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Background: Recurrent herpes simplex labialis (HSL) occurs in 20% to 40% of the US population. Although the disease is self-limiting in persons with a healthy immune response, patients seek treatment because of the discomfort and visibility of a recurrent lesion., Objective: Our purpose was to determine whether docosanol 10% cream (docosanol) is efficacious compared with placebo for the topical treatment of episodes of acute HSL., Methods: Two identical double-blind, placebo-controlled studies were conducted at a total of 21 sites. Otherwise healthy adults, with documented histories of HSL, were randomized to receive either docosanol or polyethylene glycol placebo and initiated therapy in the prodrome or erythema stage of an episode. Treatment was administered 5 times daily until healing occurred (ie, the crust fell off spontaneously or there was no longer evidence of an active lesion) with twice-daily visits., Results: The median time to healing in the 370 docosanol-treated patients was 4.1 days, 18 hours shorter than observed in the 367 placebo-treated patients (P =.008; 95% confidence interval [CI]: 2, 22). The docosanol group also exhibited reduced times from treatment initiation to (1) cessation of pain and all other symptoms (itching, burning, and/or tingling; P =.002; 95% CI: 3, 16.5); (2) complete healing of classic lesions (P =.023; 95% CI: 1, 24.5); and (3) cessation of the ulcer or soft crust stage of classic lesions (P <.001; 95% CI: 8, 25). Aborted episodes were experienced by 40% of the docosanol recipients versus 34% of placebo recipients (P =.109; 95% CI for odds ratio: 0.95, 1.73). Adverse experiences with docosanol were mild and similar to those with placebo., Conclusion: Docosanol applied 5 times daily is safe and effective in the treatment of recurrent HSL. Differences in healing time compared favorably with those reported for the only treatment of HSL that has been approved by the Food and Drug Administration.

Objectives: To test the hypothesis that infection control practices can prevent the spread of vancomycin-resistant enterococci (VRE) to residents of a long-term care facility (LCF) from an affiliated acute care facility with a high endemic rate of colonization., Design: Point prevalence study of the rate of rectal colonization., Setting: A state-supported veterans nursing home and an acute care veterans hospital., Participants: Residents in a state veterans home., Interventions: Identification of patients with rectal colonization by VRE before transfer to the state veterans home, contact isolation for colonized veterans, use of oral bacitracin to eliminate colonization., Measurements: Rectal swab and culture for VRE, review of clinical records and recording of presumptive risk factors for VRE colonization. The risk factors were age, gender, length of stay at nursing home, treatment with vancomycin or oral antibiotics, prior hospitalization at the acute care facility during the prior year, use of indwelling urethral catheters, presence of diarrhea, and fecal or urinary incontinence., Results: Sixty-nine of 200 residents were cultured in the first study (1996) and 130 of 230 residents were cultured in the second study (1998). Residents who consented to culture differed from those who did not only with regards to gender (2 vs 7, P = .012). In neither study were any residents found to be colonized with VRE who had not already been identified as positive on admission., Conclusions: Adherence to infection control practices by the patient care staff of the LTCF was associated with the absence of transmission of VRE colonization among its residents. The presence of rectal colonization with VRE in an acute care patient should not be a barrier to acceptance in a nursing home.

Recombinant human growth hormone (rhGH) is an important treatment option for patients with human immunodeficiency virus (HIV) wasting syndrome. Side effects of rhGH are minimal when administered at physiologic and moderately high dosages, as seen in growth hormone deficiency and Turner's syndrome, respectively. The dosage of rhGH is significantly higher to treat wasting syndrome and still is being studied to determine its long-term efficacy and safety. Individuals with HIV infection are at increased risk for adverse effects due to polypharmacy, immune system alterations, and treatment with newer agents that lack long-term safety data. In addition, rhGH's potential for side effects becomes greater when given at high dosages for wasting syndrome. Clinically significant hyperglycemia developed in an HIV-positive man who started rhGH for wasting syndrome 38 days before the diagnosis of diabetes mellitus.

A routine chart review over 23 months in a 256-bed community hospital revealed 246 medical records contaminated with apparent blood. Sixty percent of the records were nursing and anesthesiology records. Analysis of systematically selected records confirmed blood as the visible contaminant in 27% of the cases (8/30). Total quality improvement methodology reduced the incidents by 75%. Actions included policy development, in-service education, and changes in work practices. Although bloodborne pathogen transmission is statistically improbable, we should improve work practices to eliminate blood contamination of charts.

Sargramostim is a yeast-derived, recombinant human granulocyte-macrophage colony-stimulating factor with therapeutic potential in human immunodeficiency virus (HIV) infection. Its safety and activity when used in combination with protease inhibitors were evaluated in a randomized, double-blind trial in which 20 HIV-infected subjects on stable antiretroviral regimens, including indinavir or ritonavir, received sargramostim or placebo 3 times a week for 8 weeks. Analysis of HIV virus load excluded any 0. 5 log10 increase due to sargramostim (95% confidence interval, -0.68 to 0.44). Sargramostim was well tolerated, and inflammatory cytokines and surrogate markers of disease progression, such as serum levels of interleukin-10 and soluble tumor necrosis factor receptors types Iota and IotaIota, remained stable in subjects receiving sargramostim. Sargramostim treatment was associated with a trend toward decreased HIV RNA (>0.5 log10) and increased CD4+ cell count (>30%). These results became statistically significant only when subjects with baseline virus loads within the limits of detection or baseline CD4 cell count >50 were analyzed. No difference in indinavir pharmacokinetics was observed before or after sargramostim therapy.

Two cases of septic sacroiliac (SI) joint arthritis are presented to illustrate the difficulty of diagnosing and treating this uncommon osteoarticular infection. The patients presented are a 68-year-old woman with septic sacroiliitis caused by Streptococcus agalactiae and a 20-year-old man with Salmonella infantis infection involving the SI joint. The recent literature is reviewed and compared with previously published series. Of the 177 cases we reviewed, 47 (27%) occurred in pediatric patients. The mean age was 20 years. Only six patients (3%) were older than 60 years of age. Magnetic resonance imaging (MRI) is most useful for defining extent of infection, osteomyelitis, and abscess formation in the SI joint. Computed tomography (CT) is valuable for defining the extent of bone involvement and for guidance of percutaneous needle arthrocentesis. Other imaging modalities are useful primarily in the initial evaluation of patients with a nonspecific presentation. Four to six weeks of intravenous (i.v.) antibiotic therapy is recommended. Indications for surgical intervention include abscess formation, osteomyelitis, sequestrum of necrotic bone, and failure to respond to i.v. antibiotic therapy.

Objective: To report a case of ticlopidine-induced neutropenia resulting in Pseudomonas bacteremia., Case Summary: An 83-year-old white man developed febrile neutropenia 5 days after initiation of ticlopidine therapy. At presentation, the patient's white blood cell count was 1.1 x 10(9)/L with an absolute neutrophil count (ANC) of 0. Ticlopidine was discontinued and the patient was treated empirically with ceftazidime, gentamicin, and filgrastim. The patient's blood cultures were positive for Pseudomonas aeruginosa. By day 6 of antibiotic and fllgrastim therapy, he was clinically improved and the ANC was 17 040 x 10(6) cells/L. The filgrastim and intravenous antibiotics were discontinued and oral ciprofloxacin was started., Conclusions: Ticlopidine-induced neutropenia can occur suddenly and may result in a serious infection, such as bacteremia.

Alopecia has been described in patients infected with the human immunodeficiency virus (HIV). Zidovudine reportedly influences hair growth in these patients, causing regrowth or thickening. A 33-year-old HIV-infected man developed alopecia areata after beginning zidovudine therapy. The alopecia reversed after the drug was discontinued.

Nine cases of septic bursitis are presented, and the literature on the subject comprehensively reviewed, with an emphasis on the clinical manifestations of septic bursitis in various anatomic locations. Physical activities associated with increased susceptibility to septic bursitis and systemic conditions that increase the severity of septic bursitis are catalogued. Analysis of the microbiology of cases reported in the literature demonstrates that greater than 80% of cases of septic bursitis are caused by Staphylococcus aureus and other gram-positive organisms. However, a wide variety of gram-negative microorganisms, fungi, and other infectious agents have been reported to cause septic bursitis and may lead to complications in diagnosis and treatment. The nine cases reported here demonstrate the potential severity of septic bursitis and emphasize that significant systemic complications may result from this common musculoskeletal infection. Indications for hospitalization and/or intravenous antibiotic therapy for septic bursitis include the presence of fulminant local infection, evidence for systemic toxicity, or infection in an immunocompromised patient. Patients who fail to respond to intravenous antibiotics and percutaneous aspiration of the bursa may require surgical drainage or bursectomy by one of several methods that have been proposed. There is some recent evidence that intrabursal corticosteroid injection for therapy of nonseptic subcutaneous bursitis may be more effective than systemic antiinflammatory medication or simple bursa aspiration.

The objective of our study was to define the pharmacokinetics and pharmacodynamics of megestrol acetate in patients with human immunodeficiency virus (HIV) infection. A new suspension formulation of megestrol acetate (40 mg/ml) was administered as a single oral dose of 800 mg per day in an open label pharmacokinetic study for 21 days. On day 21 of therapy, patients were evaluated for changes in body weight and plasma samples were obtained for steady-state pharmacokinetic analysis. Ten HIV-infected men with an involuntary weight loss of > 10% baseline were evaluated. A high degree of interpatient variability in megestrol acetate pharmacokinetics was observed, with an 8- and 5-fold range in the rate and extent of absorption, respectively. All patients reported an increase in appetite, and 8 of 10 patients gained weight by 3 weeks; the median change in weight in all patients at 3 weeks was 1.8-kg gain (range: 2.3-kg loss to 6.4-kg gain). The two patients who did not gain weight had the lowest area under the curve (AUC), Cmax, and Cmin values. A statistically significant correlation between the ratio of body weight at 3 weeks/initial weight (weight index) and the percentage of the 24-h dosing interval that megestrol acetate concentrations exceeded a 300-ng/ml threshold was observed. These data indicate variable levels of systemic exposure to drug following a fixed dose of a suspension formulation of megestrol acetate. Increase in weight during the early stages of megestrol acetate therapy is related to the extent of in vivo drug exposure above a threshold concentration.(ABSTRACT TRUNCATED AT 250 WORDS)

Purpose: Pneumocystis carinii pneumonia (PCP) was reported to be the predominant cause of human immunodeficiency virus (HIV)-related deaths prior to 1988, the year that effective prophylaxis against PCP entered routine use. Our study was performed to study the causes of HIV-related death since January 1988 in a region where patient tracking is virtually complete., Patients and Methods: We surveyed physicians associated with the Brown University Acquired Immunodeficiency Syndrome (AIDS) Program who cared for greater than 95% of known HIV-positive patients in Rhode Island. These physicians identified all those HIV-infected persons who had died under their care between January 1988 and July 1990, and determined these patients' causes of death by chart review. For comparison, death certificates of identified persons were also reviewed at the Rhode Island Department of Vital Statistics., Results: Among 126 deaths since January 1988, bacterial infections were the most common cause of death (30%), whereas PCP was responsible for only 16% of deaths. Persons not receiving any form of PCP prophylaxis were more likely to die from PCP than were those who received prophylaxis (26% versus 11% [p = 0.04]). Cause of death as recorded on actual death certificates was imprecise, although bacterial infections were again the most common cause indicated. Only one death occurred in a patient with a CD4 count greater than 200/mL, and this was not HIV-related., Conclusion: PCP has not been the leading cause of death in our region since January 1988. Bacterial infections contribute substantially to mortality, and this may influence future prophylactic regimens. HIV-related deaths in patients with CD4 counts greater than 200/mL are unusual.

Methicillin-resistant Staphylococcus aureus (MRSA) has been an endemic nosocomial pathogen at the VA medical center (VAMC) in Providence, Rhode Island since 1981. From 1985 to 1987, more than 30% of all unique S aureus isolates were methicillin resistant. To evaluate the frequency of acquisition of MRSA isolates by healthcare workers, we compared the antimicrobial susceptibility patterns, multilocus enzyme genotypes and plasmid profiles of isolates recovered from nasal and hand cultures from VAMC nurses and house staff on rotation at the VAMC with those of clinical isolates from patients at the VAMC and four other affiliated hospitals. Fifty-six percent of ward nurses cultured (n = 112) were colonized with S aureus, of which 65% was methicillin resistant. Six isolates of MRSA were identified on the initial culturing of house staff (n = 65); 16 MRSA isolates were recovered at the end of a four-week rotation (p less than .02). Phenotypic and genotypic analyses demonstrated that numerous distinct MRSA strains were recovered in the study period. The incidence of MRSA among clinical isolates at the VAMC and affiliated institutions was remarkably constant throughout the three-year study period. Moreover, despite regularly sharing resident physicians, interns and medical students, MRSA isolates were commonly recovered at the other university-affiliated hospitals. Our study failed to reveal evidence of significant interhospital transmission of MRSA isolates by healthcare workers. While healthcare workers may contribute to the dissemination of MRSA within institutions, they appear to be less important in spreading MRSA between institutions.

Hematogenous osteomyelitis is usually diagnosed by an abnormal technetium Tc 99m diphosphonate bone scan in symptomatic patients who have positive blood cultures. False-normal 99mTc bone scans have been described recently in neonates with biopsy-proved osteomyelitis. This phenomenon seems to be extremely rare in adults. Two elderly patients with hematogenous vertebral osteomyelitis had normal technetium Tc 99m diphosphonate bone scans when first evaluated. In both cases the bone scans became abnormal four to six weeks after onset of symptoms and two to four weeks after the initial normal results of the study. When suggested by the clinical picture, hematogenous osteomyelitis cannot be ruled out by a normal 99mTc bone scan at any age. Gallium scan, computed tomographic scan, or bone biopsy can be helpful in such cases.

Hyponatremia due to the syndrome of inappropriate antidiuresis rather than due to isotonic hyponatremia from hyperproteinemia developed in a patient with Waldenström's macroglobulinemia. The patient was unable to excrete a water load normally despite suppression of antidiuretic hormone to normal levels. The temporal relationship between control of the tumor and resolution of the hyponatremia suggests that the tumor either produced a substance that enhanced the hydro-osmotic effect of endogenous antidiuretic hormone or produced an antidiuretic substance immunologically different from antidiuretic hormone. The syndrome of inappropriate antidiuresis should be suspected in hyponatremic patients with Waldenström's macroglobulinemia.

Musculoskeletal complications from seizures produced by epilepsy, eclampsia, hyponatremia, electroconvulsive therapy, and severe tetanus have been described. We present a case of a fracture-dislocation of the manubriosternal joint as a complication of seizures, which to the best of our knowledge has not previously been reported.

Vocal responses of kittens and mature cats were recorded in a variety of standard behavioral situations. Sonographic analysis of these responses showed similarities of responses obtained repeatedly from different cats within each recording situation. Marked differences in response patterns were noted in different recording situations. The kitten and cat vocal repertoires thus include a variety of specific responses to particular motivational or behavioral circumstances.

We describe a patient with acquired immunodeficiency syndrome who developed Staphylococcus aureus septic arthritis and osteomyelitis of the acromioclavicular joint. The case is unusual because of the rarity of reported bone and joint infections in patients with acquired immunodeficiency syndrome and because of the indolent nature of the infection.