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Introdução: O Índice de Vulnerabilidade Clínico-Funcional-20 (IVCF-20) é um instrumento de triagem para a população idosa, em que se destaca uma aplicação rápida e simples, o qual pode ser feito, inclusive, por profissionais que não sejam da área geriátrica. Dessa forma, ele envolve áreas que englobam de maneira ampla a saúde do idoso: idade, autopercepção da saúde, atividades diárias, cognição, humor, mobilidade, comunicação e comorbidades múltiplas. Sendo assim, é uma ferramenta de grande valor para a identificação de pontos de alerta na saúde do idoso e para um cuidado integral, haja vista que essa análise não apenas impacta na saúde física, mas também na saúde mental e no convívio social dessa faixa etária. Objetivo: Identificar as principais diretrizes e protocolos atuais de abordagem do idoso na saúde pública por meio da aplicação do Índice de Vulnerabilidade Clínico-Funcional-20 (IVCF-20) e seus impactos. Material e métodos: Revisão bibliográfica cuja busca dos estudos primários foi realizada nas bases de dados PubMed, SciELO, CINAHL e LILACS e na revisão de prontuários disponibilizados pelo Instituto Jenny de Andrade Faria. Resultados: Observou-se que o prognóstico de idosos atendidos no Instituto Jenny de Andrade Faria do Hospital das Clínicas da Universidade Federal de Minas Gerais (HC) que tiveram o seu IVCF-20 calculado foi positivo, no que tange à redução de quedas, à substituição ou à suspensão de medicamentos, ao aumento de vigília por cuidadores, à prevenção de quadros psicopatológicos, entre outras medidas. Conclusão: A aplicabilidade do IVCF-20 como protocolo determinante na avaliação da saúde do idoso possui imensa validez, pois consiste num instrumento de praticidade e de potencial internacional, capaz de determinar as capacidades e as limitações que permeiam o indivíduo, caracterizando-o como uma ferramenta não só preventiva, mas terapêutica, notoriamente, ao garantir a melhora da qualidade de vida da população idosa.

Introdução: Em 2015, no município de Mariana, em Minas Gerais, ocorre o Rompimento da Barragem de Fundão (RBF) de responsabilidade da Samarco Mineração. O mar de lama que acometeu a microrregião da Bacia do Rio Doce culminou não somente na morte de 19 pessoas, mas na destruição e na desestruturação patrimonial, cultural e biopsicossocial dos sobreviventes. Cinco anos após o desastre, os moradores, ainda sem a mínima recuperação desse espaço, são surpreendidos pelo advento da pandemia de COVID-19, que torna a assolar a população e a prejudicar a saúde pública local. Objetivo: Avaliar os efeitos do Rompimento da Barragem de Fundão (RBF) na qualidade da saúde pública dos moradores da microrregião da Bacia do Rio Doce com a ascensão da pandemia de COVID-19 em 2020. Material e métodos: Revisão bibliográfica cuja busca dos estudos primários foi realizada nas bases de dados PubMed, SciELO, CINAHL e LILACS, além dos registros coletados pelo subprojeto TelePAN vinculado ao programa Participa UFMG. Resultados: Os dados analisados demonstram que durante a pandemia de COVID-19 a microrregião da Bacia do Rio Doce apresentou maiores índices de desemprego, de criminalidade e de transtornos mentais, em comparação a outras cidades do interior de Minas Gerais. Pode-se identificar, ainda, maior dependência do sistema público de saúde local, o qual tem precisado se adaptar novamente para suprir essa demanda. Conclusão: A revisão da literatura atual revela um estresse maior que o esperado sobre a população e os serviços públicos locais, o qual pode refletir o advento da pandemia sobre uma comunidade que ainda enfrenta os impactos do crime ambiental em 2015. Além disso, é notável a escassez de literatura com esse recorte, o que contribui para invisibilizar a situação da região.

Objective The 2016 ACPE Standard 11 mandates the inclusion of interprofessional education (IPE) in pharmacy programs. However, challenges exist in the standardized design, delivery, and assessment of an IPE curriculum. We developed and implemented a c omprehensive, vertically and horizontally i ntegrated, m ultimodal IPE curriculum (CIM-IPE) and assessed for student, program, and institutional outcomes. Methods We established an IPE collaboration, created an institutional infrastructure, and operationalized the curriculum incorporating pharmacy, nursing, and medical students using a five-pronged approach built around 1) a didactic component, 2) high fidelity simulation with manikins with content-emphasis, 3) hospital simulation with manikins with process emphasis, 4) interprofessional case conferences, and 5) a Hotspotting IPE-elective. The 2016 Interprofessional Education Collaborative competencies and ACPE Standard 11 were used to assess outcomes, classifying developmental stages as initial, developing, developed, and proficient. Results In seven IPE events distributed across the P1 through P3 years of the CNUCOP Pharmacy curriculum, a high total number of pharmacy, nursing and medical school participants (N = 1799) were repeatedly engaged. Overall assessment data show a high success rate of the integrated CIM-IPE program with mean performance scores of 98 (SD = 13, N = 117) and 95 (SD = 5, N = 67) for the interprofessional case conferences, 100 (SD = 2, N = 117), 95 (SD = 4, N = 67), and 95 (SD = 5, N = 67) for the three simulation based IPE events. Conclusion Our curricular and assessment strategies for CIM-IPE outline a stepwise development and implementation blueprint for an inclusive and comprehensive IPE program that is readily transferable to other colleges and schools of pharmacy and other health care professional programs.

The concepts of unmanned aircraft system traffic management (UTM) and urban air mobility (UAM) are introducing high-density operations in low altitude airspace in closer proximity to populated areas than conventional high-altitude air traffic. The Flexible engine for Fast-time Evaluation of Flight Environments (Fe (sup 3)) provides the capability of statistically analyzing the high-density, high-fidelity, and low-altitude traffic system under numerous scenarios, such that stake holders can study impacts of factors in the low-altitude high-density traffic system and define requirements, policies, and protocols needed to support a safe yet efficient traffic system, and even assess operational risks and optimize flight schedules without conducting infeasible and cost-prohibitive flight tests that involve a large volume of aerial vehicles. This work provides an introduction to this simulation tool including its architecture and various models involved. Its performance and sample application in UAM and UTM are also presented.

Background We examined the impact of race on the maximum tolerated doses (MTD) and final approved doses (FAD) of single-agent molecular-targeted agents (MTA) in North America/Europe (NA/EU) and Asia. Methods We searched PubMed and regulatory databases to identify targeted drugs approved globally and compared their FAD and MTD in corresponding phase I/II studies conducted separately in NA/EU and Asia. To evaluate this further, we conducted parallel, prospective, first-in-human studies of DS-7423, a dual PI3K/mTOR inhibitor, in patients with advanced solid tumours in the US and Japan. We pooled and compared the pharmacokinetics (PK), pharmacodynamics (PD), toxicity, and efficacy between these populations. Results 17 MTA were approved in NA/EU and Asia from 2001 to 2015. Recommended phase 2 doses (RP2D) were identical across races in 14 of 17 (80%) studies and differences were not clinically meaningful. FAD were identical across all regions. 42 and 27 patients from US and Japan, respectively, were enrolled in the phase I studies of DS-7423. Despite differences in race, body weight, and body mass index, the RP2D were 240 mg/day with no differences in toxicities, PK, PD, or efficacy. Conclusions Conducting separate clinical trials of single-agent MTA in Caucasian and Asian populations may be redundant.

The presence of inflammatory cells on bronchoalveolar lavage is often used to predict disease activity and the need for therapy in systemic sclerosis-associated interstitial lung disease.To evaluate whether lavage cellularity identifies distinct subsets of disease and/or predicts cyclophosphamide responsiveness.Patients underwent baseline lavage and/or high-resolution computed tomography as part of a randomized placebo-controlled trial of cyclophosphamide versus placebo (Scleroderma Lung Study) to determine the effect of therapy on forced vital capacity. Patients with 3% or greater polymorphonuclear and/or 2% or greater eosinophilic leukocytes on lavage and/or ground-glass opacification on computed tomography were eligible for enrollment.Lavage was performed in 201 individuals, including 141 of the 158 randomized patients. Abnormal cellularity was present in 101 of these cases (71.6%) and defined a population with a higher percentage of men (P = 0.04), more severe lung function, including a worse forced vital capacity (P = 0.003), worse total lung capacity (P = 0.005) and diffusing capacity of the lung for carbon monoxide (P = 0.004), more extensive ground-glass opacity (P = 0.005), and more extensive fibrosis in the right middle lobe (P = 0.005). Despite these relationships, the presence or absence of an abnormal cell differential was not an independent predictor of disease progression or response to cyclophosphamide at 1 year (P = not significant).The presence of an abnormal lavage in the Scleroderma Lung Study defined patients with more advanced interstitial lung disease but added no additional value to physiologic and computed tomography findings as a predictor of progression or treatment response. Clinical trial registered with www.clinicaltrials.gov (NCT 000004563).

Clostridium difficile remains the leading cause of nosocomially acquired diarrhoea. C. difficile usually exhibits resistance against beta-lactam antibiotics, whereas susceptibility to other drugs may vary. This study investigated the antimicrobial susceptibility of C. difficile to different antibiotics over a period of time and characterizes molecular mechanisms for resistance. One hundred and seventy-three toxigenic and 19 non-toxigenic C. difficile strains, recovered from patients in two university hospitals in Germany between 1986 and 2001, were investigated for their susceptibility to erythromycin, clindamycin, moxifloxacin, vancomycin and metronidazole employing the Etest. The genetic background for resistance was analysed using PCR and DNA sequencing. All strains were susceptible to vancomycin and metronidazole. Resistance to erythromycin, clindamycin and moxifloxacin was found in 27%, 36% and 12% of the tested strains, respectively. High-level resistance (MIC > 128 mg/L) against erythromycin and clindamycin was detected in 25% of the strains tested. Thirty-four of the macrolide-lincosamide-streptogramin B (MLS(B))-resistant strains carried the erythromycin resistance methylase gene. The results indicate an increase in the prevalence of resistance to MLS(B) and fluoroquinolone antibiotics in C. difficile. Fluoroquinolone resistance is associated with resistance to MLS(B) antimicrobials.

2536 Background: The aim of this study was to determine the safety, maximum-tolerated dose (MTD), pharmacokinetics (PK), pharmacodynamics (PD) and efficacy of DS-7423, a novel inhibitor of PI3K/mTOR, in US and Japanese population. We further compared toxicities and recommended phase 2 dose (RP2D) of DS-7423 and approved oncology drugs in the two populations. Methods: We conductedparallel, first-in-human studies in US and Japan in patients with advanced solid tumors. We conducted a Pubmed search of pivotal and corresponding phase I studies to compare the RP2D and final approval doses of molecularly targeted agents (MTA) between US and Japan. Results: 69 patients were enrolled (n = 42 from US and n = 27 from Japan). Between populations, the only difference at baseline was body weight (BW) and body mass index (BMI). Dose-limiting toxicities included grade 3 rash (48 mg), grade 3 stomatitis (240 mg), grade 3 lung infection (240 mg), grade 4 hyperglycemia (240mg), grade 3 fatigue (320 mg), and grade 3 dehydration (320mg). The MTD and RP2D was 240 mg/d in both populations. Frequent treatment-related adverse events included diarrhea, fatigue, decreased appetite, rash, and stomatitis. No remarkable difference in AUC and Cmax were observed between populations. Prolonged stable disease was seen in cholangiocarcinoma, thymic cancer, non-small cell lung cancer, squamous cell carcinomas, carcinoid, and sarcoma. DS-7423 demonstrated PD effects on serum glucose, C-peptide and Akt phosphorylation and 18F-FDG uptake in tumors. The final RP2D of 17 MTA approved in US and Japan from 2001 to 2015 was near identical. The approved doses in both regions were identical. Conclusions: Despite differences in BW, BMI, and ethnicity, DS-7423 showed no difference in PK, PD, toxicity or efficacy between populations. We found near identical RP2D in phase I oncology studies and approved doses in pivotal studies. This supports increased international collaboration in the conduct of phase I oncology trials. Clinical trial information: NCT01364844, Japic CTI, 12766.

The use of herbal and other botanical products, including those used extensively in traditional Chinese medicine, has increased dramatically in the last decade. Yet, little scientific research exists concerning their efficacy and safety. We examined the effects of Immune+, a combination of five botanicals frequently used in traditional Chinese medicine, on the production of two cytokines. For this purpose, unstimulated or phytohemagglutinin (PHA)-stimulated peripheral blood mononuclear cells from healthy volunteers were incubated with different concentrations of Immune+. The secretion of interleukin-1beta (IL-1beta) and interferon-gamma (IFN-gamma) was measured after 72 hours of incubation. At the highest concentration tested (100 micro g/ml), Immune+ significantly increased the secretion of IL-1beta. Importantly, PHA alone had no effect on IL-1beta production, and the combination of PHA with Immune+ resulted in the same increase in IL-1beta production as seen with the botanical extract alone. Immune+ did not have any detectable effect on either unstimulated or PHA-stimulated IFN-gamma synthesis. These in vitro data support the concept that Immune+ may enhance human immune responses.

Fecal samples collected from 245 cats over a 6-month period were analyzed for the presence of Clostridium difficile. After culture on selective media, isolates were identified by a latex agglutination test, and the presence of toxin A and toxin B gene sequences was determined by polymerase chain reaction. Clostridium difficile was isolated from 23 (9.4%) of the cats, and 34.8% of that group were colonized with toxigenic strains. All of the cats colonized with toxigenic C. difficile had ≥1 of the risk factors (antibiotic use, antineoplastic therapy, immunosuppressive virus infection) associated with C. difficile infection in humans. Clostridium difficile was not found in any of the cats from a clinically healthy outpatient group of cats examined from the same hospital nor in cats from a specific-pathogen-free research colony on the same campus tested during the same time period. The data obtained in this study confirm the presence of C. difficile in cats at a veterinary teaching hospital. DNA fingerprinting analysis of these isolates allowed separation of the strains into 5 groups. Type 4 strain found in 7 cats was also recovered from the floor drain in the same hospital, suggesting a possible source of infection. Whether the organism is of clinical significance in diarrheal diseases of cats remains to be determined.

Bacteroides fragilis constitutes about 1% of the bacterial flora in intestines of normal humans. Enterotoxigenic strains of B. fragilis have been associated with diarrheal diseases in humans and animals. The enterotoxin produced by these isolates induces fluid changes in ligated intestinal loops and an in vitro cytotoxic response in HT-29 cells. We developed a nested PCR to detect the enterotoxin gene of B. fragilis in stool specimens. After DNA extraction, a 367-bp fragment was amplified with two outer primers. The amplicon from this reaction was subjected to a second round of amplification with a set of internal primers. With these inner primers, a 290-bp DNA fragment was obtained which was confirmed as part of the B. fragilis enterotoxin gene by Southern blotting with a nonradioactive internal probe and a chemiluminescence system. By this approach, B. fragilis enterotoxin gene sequences were detected in eight known enterotoxigenic human isolates and nine enterotoxigenic horse isolates. No amplification products were obtained from DNA extracted from 28 nonenterotoxigenic B. fragilis isolates or B. distasonis , B. thetaiotaomicron , B. uniformis , B. ovatus , Escherichia coli , or Clostridium difficile . The sensitivity of this assay allowed us to detect as little as 1 pg of enterotoxin DNA sequences or 100 to 1,000 cells of enterotoxigenic B. fragilis /g of stool. Enterotoxin production of all isolates was confirmed in vitro in HT-29 cells. A 100% correlation was obtained between enterotoxin detection by cytotoxin assay and the nested PCR assay. This rapid and sensitive assay can be used to identify enterotoxigenic B. fragilis and may be used clinically to determine the role of B. fragilis in diarrheal diseases.

Clostridium difficile-associated diarrhea (CDAD) recurs in approximately 15%-20% of patients after discontinuation of metronidazole or vancomycin therapy. Most recurrences are believed to be endogenous relapses due to the persistence of spores. However, there is evidence that reinfection with a different strain is a cause of recurrence. We report the case of a patient with a history of multiple episodes of C. difficile colitis. The patient, a 56-year-old female, has had 5 years of repeated recurrences, each shortly after discontinuing vancomycin therapy. During the course of these episodes, three isolates were cultured from her stools at different times. These isolates were analyzed for the presence of toxin A and B gene sequences and genotyped by means of arbitrarily primed polymerase chain reaction (AP-PCR). The original two isolates contained the toxin A and B genes, as determined by PCR, and were of the same AP-PCR type. During her last relapse, a C. difficile strain lacking at least a portion of the toxin B gene was isolated. AP-PCR analysis of this isolate showed a different DNA banding pattern from that of the previous isolates. A vancomycin susceptibility assay revealed a slight decrease in vancomycin activity as compared with that against the prior isolate. This case demonstrates two unique features: (1) recurrent infections can be due to reinfections and (2) toxin B mutants can possibly cause CDAD. This study also raises concerns about long-term vancomycin use and the development of resistance of C. difficile to vancomycin.

The epidemiology of Clostridium difficile-associated diarrhea (CDAD) is not well defined in nonepidemic situations because precise biotyping techniques have only recently become available. Arbitrarily primed polymerase chain reaction (AP-PCR) was used to determine strain identity of C. difficile isolates recovered on our oncology ward, at an incidence rate of 0.84%. Twenty-one strains of C. difficile, which were grouped into 18 different AP-PCR types, were isolated from patients' specimens. Forty-two C. difficile isolates recovered from the environment (33 toxigenic and 9 nontoxigenic) represented 9 different AP-PCR types. The most commonly found type, a toxigenic strain accounting for 29% of the environmental isolates, was widespread throughout the ward. None of the environmental types were found among the isolates from patients. Three patients' isolates were of the same AP-PCR type, and two of these patients had occupied neighboring rooms at the same time. The diversity of C. difficile isotypes suggests that endemic nosocomial CDAD is not necessarily clonally spread.

We report the results of an international Clostridium difficile typing study to cross reference strain designations for seven typing methodologies and facilitate inter-laboratory communication. Four genotypic and three phenotypic methods were used to type 100 isolates and compare the results to 39 PCR ribotypes identified among the collection.

This case report of sternal dehiscence, complicated by pronounced migration of fractured sternotomy wires, demonstrates the utility of computerized tomography (CT) in the precise localization of the wire fragments. Although CT is not typically used to evaluate sternal wire abnormalities, selected cases of sternal dehiscence can benefit from this detailed survey. A review of the literature regarding complications was also performed.

Objectives To review and summarize the status of diagnosis, epidemiology, infection control, and treatment of Clostridium difficile-associated disease (CDAD). Diagnosis A case definition of CDAD should include the presence of symptoms (usually diarrhea) and at least one of the following positive tests: endoscopy revealing pseudomembranes, stool cytotoxicity test for toxin B, stool enzyme immunoassay for toxin A or B, or stool culture for C difficile (preferably with confirmation of organism toxicity if a direct stool toxin test is negative or not done). Testing of asymptomatic patients, including those who are asymptomatic after treatment, is not recommended other than for epidemiologic purposes. Lower gastrointestinal endoscopy is the only diagnostic test for pseudomembranous colitis, but it is expensive, invasive, and insensitive (51% to 55%) for the diagnosis of CDAD. Stool culture is the most sensitive laboratory test currently in clinical use, but it is not as specific as the cell cytotoxicity assay. Epidemiology C difficile is the most frequently identified cause of nosocomial diarrhea. The majority of C difficile infections are acquired nosocomially, and most patients remain asymptomatic following acquisition. Antimicrobial exposure is the greatest risk factor for patients, especially clindamycin, cephalosporins, and penicillins, although virtually every antimicrobial has been implicated. Cases of CDAD unassociated with prior antimicrobial or antineoplastic use are very rare. Hands of personnel, as well as a variety of environmental sites within institutions, have been found to be contaminated with C difficile, which can persist as spores for many months. Contaminated commodes, bathing tubs, and electronic thermometers have been implicated as sources of C difficile. Symptomatic and asymptomatic infected patients are the major reservoirs and sources for environmental contamination. Both genotypic and phenotypic typing systems for C difficile are available and have enhanced epidemiologic investigation greatly. Infection control Successful infection control measures designed to prevent horizontal transmission include the use of gloves in handling body substances and replacement of electronic thermometers with disposable devices. Isolation, cohorting, handwashing, environmental disinfection, and treatment of asymptomatic carriers are recommended practices for which convincing data of efficacy are not available. The most successful control measure directed at reduction in symptomatic disease has been antimicrobial restriction. Treatment Treatment of symptomatic (but not asymptomatic) patients with metronidazole or vancomycin for 10 days is effective; metronidazole may be preferred to reduce risk of vancomycin resistance among other organisms in hospitals. Recurrence of symptoms occurs in 7% to 20% of patients and is due to both relapse and reinfection. Over 90% of first recurrences can be treated successfully in the same manner as initial cases. Combination treatment with vancomycin plus rifampin or the addition orally of the yeast Saccharomyces boulardii to vancomycin or metronidazole treatment has been shown to prevent subsequent diarrhea in patients with recurrent disease.

The polymerase chain reaction (PCR) was used to specifically detect toxin A gene sequences of Clostridium difficile in DNA isolated from human faeces. A set of oligonucleotide primers derived from the non-repetitive region of the toxin A gene was developed to amplify a 634-bp DNA fragment. All 28 cytotoxic strains of C. difficile, previously characterized by a toxin B-PCR assay, were positive for the presence of toxin A gene sequences. No amplification products were obtained from DNAs extracted from non-toxigenic strains, strains of C. sordellii, or C. bifermentans. In addition, amplification of DNA extracted from C. difficile 8864, a strain which does not produce toxin A, resulted in multiple bands which probed negative for toxin A gene sequences. DNAs extracted from nine stool specimens which were positive for toxin B by the cytotoxicity assay and by the toxin B-PCR assay were also positive in this assay. Toxin A gene sequences were detected in DNAs obtained from 4/11 stool specimens which were negative by the toxin B cytotoxicity assay. These four specimens were from patients who had a history of relapses due to C. difficile-associated colitis, and whose stools had previously been found to be positive by the toxin B-PCR test despite no detectable toxin B in the specimens. These data indicate a comparable degree of clinical sensitivity between these two toxin-gene PCR-based assays. This rapid, sensitive and specific assay may be useful not only in the diagnosis of C. difficile infections, but also in molecular studies of the toxin A gene in C. difficile strains.

Arbitrarily primed polymerase chain reaction (AP-PCR) was used to genotype Clostridium difficile isolates from various sources. Four major molecular types were identified among strains from the American Type Culture Collection previously typed by serogroup and from isolates from patients at the University of California, Davis Medical Center, from a patient at a Utah institution, and from the environment. These groups contained subgroups that displayed, in addition to the common group bands, at least one unique band. Two strains isolated from patients at our institution had the same DNA banding patterns. These patients were hospitalized during the same period, raising the possibility of cross-infection through hospital contact or another common source. These results suggest that this AP-PCR approach will be useful in epidemiologic studies of C. difficile infections.

Fifty three strains of C. difficile recovered from the stools of 13 patients with clinical C. difficile associated diarrhea (CDAD) were analyzed for the presence of the ermB gene, for toxigenicity and fingerprinting profile by PCR based assays. Forty five percent of the isolates were resistant to clindamycin and positive for the ermB gene. All clindamycin resistant isolates were ermB positive and belonged to the same fingerprinting group, suggesting clonal spread. These preliminary results suggest that clindamycin resistant isolates may be common etiologic agents of CDAD in Sweden.

Toxigenic Clostridium difficile is the etiologic agent of pseudomembranous colitis. We have developed an assay system for the rapid direct detection of toxigenic C. difficile in human stool samples. After DNA extraction, polymerase chain reaction (PCR) amplification is undertaken with primers targeting specific sequences in the C. difficile 16S rRNA gene. Next, toxigenic strains of C. difficile are distinguished from nontoxigenic strains by PCR amplification of toxin A and/or B gene sequences. This study included 12 patients with C. difficile colitis, seven of whom had clinical relapses after discontinuation of vancomycin therapy. We detected toxigenic C. difficile in stools from four (57%) of these seven patients before relapse--at a time when no toxin B was detectable in stools and results of anaerobic culture were negative. The PCR assay is 100-fold more sensitive than anaerobic culture methods. The course of the infection in one patient (both during and after therapy) was monitored by the PCR technique. The multigene analysis approach permitted the detection of colonization with a nontoxigenic strain when this patient's relapses had cleared. This clinically applicable assay allows earlier detection of infection with toxigenic C. difficile. The result is more timely therapeutic intervention.

Because of severe emergency department (ED) overcrowding, the authors initiated a program of referring certain patients who were assessed as not needing emergency care away from the ED. A selected group of patients who presented to a busy university ED were refused treatment and triaged away following a medical screening examination performed by a nurse. In this 3-year study 136,794 patients presented to the triage area in the ED, of which 21,069 (15%) were refused care and referred elsewhere. Letters and calls to all referral clinics, eight local EDs, and the coroner's office identified no patients who had been grossly mistriaged, and only insignificant adverse outcomes could be identified. Additional follow-up on 3,740 individuals triaged away was performed by telephone. Responses from this survey indicated that 42% of persons received care elsewhere the same day, 37% within 2 days, and 22% decided not to seek medical care. A group of 1.6% sought care at other hospital EDs for minor complaints. The authors concluded that a group of patients can be selectively triaged out of the ED without significant adverse outcomes, which may offer one approach to the problem of ED overcrowding.

Toxigenic Clostridium difficile is the most common etiologic agent of hospital-acquired diarrhea in developed countries. The role of this pathogen in nosocomial diarrhea in Eastern Europe has not been clearly established. The goal of this study was to determine the prevalence of C. difficile in patients and the hospital environment in Belarus and to characterize these isolates as to the presence of toxin genes and their molecular type. C. difficile was isolated from 9 of 509 (1.8%) patients analyzed and recovered from 28 of 1,300 (2.1%) environmental sites cultured. A multiplex PCR assay was used to analyze the pathogenicity locus (PaLoc) of all isolates, and strain identity was determined by an arbitrarily primed PCR (AP-PCR). The targeted sequences for all the genes in the PaLoc were amplified in all C. difficile strains examined. A predominantly homogenous group of strains was found among these isolates, with five major AP-PCR groups being identified. Eighty-three percent of environmental isolates were classified into two groups, while patient isolates grouped into three AP-PCR types, two of which were also found in the hospital environment. Although no data on the role of C. difficile infection or epidemiology of C. difficile -associated diarrhea (CDAD) in this country exist, the isolation of toxigenic C. difficile from the hospital environment suggests that this pathogen may be responsible for cases of diarrhea of undiagnosed origin and validates our effort to further investigate the significance of CDAD in Eastern Europe.

The polymerase chain reaction was used for the detection of Clostridium difficile, the etiologic agent of antibiotic-associated colitis. An upstream primer identical to a coding region (segment I) of the C. difficile 16S rRNA gene and a downstream primer complementary to a highly conserved region of eubacterial 16S rRNA served to amplify a targeted 270-base-pair fragment of genomic DNA. This technique allowed the detection of as few as 10 C. difficile organisms among 10(6) Escherichia coli bacteria. This level of sensitivity represents a 100-fold increase over that of conventional anaerobic culture. C. difficile was detected in DNA extracted directly from the stools of 23 patients with antibiotic-associated colitis and from those of four patients with diarrhea whose stools had been negative for C. difficile when assessed in a cytotoxicity assay. No amplification products were found in the stools of asymptomatic patients. When detected in stools of symptomatic patients, amplification products of C. difficile were confirmed by Southern blotting with a nonradioactive, horseradish peroxidase-catalyzed, chemiluminescent probing system in which biotin-labeled oligonucleotides were used. This system discriminates between C. difficile and similar organisms, such as Clostridium sordellii and Clostridium bifermentans. The combination of the polymerase chain reaction with enzyme-linked probing results in a faster and more sensitive assay for C. difficile than standard culture.

Male Syrian hamsters (Mesocricetus auratus) were used to study interactions between different toxin deficient strains of C. difficile. After sensitization with clindamycin, hamsters were intragastrically co-infected with the appropriate dilutions corresponding to 100, 1000 and 10,000 cells of four (toxin A or B-deficient) C. difficile strains (8864, P-829, W-38 and W-74). In addition, a group of hamsters was infected with C. difficile VPI 10463, a reference toxigenic strain. Colonization and mortality was observed within 48 hours in the group of hamsters infected with the reference toxigenic strain. No clinical disease was observed in the groups of hamsters co-infected with the toxin A or B-deficient strains. Re-infection of these hamsters (co-infected with toxin deficient isolates) with C. difficile VPI 10463 resulted in clinical disease and death suggesting that these strains do not confer protection against infection with a toxigenic strain. Macroscopic and microscopic observations of the cecum of re-infected hamsters demonstrated uniformly multiple large hemorrhagic areas without pseudomembranes. Hamsters infected with as few as 100-500 cells of the toxigenic strain--VPI 10463 alone demonstrated pseudomembranes and multiple hemorrhages. These results suggest that even though the toxin deficient strains did not prevent re-infection with a toxigenic strain of C. difficile, they may play a role in the histopathologic changes after re-infections in the hamster model. Further studies with a larger number of hamsters and C. difficile strains of various molecular profiles are required to better understand the interaction between these strains.

Stool specimens from 152 hospitalized patients with diarrhea were analyzed for the presence of enterotoxigenic Bacteroides fragilis (ETBF) by a nested polymerase chain reaction (PCR) assay. ETBF gene sequences were directly detected in 14/152 (9.21%) stools of patients. The prevalence of ETBF in hospital-acquired diarrhea was statistically significant when compared to a prevalence of 2.3% in control subjects (P = 0.04). B. fragilis was cultured from 19.7% (30/152) patients with diarrhea; 4 of these isolates were enterotoxigenic. To determine whether colonization with B. fragilis is heterogeneous in nature, multiple colonies from 17 individual patients were analyzed for enterotoxin gene sequences and genotyped by arbitrarily primed PCR. Of these 17 patients, 13 harbored multiple strain types suggesting heterogeneity of colonization with both enterotoxigenic and non-enterotoxigenic strains. Identification of ETBF in the stools of 10 patients in the absence of a positive culture is likely due to the noted heterogeneity and suggests that detection of enterotoxin by PCR should be performed directly in the stool. These preliminary data indicate that ETBF may play a role in hospital-acquired diarrhea of unknown origin and suggest the need for further studies.

Clostridium difficile strains are known as etiological agents of pseudomembranous colitis (PMC), antibiotic-associated diarrhea (AAC) and colitis (AAC) and hospital-acquired infections. The aim of this study was to determine the frequency of C. difficile infection among patients in the emergency room and to compare isolated strains by phenotypic and genotypic characteristics. During a period of 11 months, 56 stool samples taken from diarrheic patients hospitalized in the emergency room of the Medical Center UC Davis and 14 environmental samples were cultured for isolation of C. difficile strains. Eighteen C. difficile strains were isolated from stool samples cultured on selective TCCCA plates and 5 strains from environmental samples using Rodac plates. Eleven toxigenic (TcdA+/TcdB+), 6 non-toxigenic (TcdA-/TcdB-) and unique toxin A-negative/toxin B-positive (TcdA-/TcdB+) C. difficile strains were detected among patients' isolates and 3 toxigenic and 2 non-toxigenic strains-among environmental samples. The majority of C. difficile-positive patients were treated previously by antibiotics. Four strains isolated from patients' fecal samples and one strain isolated from the environment demonstrated high-level resistance to erythromycin and clindamycin (MIC >256mug/mL). The results obtained by AP-PCR and PCR-ribotyping revealed genetic heterogeneity among the strains isolated from patients' fecal samples. However, similarity was observed among environmental strains and strains isolated from patients' fecal samples. Considering the importance of emergency room patients as a potential source of C. difficile strains, it appears to be important examine these patients for C. difficile before transfer to the other hospital units.

We analyzed 226 strains of Clostridium difficile for the presence of erythromycin ribosomal methylase B (ermB) genes. Forty-four strains (19.4%) carried ermB genes and were resistant to erythromycin. Toxin A and toxin B gene sequences were identified in 81.9% of these 44 strains. Strains of C. difficile that carry ermB genes are common etiologic agents of C. difficile-associated diarrhea.

Recurrence of Clostridium difficile -associated diarrhea (CDAD) occurs in 15 to 20% of patients after discontinuation of treatment. Arbitrarily primed PCR was used to investigate the epidemiology of recurrent CDAD in 18 patients. Reinfection with a new strain occurred in 6 of 18 patients (33.3%), while 12 patients relapsed with the original strain shortly after discontinuation of treatment. These data suggest that reinfection with exogenous C. difficile is a common problem and that not all recurrences are due to relapse.

Vaccinations are invaluable in protection from a wide variety of diseases that can cause substantial morbidity and mortality. Although a rare complication of vaccination, autoimmune disorders represent one of these morbidities. Recently, widespread public concern has arisen from case reports suggesting that--similar to what has been observed after natural viral infections--there might be an association between specific immunizations and autoimmune diseases. Herein we address the biological plausibility of such a connection, focusing particularly on the examples of hepatitis B, rubella, and measles-mumps-rubella (MMR) vaccinations, and the autoimmune diseases they are potentially associated with. Our review of the available data suggests that, for the general population, the risk: benefit ratio is overwhelmingly in favor of vaccinations. However, the possibility cannot be ruled out that, in genetically susceptible individuals, vaccination can result in the unmasking of an autoimmune disease triggered by the immunization. We also critically examine the existing data suggesting a link between immunization against MMR and autism, and briefly discuss the controversial evidence pointing to a possible relationship between mercury exposure from vaccines and autistic disorders. There is a continued urgent need for rigorously designed and executed studies addressing these potential associations, although the use of vaccinations remains a critical public health tool for protection against infectious disease.

difficile was identified as a cause of this disease in the setting of prior antibiotic use. Subsequent observations were published rapidly, describing the organism's growth characteristics, clinical epidemiology, pathophysiology,' diagnosis, and treatments.2 Theoretically, the final chapter of its story, the control of this disease, should have been written by the early 1980s. Why then should two articles regarding its continuing clinical significance be published in the 1990s?

Toxigenic Clostridium difficile is the etiologic agent of C. difficile-associated diarrhea (CDAD), the most common cause of nosocomial diarrhea. Cross-infection between patients and transmission through the environment and medical personnel are important factors in the acquisition of CDAD. In order to understand differences in epidemiology and pathogenesis, a number of typing schemes have been developed. We will review the typing methods used to study the epidemiology of C. difficile infections and how they have evolved from a phenotypic identification to state of the art molecular methods, detecting genetic polymorphisms among strains. These molecular methods include PCR-based methods (arbitrarily primed-PCR [AP-PCR] and PCR ribotyping), restriction endonuclease analysis (REA) and pulse field gel electrophoresis (PFGE). The application, usefulness and feasibility of these methods are compared and discussed. Finally, the role of genomics as a tool to investigate CDAD is introduced.

Clostridium innocuum isolates resistant to vancomycin (MIC values of 16–24 μg/mL) were isolated from three patients with recurrent Clostridium difficile -associated diarrhea (CDAD). We discuss the clinical significance and problems associated with the identification and differentiation of these two clostridial species, which may result in misdiagnosis of patients.

Clostridium difficile is the etiological agent of antibiotic-associated colitis and the most common cause of hospital-acquired infectious diarrhea. Fluoroquinolones such as ciprofloxacin are associated with lower risks of C. difficile -associated diarrhea. In this study, we have analyzed 72 C. difficile isolates obtained from patients with different clinical courses of disease, such as toxic megacolon and relapses; the hospital environment; public places; and horses. They were investigated for their susceptibilities to moxifloxacin (MXF), metronidazole (MEO), and vancomycin (VAN). Mutants highly resistant to fluoroquinolones were selected in vitro by stepwise exposure to increasing concentrations of MXF. The resulting mutants were analyzed for the presence of mutations in the quinolone resistance-determining regions of DNA gyrase ( gyrA ), the production of toxins A and B, and the epidemiological relationship of these isolates. These factors were also investigated using PCR-based methods. All strains tested were susceptible to MEO and VAN. Twenty-six percent of the clinical isolates (19 of 72) were highly resistant to MXF (MIC ≥ 16 μg/ml). Fourteen of these 19 strains contained nucleotide changes resulting in amino acid substitutions at position 83 in the gyrA protein. Resistant strains selected in vitro did not contain mutations at that position. These findings indicate that resistance to MXF in a majority of cases may be due to amino acid substitution in the gyrA gene.

Background: In vitro studies have demonstrated that ciprofloxacin suppresses Escherichia coli attachment on stents, and ciprofloxacin has been shown to prolong stent patency in cats. However, clinical studies with antibiotic prophylaxis have produced conflicting results. The aim of this study was to isolate and identify the bacteria that attach early on unblocked stents removed from patients and to study their enzyme activities. Methods: Eighteen unblocked biliary stents were removed from 17 patients (benign obstruction in 14 and malignant obstruction in 4). All patients received antibiotic prophylaxis (mean of 6 days). Stents were in place for a mean of 33 days. The inside of stents was scraped and sludge was cultured aerobically and anaerobically. Identification of isolated bacteria and measurement of β-glucuronidase and phospholipase C activities were performed by using standard techniques. Gastric and duodenal juice from 18 patients with no biliary diseases was used as control samples. Results: All stents were patent and only 6 had visible sludge. There were 19 anaerobes isolated from 16 stents ( Clostridium perfringens 13, Clostridium bifermentans 4 and Bacteroides fragilis 2). Phospholipase C was detected in all Clostridium species. β-Glucuronidase was produced only by 12 of 13 C perfringens isolates. Sixteen aerobes including Enterococcus species and Bacillus species were isolated but none produced β-glucuronidase or phospholipase C. There were no aerobic gram-negative bacteria isolated from stents. Clostridium species and B fragilis were not recovered from the control samples. Conclusions: In patients who had received antibiotic prophylaxis against gram-negative bacterial infection, anaerobic bacteria may play a role in initiating stent blockage. (Gastrointest Endosc 2000;52:725-9.)

In order to determine genetic relatedness of Bacteroides fragilis isolates from different clinical sources, arbitrarily primed polymerase chain reaction (PCR) (AP-PCR) was used to compare 17 strains isolated from patients with inflammatory bowel disease (IBD) and 20 strains isolated from foals with diarrhea. Three reference ATCC strains were also analyzed. Eighteen unique types were identified with a 22-mer arbitrary primer (ERIC-2) among the 20 patient isolates. Types 1 (enterotoxigenic) and 9 (nonenterotoxigenic), were each found in the stools of two patients. All other isolates showed a distinct and unique DNA banding pattern indicating a high degree of genotypic variability. Eleven types were identified among the foal isolates. Type 20, a nonenterotoxigenic type, was present in 30% of the foals. No correlation was found between the human and horse isolates. No clear relationship between a disease state (diarrhea or IBD) and specific types was observed. AP-PCR will be useful as a rapid method to determine genetic relatedness and in future epidemiologic studies of diarrheal diseases due to B. fragilis.

The epidemiology of Clostridium difficile-associated diarrhea (CDAD) in an endemic setting was investigated by use of DNA typing methods to determine the strain identity of C. difficile isolates. Two predominant toxigenic clones were found in the environment and accounted for 29.8% (type 1) and 15.5% (type 2) of CDAD cases, respectively. In endemic settings, the environment and cross-transmission may play a role in acquisition of CDAD.

Ninety-three Bacteroides fragilis isolates from different geographic locations were analyzed for the presence of an enterotoxin-encoding gene. It was shown that blood culture isolates were more likely to carry this gene than strains from other sources. All enterotoxin-positive strains belonged to the PCR fingerprint group I.

The genes for Clostridium difficile toxins A and B (tcdA and tcdB) are part of a 19.6-kb pathogenicity locus (PaLoc) that includes the genes tcdD, tcdE, and tcdC. To determine whether the C. difficile PaLoc is a stable and conserved genetic unit in toxigenic strains, a multiplex polymerase chain reaction was used to analyze 50 toxigenic, 39 nontoxigenic, and 2 toxin-defective isolates. The respective amplicons were identified for tcdA-E in the toxigenic isolates; these were absent in the nontoxigenic isolates. C. difficile P-829 lacked at least a fragment of tcdD, tcdB, tcdE, and tcdC, but tcdA was present. C. difficile 8864 had deletions in the tcdA and tcdC genes. These data suggest that the PaLoc is highly stable in toxigenic C. difficile, nontoxigenic isolates lack the unit, and isolates with a defective PaLoc can still cause clinical disease. Further studies are needed to define the role of individual genes in the pathogenesis of C. difficile-associated diarrhea.

Intestinal colonization with toxigenic strains of Clostridium difficile was documented in 9 of 10 horses with acute onset diarrhea in a veterinary medical teaching hospital, whereas a similar isolate was detected in only 1 of 23 other horses without diarrhea in the hospital. One horse with diarrhea was infected simultaneously with both C. difficile and Salmonella krefeld. Clostridium difficile was detected by fecal culture on selective medium, confirmed with a latex particle agglutination test, and identified as toxigenic by polymerase chain reaction amplification of toxin A and toxin B gene sequences. Using an arbitrarily-primed polymerase chain reaction, 6 distinct C. difficile isolates were detected in the feces of the 9 affected horses at the time of the outbreak of diarrhea.

An unusual and fatal case of primary varicella in an adult is presented. Involvement of the small intestine first manifested as abdominal pain and later progressed to gastrointestinal bleeding with subsequent dissemination of the infection. Although it has previously been speculated that gastrointestinal bleeding can result from infection with the varicella-zoster virus, the data from this case include histologic and cultural evidence that supports the clinical observations. The literature has been reviewed, and the management of this patient has been critically evaluated.

This article describes the State-supported University of California AIDS research award program and its major accomplishments. It shows how a partnership between a University and a State resulted in the formation of a successful, efficient, and cost-effective AIDS research award program. This program provides funds for rapid testing of investigator-initiated meritorious research ideas, new drugs, and treatment modalities. Funds were also utilized to establish three AIDS Clinical Research Centers, which evolved into regional consortia that coordinate trials of new drugs and other modalities. This program succeeded in involving investigators whose efforts have led to excellent medical care, advanced technologies, and new drugs for treating AIDS and AIDS-related diseases. The University remains committed to continuing support of all areas of AIDS research, emphasizing drug and vaccine development, pediatric AIDS, and AIDS prevention studies in groups at high risk for HIV infection.