The yeast connection: is Candida linked to breastfeeding associated pain?

OBJECTIVE

The objective of the study was to determine whether the isolation of Candida from breastfeeding women is associated with self-reported pain.

STUDY DESIGN

A prospective cohort study was conducted from May 2004 to July 2006. Ninety-eight breastfeeding women were enrolled: 20 women reported breastfeeding associated pain, and 78 women were asymptomatic. Cultures were obtained from breast milk, areolae, and infants' oropharynx.

RESULTS

Six of the 20 symptomatic women had breast milk cultures positive for yeast, compared with 6 of 78 controls (30% vs 7.7%, P = .015). Among the 12 women from whom yeast was isolated, 11 grew Candida albicans. Incidence of Staphylococcus aureus isolation did not differ significantly between groups (5 of 20 vs 15 of 78, P > .05).

CONCLUSION

C. albicans is found more often in breastfeeding mothers who report pain as compared with asymptomatic breastfeeding mothers. Further studies, including treatment trials, are needed to determine whether Candida plays an etiologic role in breastfeeding associated pain.

Introduction of Infection Control Measures to Reduce Infection Associated With Implantable Pain Therapy Devices

INTRODUCTION

Implantable pain therapy devices for chronic pain include spinal cord stimulators (SCS) and intrathecal drug delivery systems (IDDS). A number of different complications can occur after implantation of these devices, but among the most serious is infection. Based on Centers for Disease Control and Prevention guidelines for prevention of surgical site infection, published literature on infection risk with implantable pain therapy devices, and recommendations from groups within our own our institution, we introduced infection control measures for all patients receiving either SCS or IDDS.

METHODS

After approval from the Institutional Review Board, we performed a retrospective review of patients undergoing primary implantation of SCS or IDDS before and after introduction at our institution of safety measures designed to reduce device-related infection. We compared infection incidence and compliance to infection precautions before and after introduction of these measures.

RESULTS

Thirty-four SCS or IDDS were implanted before implementation of the infection control measures and 58 were placed after. Five device-related infections occurred. Adherence to most infection precautions improved during the study period, but 100% compliance was seen only with venue used for implantation. Infection incidence declined after introduction of the safety measures, but the reduction was not statistically significant.

CONCLUSIONS

Introduction of infection control measures for implantable pain therapy devices improved adherence to most infection precautions in our practice. Lack of specific documentation could have hindered practice surveillance within our group. A tool to document performance of infection control measures would be useful not only as a marker of compliance but could also serve as a reminder to perform certain safety measures.

Parents' awareness of and knowledge about young children's urinary tract infections

OBJECTIVE

To provide insight into parents' awareness of and knowledge about urinary tract infections (UTIs) in young children.

METHODS

Twenty interviews with parents who had a child recently diagnosed with a UTI were audiotaped, transcribed verbatim, and qualitatively analysed.

RESULTS

Most parents knew the typical symptoms related to UTI. But, according to the parents, neither they nor all general practitioners (GPs) thought of a UTI in case of atypical symptoms. The awareness that UTI can be a serious illness usually came to parents later, partly because health care workers often did not explicitly mention this. According to the parents, health care workers should be more aware of UTIs in children. Parents felt that health education or mass screening might not be desirable because it would increase anxiety or would be perceived as not relevant.

CONCLUSION

Parents could not consistently recognise UTI in their children and were most times unaware of the possible consequences of a UTI. Nevertheless, parents were sceptical about health education and mass screening.

PRACTICE IMPLICATIONS

There seems little scope for health education addressed at parents or screening for UTI in young children. Instead, physicians and nurses should be alert for the possibility of UTIs in young children, and more information should be given once a UTI is diagnosed.

History, physical and laboratory findings, and clinical outcomes of lactating women treated with antibiotics for chronic breast and/or nipple pain

This chart review study describes the history, physical and laboratory findings, and clinical outcomes in patients who presented to a lactation specialist between 1997 and 2002 and were treated with antibiotics for their chronic breast and/or nipple pain. A total of 69 charts were reviewed. Five were excluded because of loss of follow-up. Eighty-two percent of patients described postpartum breast tenderness, 74% had nipple sores postpartum, and 79% were tender on physical examination. Nipple lesions were present among 73% of the women. Breast milk or nipple cultures were performed for 60 of 64 patients and were positive for pathogenic bacteria among 50% of the patients cultured. The average duration of antibiotic treatment was 5.7 weeks, and 94% of the women had pain resolution. Symptoms of deep breast aching, breast tenderness on palpation, and nipple lesions may be suggestive of a bacterial lactiferous duct infection. Treatment with antibiotics for 4 to 6 weeks may be appropriate.

Molecular analysis of Filifactor alocis, Tannerella forsythia, and treponema denticola associated with primary endodontic infections and failed endodontic treatment

The aim of this study was to investigate the presence of strict anaerobes such as Filifactor alocis, Tannerella forsythia, and Treponema denticola in primary and secondary root-infected canals with periapical lesions by molecular analysis and the association of these species with specific endodontic signs and symptoms. Microbial samples were taken from 100 root canals, 50 with necrotic pulp tissues (NPT, primary infection), and 50 with failed endodontic treatment (FET, secondary infection). DNA was extracted from the samples, which were analyzed for the presence of three endodontic pathogens using species-specific primers and PCR. F. alocis were isolated from 23 canals with NPT and 12 canals with FET; T. forsythia from 12 canals with NPT and three canals with FET; T. denticola from 19 canals with NPT and 12 canals with TEP. Suggested associations were found between primary infection and the presence of F. alocis and T. forsythia (both p < 0.05). In particular, associations were found between: pain and F. alocis; swelling and F. alocis; tenderness to percussion and T. forsythia; mobility and T. forsythia and T. denticola; wet canals and F. alocis, T. forsythia, and T. denticola; purulent exsudate and F. alocis, T. forsythia and T. denticola; abscess and F. alocis, T. forsythia, and T. denticola (all p < 0.05). The findings of this study indicated that F. alocis, T. forsythia, and T. denticola seem to be associated with endodontic signs and symptoms. Additionally, F. alocis and T. forsythia were detected more frequently in teeth with necrotic pulp than in teeth with failing endodontic treatment.

Invasive aspergillosis producing painful ophthalmoplegia

Painful ophthalmoplegia is caused by the lesions of orbital apex and anterior cavernous sinus. Cavernous sinus syndrome can be produced by intracranial invasive aspergillosis. A case of painful ophthalmoplegia due to invasive aspergillosis caused by Aspergillus niger in a diabetic patient is presented.

Quantification of endotoxins in necrotic root canals from symptomatic and asymptomatic teeth

The purpose of this investigation was to quantify the concentration of endotoxin in necrotic root canals and investigate the possible relationship between the concentration of endotoxin and endodontic signs and symptoms. Samples were collected from root canals of 50 patients requiring endodontic treatment due to necrosis of the pulpal tissue. Anaerobic techniques were used to determine the number of c.f.u. in each sample. A quantitative chromogenic Limulus amoebocyte lysate assay was used to measure the concentration of endotoxin in each sample. The presence of c.f.u. was detected by culture in all samples (range 10(2)-5x10(6)). In samples from cases of patients with spontaneous pain, the mean c.f.u. was 1.43x10(6) while in asymptomatic cases it was 9.1x10(4). Endotoxin was present in all the samples studied [range 2390.0-22100.0 endotoxin units (EU) ml-1]. The mean concentration of endotoxin in samples from patients with spontaneous pain was 18540.0 EU ml-1 while in asymptomatic cases it was 12030.0 EU ml-1. Asymptomatic cases generally had lower levels of endotoxin (i.e. a negative association). A positive association was found between endotoxin and symptomatic cases (e.g. spontaneous pain, tenderness to percussion, pain on palpation, swelling and purulent exudates). This study showed that endotoxin is present in high concentrations in root canals of symptomatic teeth. There was a positive correlation between the concentration of endotoxin in the root canal and the presence of endodontic signs and symptoms.

Symptoms in the host: infection and treatment model

AIMS AND OBJECTIVES

The aim is to devise a decision-making model to help nurses and allied professionals treat the symptoms of infectious diseases in a logical way that maximizes the benefits of symptoms and minimizes any harm that they might do.

BACKGROUND

This paper considers the symptoms of infectious diseases from an evolutionary perspective, applying theories from ecology and evolution to nursing. Building upon evolutionary theories that suggest symptoms occur as the result of host defences, pathogen manipulations or as pure side-effects, it is suggested that those symptoms that have evolved as host defences should not always be treated because of their beneficial effects. However, clinical decision-making is more complex because of the rapid changes in environment and behaviour, which may impact upon the usefulness of symptoms to the host.

CONCLUSIONS

Although some symptoms can be identified as being beneficial adaptations, this alone is not sufficient indication to decide which symptoms should or should not be treated. Other considerations include any negative outcomes and behavioural and environmental changes that may affect the significance of any adaptation.

RELEVANCE TO CLINICAL PRACTICE

Nurses should aim to maximize the host defences of the patients they are caring for in order to speed recovery and to reduce transmission and the need for antibiotics. This model helps nurses to identify factors that should be considered when these decisions are made and suggests some principles that might be followed in other situations.

Transobturator tape erosion associated with leg pain

A 39 year-old vaginal multipara status postpubovaginal sling in 2002 and a transobturator tape procedure in 2004 presented with persistent stress incontinence and vaginal polypropylene mesh erosion. Ten days later, she presented to the emergency room with severe right groin pain, difficulty walking, fever, and chills. She described shooting pain originating from the right inguinal ligament radiating down her right leg anteriorly. Although her neurologic examination was normal, palpation of the right obturator internus muscle reproduced her pain. MRI clearly revealed the course of the mesh tape through the obturator muscles and marked increase in the size of the right adductor and obturator internus muscles, apparently compressing the adjacent neurovascular fascicle. The patient was taken to the operating room where the polypropylene tape was easily removed through the vaginal erosion. Mesh cultures were positive for bacteroides fragilis. She experienced complete symptom resolution within 1 week of tape removal.

Thermal hyperalgesia and light touch allodynia after intradermal Mycobacterium butyricum administration in rat

We examined the time course (7 weeks) of thermal hyperalgesia and light touch allodynia in rats after intradermal administration of Mycobacterium butyricum. Nociceptive thresholds to heat and light touch were assessed. Paw edema and temperature, motor function, body weight, and propioception were also tested. Some rats developed arthritis (named AA rats) but others did not (named non-AA rats). Both groups were compared with healthy animals. Persistent hyperalgesia was found in both groups; in AA rats it appeared before clinical evidence of arthritis. Transient allodynia ocurred only after edema development and fell when edema decreased. Motor function was impaired only in AA rats. The results of this study demonstrate that hyperalgesia, but not allodynia, appeared after Mycobacterium butyricum in both groups, suggesting that changes in sensitivity were not merely the result of local hypersensitivity of the inflamed tissue, but may also be due to alterations in nociception in the central nervous system.

Aspergillus granuloma of the cavernous sinus: magnetic resonance imaging with pathologic correlation

This case illustrates the correlation between Magnetic Resonance Imaging (MRI) and the pathological findings in a case of cavernous sinus (CS) aspergilloma.

Criteria for identifying wound infection--revisited

The accurate identification of wound infection provides a clinical challenge to those involved in patient care and would appear to have not kept pace with other developments in the field of wound care. Attempts have been made to improve on the situation but diverse opinions together with lack of consensus prevail. The literature on infection criteria was reviewed and a set of criteria were collated; a number of criteria at the time were described as subtle in nature and have undergone validation studies. This article suggests a new perspective on the clinical identification of wound infection--ie, the signs of infection are closely associated with the wound type. Infection criteria for six wound types are explored and presented. This approach is intended for consideration together with the results of an impending Delphi study that will raise awareness of this issue, promote discussion, and lead to validation of an accurate set of clinical criteria.

Correlation of Candida species and symptoms among patients with vulvovaginal candidiasis in Maringá, Paraná, Brazil

Vulvovaginal candidiasis (VVC) is an infection caused by abnormal yeast growth in the mucosa of the female genital tract which is commonly diagnosed in gynecology. The aim of this study was to correlate the frequency of yeasts and their respective species in asymptomatic women with different clinical manifestation of VVC; evaluate possible relationships between number of fungus colonies and symptoms in this pathology. All patients who visited the laboratory within a period of five months, for routine examinations of vaginal secretion, independent of the presence or absence of symptoms of VVC were included in this study. Of these, women with immunodeficiency or with an infection of the genital tract by another agent were excluded. Candida albicans was the most frequently yeast isolated (60%). Among non-C. albicans yeasts, 61.5% were isolated of the asymptomatic women, 38.7% from patients with VVC and 11.1% of those from patients with RVVC. C. albicans was associated with symptoms of VVC and while, the presence of non-C. albicans yeasts with asymptomatic women. However, there was no association between the number of fungal colonies and symptoms.

Neuropathic pain in leprosy

Neuropathic pain appears to be much more common in leprosy than has been generally appreciated. Emphasis in leprosy control programs has been on the distribution of multi-drug therapy, on early and better detection, and on the prevention of disability related to anesthetic limbs. Most have thus been inattentive to the problem of neuropathic pain in leprosy patients. Neuropathic pain does not respond to the usual analgesics employed for reactions, for example, and so it is important that those treating leprosy patients give this problem the special attention it requires, both in diagnosis and in treatment.

Neuropathic pain in leprosy patients

The introduction of multidrug therapy by the World Health Organization has dramatically reduced the world prevalence of leprosy but the disease is still a public health problem in many countries, with a world prevalence of almost 600,000 cases in 2001. Damage to peripheral nerves is a key component of leprosy and the sensory and motor loss that follows is the basis for many of the classical features of this disease, such as skin wounds, cracks, plantar ulcers, clawed hands, drop foot, and incomplete closure of the eyelids. One of the most remarkable aspects of leprosy to lay persons and health care workers alike is that patients are reputed to feel no pain. However, neuropathic pain is arising as a major problem among leprosy patients. It can be nociceptive due to tissue inflammation, which mostly occurs during episodes of immune activation or neuropathic due to damage or dysfunction of the nervous system. This study, conducted among 358 leprosy patients, reveals a considerable prevalence of neuropathic pain and presents evidence that this common problem should be a high priority of those in charge of leprosy control programs.

Penile prosthesis cultures during revision surgery: a multicenter study

PURPOSE

Initial implantation of inflatable penile prosthesis has a 3% risk of infection. Reoperation of penile implants has a higher rate of infection, estimated between 10% and 18%. To explain the higher risk in revision surgery in this prospective study we cultured clinically uninfected prostheses requiring revision. Prosthesis pain was also investigated as a predictor of positive culture.

MATERIALS AND METHODS

At 3 institutions cultures were prospectively obtained from 77 clinically uninfected penile prostheses at revision surgery. Immediately upon surgical exposure of the pump cultures were obtained. If a bacterial biofilm was noted on any component it was additionally cultured. All culture isolates positive for a staphylococcus species were tested for sensitivity to rifampin and tetracycline (minocycline). An implant is now available that is coated with these antibiotics. Patient history of chronic prosthesis pain was ascertained.

RESULTS

Culture positive bacteria were found in 54 of 77 (70%) patients with clinically uninfected penile prostheses. In some patients more than 1 organism grew and, occasionally, the pump culture was negative but the biofilm was positive. Of 54 patients 49 had positive (90%) culture for staphylococcus genus with 10 different species. All staphylococcal species were sensitive to rifampin and/or tetracycline. We did not find a significant association between prosthesis related pain and culture laboratory results.

CONCLUSIONS

The majority of clinically uninfected penile prostheses have organisms growing in the implant spaces at reoperation. Most of these organisms are staphylococcal species that are sensitive to rifampin/minocycline.

Characterization of Shiga toxin-producing Escherichia coli strains isolated from human patients in Germany over a 3-year period

We have investigated 677 Shiga toxin-producing Escherichia coli (STEC) strains from humans to determine their serotypes, virulence genes, and clinical signs in patients. Six different Shiga toxin types (1, 1c, 2, 2c, 2d, and 2e) were distributed in the STEC strains. Intimin (eae) genes were present in 62.6% of the strains and subtyped into intimins alpha1, beta1, gamma1, epsilon, theta, and eta. Shiga toxin types 1c and 2d were present only in eae-negative STEC strains, and type 2 was significantly (P < 0.001) more frequent in eae-positive STEC strains. Enterohemorrhagic E. coli hemolysin was associated with 96.2% of the eae-positive strains and with 65.2% of the eae-negative strains. Clinical signs in the patients were abdominal pain (8.7%), nonbloody diarrhea (59.2%), bloody diarrhea (14.3%), and hemolytic-uremic syndrome (HUS) (3.5%), and 14.3% of the patients had no signs of gastrointestinal disease or HUS. Infections with eae-positive STEC were significantly (P < 0.001) more frequent in children under 6 years of age than in other age groups, whereas eae-negative STEC infections dominated in adults. The STEC strains were grouped into 74 O:H types by serotyping and by PCR typing of the flagellar (fliC) genes in 221 nonmotile STEC strains. Eleven serotypes (O157:[H7], O26:[H11], O103:H2, O91:[H14], O111:[H8], O145:[H28], O128:H2, O113:[H4], O146:H21, O118:H16, and O76:[H19]) accounted for 69% of all STEC strains. We identified 41 STEC strains belonging to 31 serotypes which had not previously been described as human STEC. Twenty-six of these were positive for intimins alpha1 (one serotype), beta1 (eight serotypes), epsilon (two serotypes), and eta (three serotypes). Our study indicates that different types of STEC strains predominate in infant and adult patients and that new types of STEC strains are present among human isolates.

Microbiological examination of infected dental root canals

OBJECTIVES

The aim of this study was to investigate the root canal microbiota of primary and secondary root-infected canals and the association of constituent species with specific endodontic signs and symptoms.

METHODS

Microbial samples were taken from 60 root canals, 41 with necrotic pulp tissues (primary infection) and 19 with failed endodontic treatment (secondary infection). Strict anaerobic techniques were used for serial dilution, plating, incubation and identification.

RESULTS

A total of 224 cultivable isolates were recovered belonging to 56 different bacterial species. Individual root canals yielded a maximum of 10 bacterial species. Of the bacterial isolates, 70% were either strict anaerobes or microphilic. The anaerobes most frequently isolated were: Peptostreptococcus micros (35%), Fusobacterium necrophorum (23.3%), Fusobacterium nucleatum (11.7%), Prevotella intermedia/nigrescens (16.7%), Porphyromonas gingivalis (6.7%) and Porphyromonas endodontalis (5%). The root canal microflora of untreated teeth with apical periodontitis was found to be mixed, comprising gram-negative and gram-positive and mostly anaerobic microorganisms and usually containing more than 3 species per canal. On the other hand, facultative anaerobic and gram-positive bacteria predominated in canals with failed endodontic treatment, which harbored 1-2 species per canal. Suggested relationships were found between anaerobes, especially gram-negatives, and the presence or history of pain, tenderness to percussion and swelling (P<0.05). In particular, associations were found between: a) pain (n=29) and P. micros (P<0.01), P. intermedia/nigrescens and Eubacterium spp. (both P<0.05); b) history of pain (n=31) and P. micros (P<0.01) Porphyromonas and Fusobacterium spp. (P<0.05); c) tenderness to percussion (n=29) and Porphyromonas spp. (P<0.01), Peptostreptococcus and Fusobacterium spp. (P<0.001); d) swelling (n=20) and Peptostreptococcus spp. (P<0.01), Porphyromonas and Enterococcus spp. (P<0.05); e) wet canals (n=33) and Porphyromonas and Fusobacterium spp. (P<0.05); f) purulent exudate (n=20) and Porphyromonas, Peptostreptococcus and Fusobacterium spp. (P<0.05); previous endodontic treatment and Enterococcus faecalis, Streptococcus spp., P. micros, F. necrophorum (P<0.05).

CONCLUSIONS

Our findings indicate potential complex interactions of species resulting in characteristic clinical pictures which cannot be achieved by individual species alone. They also indicate that the microbiota of primary infected canals with apical periodontitis differs in number and in species from the secondary infected canals by using the culture technique.

Microbiological analysis of infected root canals from symptomatic and asymptomatic teeth with periapical periodontitis and the antimicrobial susceptibility of some isolated anaerobic bacteria

The purpose of the present study was to investigate the correlation between the composition of the bacterial flora isolated from infected root canals of teeth with apical periodontitis with the presence of clinical signs and symptoms, and to test the antibiotic susceptibility of five anaerobic bacteria mostly commonly found in the root canals of symptomatic teeth against various substances using the E-test. Microbial samples were taken from 48 root canals, 29 symptomatic and 19 asymptomatic, using adequate techniques. A total of 218 cultivable isolates were recovered from 48 different microbial species and 19 different genera. Root canals from symptomatic teeth harbored more obligate anaerobes and a bigger number of bacterial species than the asymptomatic teeth. More than 70% of the bacterial isolates were strict anaerobes. Statistical analysis used a Pearson Chi-squared test or a one-sided Fisher's Exact test as appropriate. Suggested relationships were found between specific microorganisms, especially gram-negative anaerobes, and the presence of spontaneous or previous pain, tenderness to percussion, pain on palpation and swelling amoxicillin, amoxicillin + clavulanate and cephaclor were effective against all the strains tested. The lowest susceptibility rate was presented by Prevotella intermedia/nigrescens against Penicillin G. Our results suggested that specific bacteria are associated with endodontic symptoms of infected teeth with periapical periodontitis and the majority of the anaerobic bacterial species tested were susceptible to all antibiotics studied.

Pain as presenting symptom in Lyme neuroborreliosis

Neurogenic pain with radiculitis is often the starting symptom in adult patients with tick-borne Lyme neuroborreliosis and in some cases the only clinical manifestation. Cranial paresis and other neurologic signs usually occur after the onset of pain. The present paper describes four patients who had severe pain as the main presenting symptom of Lyme neuroborreliosis. Opioids had good short-term effect in two of the cases. Oral doxycycline treatment was used successfully to eliminate the infection.