculation may not be effective in preventing early infection. Further trials in animals appear warranted to evaluate protection by other strategies, such as passive immunity or combinations of agents that penetrate the brain and attack HIV-1 viral replication at differing sites.

We report a 68-year-old man who received an IV inoculation of WBCs for an indium radionuclide scan containing 600 to 700 tissue culture infectious doses of human immunodeficiency virus type 1 (HIV-1) from an HIV-1-infected individual. The recipient immediately received zidovudine, then was switched to dideoxyinosine and interferon-alpha, but died of hepatorenal syndrome and hepatic encephalopathy 15 days later. HIV-1 cultures were positive from the recipient's blood on day 14 but not days 0, 1, and 8. At autopsy, cultures of parietal lobe isolated HIV-1. HIV-1 nucleic acid was present in several brain areas, but not in several other organs, by two independent laboratories using the polymerase chain reaction. The brain showed mild perivascular cuffing and a mild lymphocytic meningitis, but there was no evidence of glial nodules, giant cells, or white matter abnormalities. HIV-1 pg41 viral antigen was seen by immunoperoxidase staining in rare infiltrating cells within perivascular and subpial spaces. Thus, HIV-1 was isolated from brain 15 days after mistaken HIV-1 inoculation and 1 day after virus was first recovered from blood.

A survey of persons soliciting sex in an area known to be frequented by prostitutes in Albuquerque, NM, included 43 females and 66 males. Seroprevalence rates found in this population-based study were as follows: human immunodeficiency virus type 1 (HIV-1), 3%; hepatitis B, 39%; hepatitis C, 45%. Increased age, intravenous drug use, and condom use were independent risk factors for hepatitis B. Female gender and intravenous drug use were independent risk factors for hepatitis C. Neither sharing injection equipment nor engaging in receptive anal intercourse was independently associated with hepatitis B or C.

During a 9-year period, six women with ulcerative colitis (UC) and rectovaginal fistulas were surgically treated. Three underwent ileoanal pull-through procedures with simultaneous repair of the rectovaginal fistulas. Two patients had Kock pouches, and one had a Brooke ileostomy because extensive destruction of the rectal sphincter prohibited ileoanal procedures. The three patients who had ileoanal procedures all had excellent functional results. There has been no evidence of Crohn's disease or fistula recurrence. We believe that rectovaginal fistulas occur more frequently in UC than is generally accepted, and they can be safely managed with current reconstructive techniques.

Melioidosis, infection by the soil bacterium Pseudomonas pseudomallei, has the potential for prolonged latency with recrudescence into an acute, often fulminating, and fatal infection. Although the organism is never found in North America, infection is endemic in areas of southeast Asia, and populations of service personnel exposed during the Vietnam war and southeast Asian immigrants are at risk of severe recrudescent disease. Diagnosis, however, has been missed or delayed because of lack of familiarity with this disease. We present a case of recrudescent melioidosis that illustrates the difficulties encountered in diagnosis and treatment. This case involves a 76-year-old Vietnam veteran who presented with melioidosis of the bone 18 years after exposure to the organism and 10 years after a missed diagnosis of latent pulmonary disease. This case illustrates the protean nature of latent infection and the difficulty of selecting successful antibiotic therapy.

Use of sputum culture for diagnosis of tuberculosis is an inefficient detection technique in a disease of declining prevalence. We found such testing at our 400 bed acute care hospital resulted in less than 2 percent positive when done with prior patient screening. In an effort to minimize detection costs, restrictions requiring that a tuberculin skin test and chest roentgenogram be performed prior to processing the MTB culture were instituted. This resulted in 672 fewer cultures being processed in the trial year, a significant (44 percent) reduction compared to the prior year. At $50.00 per culture, this represents an annual savings of more than $30,000.

The risk of acquiring hepatitis associated with work in a moderate-sized acute-care teaching hospital was determined by a seroepidemiologic survey of hepatitis B surface antigen and antibody. A blood specimen and a completed questionnaire were obtained from 76 percent of the staff members involved in patient care activities and all preemployment applicants (a total of 767 persons). One employee was found to have transiently positive tests for hepatitis B surface antigen, whereas 94 (12.2 percent) were found to have hepatitis B surface antibodies. Using the national incidence rate for volunteer blood donors of 4.4 percent as a norm, significantly higher antibody incidence was seen in nursing personnel (16.9 percent), laboratory workers (14.0 percent), surgeons (37.5 percent) and dental workers (40.0 percent). Rates were not significantly raised among house officers, internists, respiratory therapists or housekeeping employees. Increased incidence was statistically related to age and known history of hepatitis, but not to sex, known needle-stick exposure, contact with patients having hepatitis, prior blood transfusion, blood handling or nonhospital exposure to hepatitis. In persons whose tests were positive for antibodies there was a 4 percent increment per decade of age among long-term employees; duration of employment approached significance as a risk factor. Of those with hepatitis B antibody, only 16 percent were aware of a prior bout of hepatitis.

In 39 patients with treated unresponsive pneumonia complicated by life-threatening underlying disease, direct needle aspiration of the lung was performed to establish a cause. An infectious agent was detected in 18 patients (46 percent), a nonbacterial cause was found in one, and cure of a recent infection was substantiated in six patients. An incorrect diagnosis was made in seven patients (one false-positive and six false-negative), and an indeterminant answer was obtained by needle aspiration in seven. Serious complications occurred in 11 patients, most commonly in those who had hypoxia or thrombocytopenia, but no morbidity occurred in 22 patients. The diagnostic yield allowed effective rational therapy to be selected for multiple potential pathogens in 12 patients and detected pathogens not suspected in six instances. The technique compares favorably to other invasive techniques for establishing definitive information in this group of seriously ill patients.

Two cases of acute bacterial meningitis occurred with an absent CSF WBC response. To determine the incidence and clinical characteristics of such patients, 50 consecutive cases of meningitis were reviewed retrospectively. In addition to the two initially noted cases, five additional cases were found. In the seven cases, there were six or fewer cells, but bacteria were detected in the CSF. A distinctive clinical and laboratory syndrome emerged. All seven patients were either old or had Hodgkin's disease or severe alcoholism. All patients had evidence of an overwhelming infection with confusion or nuchal rigidity. As compared with the remaining 45 patients with meningitis and CSF pleocytosis, no fever (less than 38 degrees C), a lower peripheral WBC count, and near-normal CSF glucose and protein concentrations were common. Organisms involved were EScherichia coli in three patients, Pneumococcus in three patients, and mixed anaerobes in patient. A fatal outcome ensued in six of seven patients. Despite the correct choice of an antibacterial agent, doses were late and suboptimal for meningitis. This syndrome is surprisingly common in host-defective cases, has an ominous prognosis, and must be treated expectantly with antimicrobial agents that enter the CSF.

The severity of diarrhea and nutritional status were measured in a prospective study of 97 patients hospitalized with cholera in Dacca, Bangladesh. Ninety-five percent of both adults and children were below their respective medians in weight as related to height; greater than 15% of each group showed second-degree protein-calorie malnutrition. Duration of diarrhea, but no volume of stool per hour, was prolonged by 30%-70% in those adults and children suffering from more severe malnutrition. The increased stool loss was unrelated to antibiotic usage, to presence of intestinal parasites, or to the refeeding diet given. It is suggested that the prolongation of diarrhea represents the continued effect of cholera toxin that is irreversibly bound to intestinal mucosal cells, the replacement of which would be retarded under conditions of poor nutrition.

Endovascular infection of the atherosclerotic aorta is a substantial risk in patients older than 50 years of age who have bacteremia due to Salmonella. Until recently, the resultant salmonella aortitis was uniformly fatal. Two patients who were cured are described, and the characteristics of 10 other reported long-term survivors are given. This recent improvement in prognosis may have been related to (1) earlier diagnosis, (2) improved surgical management (axillofemoral bypass graft), and/or (3) increased use of bactericidal antibiotics. A change in bacteriology (fewer infections due to Salmonella cholerae-suis) was also seen in the more recent cases.

Because of declining prevalence of tuberculosis in the United States, standard laboratory tests detect fewer actively infected patients. Of 6,884 cultures for Mycobacterium tuberculosis (MTB) in three years at our hospital, only 2% were positive. To select other effective screening variables, we retrospectively reviewed patients in whom cultures were ordered. Charts of 79 patients with active tuberculosis and 226 patients whose cultures were negative were reviewed for 45 signs, symptoms, and laboratory tests determined at the time of initial contact. Those variables which distinguished the MTB-active from the nonactive were: history of weight loss, prior exposure, night sweats, fever, abnormal chest roentgenogram, positive skin test (PPD) (at P less than .001), and cough and abnormal pulmonary examination (at P less than .05). An algorithmic analysis suggests that weight loss and/or cough, followed by abnormal chest x-ray film and/or positive PPD, would detect 77% of the MTB-infected persons in whom these tests were done. The classic signs and symptoms of pulmonary tuberculosis continue to be excellent screening variables. When combined with the chest x-ray film and PPD, they may allow use of the culture as a confirmatory test, rather than its current inappropriate use as a screening test, for a disease of low prevalence.

Eosinophilia in peripheral blood and tissue of patients with coccidioidomyocsis was reviewed in an examination of the importance of this cellular response to Coccidioides immitis. Peripheral blood eosinophilia (greater than 5%) was found in each of two patients with primary infection but was markedly more pronounced (27%-53%) in three of five patients with disseminated coccidioidomycosis. Unusually large numbers of tissue eosinophils and organized microabscesses containing eosinophils were found in six patients with progressive or disseminated disease. These six patients all demonstrated cutaneous anergy to coccidioidin. Eosinophilic microabscesses were found surrounding rupturing spherules and free endospores. Phagocytosis of free endospores was not demonstrated by the technique used. The bone marrow of two patients with disseminated disease showed a marked increase in eosinophilic myeloid precursors; this result suggested the presence of an eosinophilopoietin. Although peripheral blood eosinophilia has been explained as a hypersensitivity response to C. immitis that represents a favorable prognosis, the data reported herein suggest that peripheral blood eosinophilia of greater than 20% and the presence of eosinophilic microabscesses correlate with progressive or disseminated infection and thus are indicative of a poor prognosis.

Eight cases of sternal/mediastinal infection due to Enterobacter species were seen in postoperative cardiac patients during 1980 to 1981. The attack rate was 14.5% (8/55), compared to 3.7% (2/54) for an identical period in 1979 to 1980 (p less than 0.05). Cases varied in severity from fulminant, acute bacteremic infections (one death) to less severe wound infection. Late complications or recurrences were not seen. There was a hospital-wide increase, relative to all other gram-negative bacillary isolates, in Enterobacter laboratory isolations, but no increased rate of infection in any other specific surgical condition. No personnel, materials, or techniques were associated with the outbreak, and all but two environmental cultures were negative. Case-control analysis suggested that surgical complications and prophylactic cephalosporins were associated with infection. Prospectively, an additional 85 cardiac surgery patients had increased Enterobacter skin/wound colonization following perioperative prophylaxis with cephalosporin antibiotics. After introduction of barrier isolation and restriction of contacts no further mediastinitis occurred in 100 subsequent cardiac surgery patients. This study indicates that Enterobacter may be major pathogens causing post-cardiac-surgery infection not prevented by cephalosporin prophylaxis.

Cholera toxin may depress cell-mediated immunity by stimulation of adenyl cyclase and production of cyclic AMP in cellular systems or when given parenterally to experimental animals. Whether or not similar effects might be found during clinical infection with Vibrio cholerae was the subject of this study. Delayed hypersensitivity reactions to skin test antigens were found to be markedly depressed in Bengali patients with cholera 24 h after fluid repletion. Skin test response rates were lower in children and in adults with the disease than in both normal adults and children or in adults with an equivalent degree of malnutrition. Patients with equal degrees of dehydration due to noncholera diarrhea were significantly less immunosuppressed. Concurrent depression of other manifestations of cell-mediated immunity was not found.

Antimicrobial resistance has been found since 1910. Mechanisms responsible for the resistance antedate introduction of antibiotics. However, proliferation of resistant strains can be closely linked to patterns of antibiotic use. This is seen most often in the hospital setting. Infection control personnel should monitor: (1) antibiotic resistance at least four times per year; (2) key bacteria for multi-drug resistance; and (3) certain index drugs where emergence of resistance may be critical. If a problem with resistant strains develops, the following steps should be taken: (1) identify and decrease inappropriate antibiotic use; (2) segregate patients harboring resistant strains; and (3) consider elimination of certain or all antibiotics.