Protocol for increasing organ donation after cerebrovascular deaths in a district general hospital

In a district general hospital serving 303,000 people, deaths from cerebrovascular incidents over 12 months were analysed retrospectively. 8 patients who died in general wards were identified as potential organ donors. A working party then devised a protocol for managing such donors by transfer to the intensive care unit for support until organ retrieval could be arranged. In the first 19 months with the protocol, organs (1 heart, 2 sets of heart valves, 2 livers, and 16 kidneys) were retrieved from 8 patients who would not otherwise have become donors. If these results were replicated nationally a further 16.7 donors per million per year would be added to the current annual UK rate of 14.6 donors per million.

Comparison of propofol and midazolam for sedation in critically ill patients

101 critically ill patients admitted to five intensive-care units were allocated randomly to receive a continuous intravenous infusion of either propofol or midazolam for sedation for up to 24 h. In addition, morphine was given to provide analgesia. The mean duration of infusion was 20.2 h (range 3.0-24.5) in the propofol group and 21.3 h (4.0-47.0) in the midazolam group and infusion rates were 1.77 mg/kg/h (range 0.40-5.00) and 0.10 mg/kg/h (0.01-0.26), respectively. The infusion rates were adjusted as necessary, and the desired level of sedation was achieved easily in most patients in both groups. There were slight falls in arterial pressure, but there were no significant differences between the groups. Heart rate was lower in patients who received propofol. Some small changes occurred in biochemical and haematological variables in both groups, but they were not clinically significant. There was no indication that either drug substantially impaired adrenal steroidogenesis. When the infusion was discontinued, there was less variability in recovery of consciousness in patients who had received propofol. In a subgroup of patients, weaning from mechanical ventilation was achieved significantly faster after discontinuation of propofol than of midazolam. Propofol proved to be a satisfactory agent for sedation of these critically ill patients and compared favourably with midazolam.

Heat stroke--an uncommon presentation

A case of heat stroke is reported in which there was a delayed diagnosis and a fatal outcome. Recent literature is reviewed.

High-level vancomycin-resistant enterococci causing hospital infections

Nosocomial infection or colonization due to enterococci with high-level resistance to vancomycin (minimal inhibitory concentrations [MICs] between 64 and greater than 2000 mg/L) has occurred in 41 patients with renal disease. These vancomycin-resistant enterococci were cultured from many sources including blood. All but one strain contained one or more plasmids ranging in molecular weight from 1.0 to 40 Megadaltons (MDa). Vancomycin resistance was transferable by conjugation to a susceptible recipient strain of Enterococcus faecalis but this was not always associated with plasmid DNA. The emergence of transferable high-level vancomycin resistance in enterococci causing significant clinical infections is of particular importance since vancomycin is widely regarded as a reserve drug for the management of infections with multi-resistant Gram-positive organisms.

In-vitro activity of seventeen antimicrobial compounds against seven species of mycobacteria

Within attainable serum concentrations, quinolones, especially ciprofloxacin, inhibited strains of Mycobacterium tuberculosis, M. xenopi, M. kansasii, M. fortuitum and M. marinum; vancomycin inhibited M. tuberculosis, the M. avium-intracellulare-scrofulaceum complex. M. kansasii, M. xenopi and M. chelonei; erythromycin was active against M. kansasii, M. xenopi and M. fortuitum, minocycline against M. kansasii and M. marinum and netilmicin and cefuroxime against M. xenopi. Aztreonam showed some activity against M. tuberculosis but little or no effect was shown by five cephalosporins or imipenem.

In vitro activity of ciprofloxacin in combination with standard antituberculous drugs against mycobacterium tuberculosis

Chequer-board titrations show that the in vitro activity of ciprofloxacin against Mycobacterium tuberculosis is independent of that of streptomycin, isoniazid, ethambutol and pyrazinamide and confirm that there is antagonism between ciprofloxacin and rifampicin.

Presumptive identification of nocardias in a clinical laboratory

One hundred and thirty-six cultures of aerobic streptomycetes were examined by simple cultural and microscopical methods. Nocardia spp. were recognized by their resistance to lysozyme and identified to the three important species by casein, xanthine and tyrosine hydrolysis tests.

Bovine tubercle bacilli and disease in animals and man

In 1882 Robert Koch reported the isolation oftuberkelbazillenfrom human and bovine sources. Sixteen years later, Theobald Smith (1898) demonstrated that strains of Koch's tubercle bacilli from these two hosts differed in cell morphology, cultural characteristics and virulence in rabbits. He did not believe that these variants were limited to the hosts from which they were isolated nor that the differences resulted from adaptations to a given host. Indeed, he remarked that ‘It might be better to omit the host designation of such varieties in order to anticipate assumptions that they are necessarily limited to the host whose name they bear.’ Nevertheless, heedless of his own misgivings he termed them the ‘human’ and ‘bovine’ types.

The nature of mycobacterial disease in south east England, 1977-84

The nature and incidence of bacteriologically confirmed mycobacterial disease in south east England over the eight year period 1977-84 has been determined by a study of cultures received by the PHLS Regional Centre for Tuberculosis Bacteriology at Dulwich. The number of cases of tuberculosis in the ethnic European population has shown a decline, more so among males than females, but there has not been a significant decline in cases among ethnic Asians. Most tuberculosis is due to the classical human tubercle bacillus but cases due to the Asian human type, the bovine type (M. bovis), and the African types (M. africanum) also occur. The number of cases of disease due to 'atypical' mycobacteria has doubled over the eight year period, and these now account for about 5% of bacteriologically diagnosed mycobacterial disease in this region. The continuing role of reference facilities for the surveillance of tuberculosis and the diagnosis and management of the growing numbers of other mycobacterial infections is stressed.

Differentiation of Mycobacterium chelonei from M. fortuitum by ciprofloxacin susceptibility

Seventy-five strains of Mycobacterium fortuitum were inhibited by 3.0 mg/l ciprofloxacin but 36 strains of M. chelonei were resistant. The results correlated well with those obtained by the nitratase test. The ciprofloxacin sensitivity test is a useful supplement to the tests used to identify these two species.

In-vitro susceptibility of mycobacteria to ciprofloxacin

Two hundred and seventy-six strains of mycobacteria were tested for susceptibility to ciprofloxacin (Bay 0 9867), a 4-quinolone antimicrobial agent. Most strains of Mycobacterium tuberculosis, Myco. fortuitum, Myco. kansasii, Myco. marinum and Myco. xenopi were sensitive to minimum inhibitory concentrations (MICs) of 0.78-1.56 mg/l, equivalent to resistance ratios of 1 or 2. Most strains of Myco. avium-intracellulare and Myco. chelonei required MICs of 12.5 mg/l or more, giving resistance ratios of 8.

Mycobacterium xenopi and Mycobacterium kansasii in a hospital water supply

A steady rise in the number of isolations of Mycobacterium xenopi from patients in a general hospital led to an examination of water taps. Most patients had been accommodated in a group of wards which had a common water supply. This organism was recovered from 35 of 69 outlets, mostly from hot and mixer taps in those wards. Mycobacterium kansasii was also isolated from 14, mostly cold and mixer taps. Ten strains of Myco. xenopi were recovered from 131 taps sampled at 10 other locations. We conclude that colonization of water supplies by mycobacteria is a likely source of contamination of clinical specimens.

Mycobacterium marinum infections in man

Mycobacterium marinum, formerly known as ‘Mycobacterium balnei’, is a free-living organism which causes disease in fish and occasionally in man. When such infections occur in man they are usually associated with some aquatic activity, e.g. swimming, fishing, boating and keeping tropical fish. For this reason, the organism has been called a ‘leisure-time pathogen’ by Feldman, Long & David (1974) and the disease a ‘hobby hazard’ by Heineman, Spitzer & Pianphongsant (1972).

Subdivision of Mycobacterium tuberculosis for epidemiological purposes: a seven year study of the "Classical' and 'Asian' types of the human tubercle bacillus in South-East England

Human strains of Mycobacterium tuberculosis were divided into the 'Classical' and 'Asian' types according to their sensitivity to thiophen-2-carboxylic acid hydrazide. The isolation of these two types in South-East England was studied during a seven-year period (1977-1983). The 'Asian' type was more prevalent among ethnic Asian patients than among ethnic Europeans. Among Europeans there was a decline in the isolation rate of 'Classical' strains and a small but significant increase in 'Asian' strains during the study period, so that the proportion of the latter type in this group is increasing. The type of bacillus was unrelated to the site of isolation except that the incidence of lymphadenitis due to the 'Asian' type among European females was significantly higher than expected. In general, European patients tended to be older than Asian patients, and the differences in age distribution according to site of isolation and type of bacillus in each ethnic group were small. A notable exception occurred with European females infected with the 'Asian' type, whose age distribution was similar to the Asians. In view of the differences in behaviour of the two types of human tubercle bacilli in this country there is a need to continue a bacteriological surveillance and also to determine whether the nature of the host-pathogen interaction varies according to the type of bacillus.

A study of the relationship between the resistance of Mycobacterium tuberculosis to isonicotinic acid hydrazide (isoniazid) and to thiophen-2-carboxylic acid hydrazide

Thiophen-2-carboxylic acid hydrazide (TCH) is used to distinguish TCH-sensitive bovine, 'Asian human' and 'African' strains from TCH-resistant 'classical' human strains of Mycobacterium tuberculosis. It has been claimed that this test cannot be applied to isoniazid-resistant strains as these also become resistant to TCH. Although such cross-resistant mutants were readily isolated in vitro, a study of the incidence of TCH resistance in a large series of INH-sensitive and -resistant strains isolated from patients indicated that the emergence of this type of mutant is the exception rather than the rule in vivo. Thus, the use of TCH for subdividing the species M. tuberculosis remains valid for epidemiological purposes, irrespective of the occurrence of isoniazid resistance.