Dental divisions: exploring racial inequities of dental caries amongst children

DATA SOURCES

The search strategy involved three sequential stages. Initially, MEDLINE/PubMed was explored for relevant articles, identifying pertinent terms for formal searching. Using the terms ethnic, race, minoritised and dental caries, a strategy was formed and nine databases searched. Finally, hand-searching of reference lists of included articles and sourcing grey literature from relevant government reports, national oral health surveys, and registries which had comparative data for dental caries between racial groups, completed the search.

STUDY SELECTION

Studies included were original primary research which reported dental caries and compared racially minoritised children, aged 5-11 years, to similarly aged from national, majority, or privileged populations. Dental caries had to be recorded from a clinical examination which assessed decayed, missing, and filled teeth (dmft) in primary dentitions. Studies were excluded if they used immigration status as a basis of racial status, or they were a case report, case series, in vitro study, or literature review.

DATA EXTRACTION AND SYNTHESIS

After removing duplicates, two independent researchers screened abstracts, prior to extracting critical data following full-text reviews of included articles. Information collected included study and participant characteristics, definitions of race, and dental caries measurement. The authors of studies which had missing data were contacted, whilst those not written in the English language were translated. Methodological quality of each study was independently assessed by two reviewers using a modified version of the Newcastle-Ottawa scale. All studies were included in the review regardless of quality. A narrative overview of all included studies was conducted. Meta-analyses were completed using studies that reported the mean and standard deviation of the caries outcomes in both groups. Caries outcomes included severity (defined as mean dmft) or prevalence (percentage of teeth with untreated dental caries > 0%). Due to anticipated heterogeneity, statistical analyses approaches such as I2 statistics were used to estimate between-study variability. Additional sub-group analyses were conducted based on country of study and world income index. Contour-enhanced funnel plots and trim-and-fill analysis were completed to explore potential publication bias. Sensitivity analyses were performed to ensure robustness of the findings.

RESULTS

Seventy-five studies were included from a variety of countries. A higher mean dmft score of 2.30 (0.45, 4.15) and prevalence of decayed teeth (d > 0) was 23% (95% CI: 16, 31) was noted amongst racially minoritised children compared to privileged children's populations. Notable disparities were reported in high-income countries, with minoritised children burdening the greatest distribution of caries incidence. The study faced challenges in consistent racial classification and encountered high heterogeneity in its findings, leading to varied GRADE assessment scores.

CONCLUSIONS

The study calls for global, social, and political changes to tackle the substantial disparities in dental caries among minoritised children to achieve oral health equity.

Evaluation of UK paediatric nephrology teams' understanding, experience and perceptions of oral health outcomes and accessibility to dental care: a mixed-methods study

BACKGROUND

Oral health conditions are common in children and young people (CYP) with kidney disorders. There is currently limited literature on how confident paediatric nephrology teams feel to identify and manage oral health concerns for their patients.

METHOD

An exploratory mixed-method survey was distributed across all 13 UK specialist paediatric nephrology centres with responses received from consultants, registrars, specialist nurses and special interest (SPIN) paediatricians.

RESULTS

Responses received from 109 multidisciplinary team members of 13/13 (100%) UK tertiary units. Ninety-two percent (n = 100) of respondents reported they had never received any training in oral health and 87% (n = 95) felt that further training would be beneficial to optimise care for patients and improve communication between medical and dental teams. Most respondents reported that they did not regularly examine, or enquire about, their patients' oral health. Only 16% (n = 17) reported that all their paediatric kidney transplant recipients underwent routine dental assessment prior to transplant listing. Severe adverse oral health outcomes were rarely reported and only 11% (n = 12) of respondents recalled having a patient who had a kidney transplant delayed or refused due to concerns about oral infection. Seventy-eight percent (n = 85) felt that joint working with a dental team would benefit patients at their unit; however, 17% (n = 18) felt that current infrastructure does not currently support effective joint working.

CONCLUSIONS

Across the UK, paediatric kidney health professionals report lack of confidence and training in oral health. Upskilling subspecialty teams and creating dental referral pathways are recommended to maximise oral health outcomes for CYP with kidney diseases.

Molar incisor hypomineralisation: Teaching and assessment across the undergraduate dental curricula in the UK

BACKGROUND

No consensus exists on how molar incisor hypomineralisation (MIH) should be covered by the undergraduate dental curricula.

AIM

To assess the current teaching and assessment of MIH in the UK.

DESIGN

A piloted questionnaire regarding the teaching and assessment of MIH was disseminated to paediatric, restorative and orthodontic teaching leads in each UK dental school (n = 16). Data were analysed using descriptive statistics, chi-squared and Kruskal-Wallis tests.

RESULTS

Response rates from paediatric, restorative and orthodontic teams were 75% (n = 12), 44% (n = 7) and 54% (n = 8), respectively. Prevention of caries, preformed metal crowns, anterior resin composites and vital bleaching were taught significantly more by paediatric teams (p = .006). Quality of life and resin infiltration were absent from restorative teaching. Orthodontic teaching focussed on the timing of first permanent molar extractions. Paediatric teams were mainly responsible for assessment. Risk factors, differential diagnoses for MIH and defining clinical features were more likely to be assessed by paediatric teams than by others (p = .006). All specialities reported that students were prepared to manage MIH.

CONCLUSION

Molar incisor hypomineralisation is primarily taught and assessed by paediatric teams. No evidence of multidisciplinary or transitional teaching/assessment existed between specialities. Developing robust guidance regarding MIH learning in the UK undergraduate curricula may help improve consistency.

Qualitative study exploring general dental practitioners' views of MIH and its management in the UK and Australia

BACKGROUND

Molar-incisor hypomineralisation (MIH) is a prevalent condition, and how it is managed varies greatly between professional groups.

AIM

To explore, and compare, the UK and Australian general dental practitioners' management of MIH in children.

DESIGN

Face-to-face (remote) semistructured interviews were undertaken, using country-specific topic guides. Participants were purposively sampled and recruited through national conferences and research networks (eviDent Foundation and Northern Dental Practice Based Research Network). Interviews (from each country) were audio-recorded, transcribed verbatim and independently analysed using thematic analysis.

RESULTS

Two major themes arose from the UK interviews: (i) decision-making complexities and understanding of treatment options and (ii) need for specialist input. The main Australian themes were (i) multidisciplinary approach to management supporting decision-making complexities and (ii) economic implications for care. Several difficulties, such as financial implications, multidisciplinary care and clinical decision-making, were identified as barriers to effectively managing MIH by GDPs in primary care.

CONCLUSION

There are similarities and differences in the knowledge and management of MIH amongst UK and Australian nonspecialists. The different healthcare systems played a significant role in shaping how GDPs manage MIH with barriers relating to affordability, multidisciplinary care and clinical decision-making.

An update of the aetiological factors involved in molar incisor hypomineralisation (MIH): a systematic review and meta-analysis

PURPOSE

To systematically review the aetiological factors associated with molar incisor hypomineralisation (MIH). To this day, the aetiology remains unknown. Determining risk factors would allow risk assessment and enhance early diagnosis of MIH in young patients. The aim was to assess, evaluate and summarise the relationship between MIH and reported aetiological hypotheses.

METHODS

Electronic database searches of MEDLINE, EMBASE, EBSCO, LILACS and Cochrane Library were conducted. Authors conformed to PRISMA guidelines. Studies were screened, data extracted, assessment of risk of bias and calibration was completed by two independent reviewers. Meta-analyses with heterogeneity calculations were performed.

RESULTS

Of the potential 8949 studies, 64 studies were included in the qualitative analysis whilst 45 were included in the quantitative analysis. Prenatal factors: results are inconclusive as only unspecified maternal illnesses appear to be linked to MIH. Perinatal factors: prematurity (OR 1.45; 95% CI 1.24-1.70; p = 0.0002) and caesarean delivery (OR 1.45; 95% CI 1.09, 1.93; p < 0.00001) are associated with an increased risk of developing MIH. Birth complications are also highlighted. These three factors can lead to hypoxia, and children with perinatal hypoxia are more likely to develop MIH (OR 2.76; 95% CI 2.09-3.64; p < 0.0001). Postnatal factors: measles, urinary tract infection, otitis media, gastric disorders, bronchitis, kidney diseases, pneumonia and asthma are associated with MIH. Fever and antibiotic use, which may be considered as consequences of childhood illnesses, are also associated with MIH. Genetic factors: an increasing number of studies highlight the genetic and epigenetic influences in the development of MIH.

CONCLUSION

Several systemic and genetic and/or epigenetic factors acting synergistically or additively are associated with MIH, revealing a multifactorial aetiology model. Peri- and postnatal aetiological factors are more likely to increase the odds of causing MIH than prenatal factors.

Best clinical practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH): an updated European Academy of Paediatric Dentistry policy document

AIM

To update the existing European Academy of Paediatric Dentistry (EAPD) 2010 policy document on the 'Best Clinical Practice guidance for clinicians dealing with children presenting with Molar-Incisor-Hypomineralisation (MIH).'

METHODS

Experts, assigned the EAPD, worked on two different topics: (A) Aetiological factors involved in MIH, and (B) Treatment options for the clinical management of MIH. The group prepared two detailed systematic reviews of the existing literature relevant to the topics and following a consensus process produced the updated EAPD policy document on the 'Best Clinical Practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH).' The GRADE system was used to assess the quality of evidence regarding aetiology and treatment which was judged as HIGH, MODERATE, LOW or VERY LOW, while the GRADE criteria were used to indicate the strength of recommendation regarding treatment options as STRONG or WEAK/CONDITIONAL.

RESULTS

(A) Regarding aetiology, it is confirmed that MIH has a multifactorial aetiology with the duration, strength and timing of occurrence of the aetiological factors being responsible for the variable clinical characteristics of the defect. Perinatal hypoxia, prematurity and other hypoxia related perinatal problems, including caesarean section, appear to increase the risk of having MIH, while certain infant and childhood illnesses are also linked with MIH. In addition, genetic predisposition and the role of epigenetic influences are becoming clearer following twin studies and genome and single-nucleotide polymorphisms analyses in patients and families. Missing genetic information might be the final key to truly understand MIH aetiology. (B) Regarding treatment options, composite restorations, preformed metal crowns and laboratory indirect restorations provide high success rates for the posterior teeth in appropriate cases, while scheduled extractions provide an established alternative option in severe cases. There is great need for further clinical and laboratory studies evaluating new materials and non-invasive/micro-invasive techniques for anterior teeth, especially when aesthetic and oral health related quality of life (OHRQoL) issues are concerned.

CONCLUSIONS

MIH has been studied more extensively in the last decade. Its aetiology follows the multifactorial model, involving systemic medical and genetic factors. Further focused laboratory research and prospective clinical studies are needed to elucidate any additional factors and refine the model. Successful preventive and treatment options have been studied and established. The appropriate choice depends on the severity of the defects and the age of the patient. EAPD encourages the use of all available treatment options, whilst in severe cases, scheduled extractions should be considered.

A systematic review of the quality and scope of decision modelling studies in child oral health research

Background

Decision analytic models are often used in economic evaluations to estimate long-term costs and effects of treatment which span beyond the time-frame of a clinical trial, therefore providing a better understanding of the long-term implications of decisions that conventional trial-based economic evaluations fail to provide. This is particularly relevant for considering oral health interventions in children as treatments may affect adult oral health. However, in the field of child oral health there has not been an evaluation of the quality and scope of decision analytical models which extend into adulthood. The aim of this review is to examine the scope and quality of decision modelling studies, with horizons extending into adulthood, within the field of child oral health.

Methods

The following databases were searched: NHS Economic Evaluation Database (CRD York), MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, the Cochrane Library and Econlit. Full economic evaluations, in the field of child oral health, published after 1997 which included a decision model with a horizon that extended beyond the age of 18 years old were included. Included studies were appraised against the Drummond checklist and the Consolidated Health Economic Evaluation Reporting Standards by calibrated reviewers.

Results

Four hundred studies were identified, of which nine met the inclusion criteria. Of the nine, eight were cost-effectiveness models. The majority focussed on the prevention or management of dental caries. The mean percentage of applicable Drummond checklist criteria met by the studies in this review was 82% (median = 85%, range = 54–100%). Discounting of costs and performing an incremental analysis were noted as key methodological weaknesses. The mean percentage of applicable CHEERS criteria met by each study was 82% (median = 87%, range = 32–96%). Justifying the type of model, analytical methods used, and sources of funding were most commonly unreported.

Conclusions

There is a paucity of decision analytical models in the field of child oral health. Most of those that are available are of high methodological and reporting quality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01680-3.

The interaction and interference of preformed metal crowns on magnetic resonance imaging: a scoping review with a systematic methodology

Purpose

Preformed metal crowns are widely used to restore primary and permanent teeth. Children may require magnetic resonance imaging (MRI) for diagnosis and monitoring of diseases in the head and neck region. Metallic objects, in the field of view, may compromise the diagnostic value of an MRI. The impact on the diagnostic quality of an MRI in children who have had preformed metal crowns placed has not been assessed. The aim of this systematic review was to evaluate the impact that PFMCs have on MRI imaging quality and thus the overall diagnostic value.

Methods

Electronic searches of the following databases were completed: MEDLINE, EMBASE, Cochrane Library, Web of Science and Open Grey. Primary in vivo studies on children who had at least one preformed metal crown placed and required an MRI investigation were to be included. PRISMA guidelines were followed and screening/data extraction was carried out by two independent calibrated reviewers.

Results

A total of 7665 articles were identified. After removing duplicates, 7062 were identified for title and abstract screening. Thirty-four articles underwent full-text review, of which none met the inclusion criteria. Most common reasons for exclusion were not placing preformed metal crowns (n = 16) or in vitro studies (n = 12).

Conclusion

No in vivo studies were identified to establish the hypothetical impact preformed metal crowns would have on the diagnostic quality of an MRI in the head and neck region. Decision making needs to be guided on a case by case basis. Further high-quality clinical studies are required.

Primary Care Dentists' management of permanent dentition traumatic dental injuries in 7- to 16-year-olds: A sequential mixed-methods study

BACKGROUND/AIMS

Primary care dentists play a pivotal role in the management of traumatic dental injuries in children, despite little evidence on the barriers they face in providing care. The aim of this study was to explore and contextualize the knowledge and attitudes of general dental practitioners regarding their management of permanent dentition traumatic dental injuries in children aged 7-16 years old.

MATERIAL AND METHODS

A two-phase sequential mixed-methods study included a questionnaire that was disseminated to all 619 primary care dentists, identified via a triangulated sampling strategy, based across the north-east of England (Phase I). Statistical analyses were performed using Mann-Whitney U- and Kruskal-Wallis tests, Spearman's correlation and chi-square test. Multivariate factor analysis, with principal components extraction, was used to test between multiple ordinal variables. Respondents were invited to a face-to-face or telephone semi-structured interview (Phase II). Interviews were transcribed verbatim and analysed using inductive thematic analysis.

RESULTS

Primary care dentists were less confident in managing complex dental trauma. Inadequate financial remuneration was the main reason for not providing care, often prompting a referral to the local dental hospital. This was more apparent for those who qualified before 2000. More recently qualified dentists felt the long-term costs, related to traumatic dental injuries, were insufficiently remunerated. Most still provided emergency management, irrespective of remuneration, as long as they had the requisite knowledge and skills. Four major themes arose: impact of traumatic dental injuries on patients, parents and primary care dentists; barriers to providing treatment; educational opportunities for primary care dentists; and interactions between primary and secondary care services.

CONCLUSIONS

There is high confidence in managing simple traumatic dental injuries but less for complex injuries. A lack of sufficient financial remuneration associated with the long-term management of dental trauma was the main barrier for dentists to manage these cases.

Success of endodontic management of compromised first permanent molars in children: A systematic review

BACKGROUND

Endodontic therapies may be required in the management of compromised first permanent molar teeth; their success in children, however, is unknown.

AIM

To determine the success of endodontic therapies used on first permanent molar teeth in children aged sixteen and under.

DESIGN

MEDLINE, Embase, Cochrane library, CENTRAL, Clinicaltrials.gov, and the ISRCTN registry as well as relevant paediatric, endodontic, and traumatology journal were searched using a detailed search strategy. References of included studies were hand-searched. A PICOS question was formulated: (P): children aged sixteen and under; (I): endodontic therapies (not pulp capping) on a first permanent molar tooth; (C): no treatment; (O): clinical success of endodontic therapy; and (S): all study types included. Bias was assessed using the Cochrane and Robins-I risk tools. Quality of evidence was assessed using the GRADE approach. Significant heterogeneity precluded meta-analysis.

RESULTS

4172 studies were retrieved and eleven were included in the narrative review. Partial and coronal pulpotomies have high success rates in the short term and long term. Limited evidence is available for conventional pulpectomy or regenerative techniques.

CONCLUSIONS

Partial and coronal pulpotomies are successful endodontic therapies for use in a compromised child's first permanent molar.

Management of compromised first permanent molars in children: Cross-Sectional analysis of attitudes of UK general dental practitioners and specialists in paediatric dentistry

BACKGROUND

It is unclear on how children with compromised first permanent molars (cFPMs) are currently managed in the UK by either general dental practitioners (GDP) or specialists in paediatric dentistry (SPD).

AIM

Explore the current attitudes to the management of compromised first permanent molars amongst UK general dental practitioners and specialists in paediatric dentistry.

DESIGN

Self-completed online questionnaire including three clinical vignettes of 7, 9, and 15 years old with cFPM. All registered SPDs (n = 236), as of May 2017, 500 randomly selected GDPs from England, selected from a national performers list, and 52 Scottish GDPs, part of Scottish dental practice research network, were invited to complete the questionnaire.

RESULTS

About 71.6% (n = 53) of SPDs agreed that children with cFPM should be referred to a paediatric specialist for treatment planning, whereas the reverse for GDPs is true, as 86.8% (n = 138) believe they have a responsibility to treat these teeth. Responses to clinical vignettes suggest a slight preference amongst GDPs to restore cFPM, including root canal treatment, whereas SPDs have a slight preference towards extraction.

CONCLUSION

Current pathways for cFPM, amongst UK general dental practitioners and specialists in paediatric dentistry, vary greatly between and within each professional group.

Molar incisor hypomineralisation

Data sourcesThe Medline and Embase databases and hand searches in the journals International Journal of Paediatric Dentistry and European Archives of Paediatric Dentistry.Study selectionEnglish language cohort and case-control studies.Data extraction and synthesisStudy selection was carried out independently by two reviewers with data abstraction being conducted by a single reviewer and checked by a second reviewer. Risk of bias was assessed using a modified version of the Newcastle-Ottawa Scale (NOS). Adjusted (aOR) and unadjusted odds ratios (uOR), P-values and 95% confidence intervals (CI) were obtained from the studies. Meta-analysis was not conducted.ResultsTwenty-eight studies were included; 25 reported on MIH, three on hypomineralised second primary molars (HSPM). Nineteen of the studies were of cohort design (six prospective,13 retrospective) and nine were case controls. There was little evidence of an association between the most frequently investigated prenatal factors (smoking, maternal illness, maternal medication, maternal stress) and MIH. Similarly there was little evidence of an association between MIH and perinatal factors such as prematurity, low birth weight, caesarean delivery and birth complications. Early childhood illness, up to three or four years of age, was widely investigated, with six studies reporting a crude association. Associations between antibiotics, anti-asthma medication and breastfeeding were also evaluated. Only three studies looked at HSPM; one study suggested that maternal antibiotic use during pregnancy is unlikely to be associated with HSPM but maternal alcohol intake may be. Another study reported possible associations with a large number of factors, with perinatal factors and neonatal illness being most common, followed by prenatal factors.ConclusionsPrenatal and perinatal factors are infrequently associated with MIH. However, despite a lack of prospective studies, early childhood illness (in particular fever) appears to be associated with MIH. Further prospective studies that adjust for confounding based on biological principles, as well as genetic and epigenetic studies, are needed because the aetiology is likely to be multifactorial.

Aesthetic preformed crowns for primary teeth

Data sourcesMedline, Cochrane central register of controlled trials, US National Institutes of Health Trials Register and the World Health Organization International Clinical Trials Registry Platform.Study selectionEnglish language randomised clinical trials comparing APCs with conventional restorative techniques for primary teeth.Data extraction and synthesisStudy selection and data abstraction were conducted independently by two reviewers. Risk of bias was assessed using the Cochrane risk of bias tool. Study characteristics and results were described qualitatively. Meta-analysis was not conducted.ResultsSeven studies were included, six reported on primary molars and one on primary incisors. There was great variety in the design of the RCTs, however, all compared pre-veneered stainless steel crowns (SSCs) with other crowns or two different pre-veneered SSCs. The risk of bias in all studies was high with significantly different outcome measures used.ConclusionsSSCs cannot be replaced by APCs for restoring decayed primary molar teeth due to the insufficient quality of evidence available. After a follow-up of only six months, zircon crowns gave significantly better results than the others regarding gingival health and crown fractures. Due to the small number of RCTs on this topic and their risk of bias, future RCTs should be carried out in primary teeth.

A Change in Practice Protocol: Preformed Metal Crowns for Treating Non-Infected Carious Primary Molars in a General Practice Setting – A Service Evaluation

Restoring non-infected carious primary molars can pose a challenge to the general dental practitioner. This paper aims to assess the effect on primary caries management and patient experience in a general dental practice setting, when restoring non-infected carious primary molars using a Hall preformed metal crown (PMC).

Fluoride varnish applications and caries incidence in pre-schoolers

DESIGN

A two year placebo-controlled, double-blind, randomised control trial in 1-4-year-old children.

INTERVENTION

Children were recruited from low income families in Rio de Janeiro, Brazil, with access to a fluoridated public water supply. Both groups received oral hygiene instruction along with provision of toothbrushes and 1450 ppm F- toothpaste. The control group had a placebo fluoride varnish applied every six months. The intervention group had 22,600 ppm F- varnish applied every six months. Clinical examinations for the presence of caries were conducted at baseline and at each subsequent six monthly visit.

OUTCOME MEASURE

The primary outcome was the proportion of children in each group that went on to clinically develop any new carious surfaces using the ICDAS criteria. The number of new carious surfaces was assessed as a secondary outcome, both at the enamel and dentine level. The study also reported on the safety and acceptability of the varnish.

RESULTS

Two hundred children participated in the trial, 91% were followed up at two years and adherence to the six-monthly applications was 84% in the intervention and 85% in control groups. The results did not show a significant difference for the development of new lesions between the two groups. In the fluoride varnish group 36% had developed new dentinal lesions compared to 47% in the placebo group, a difference of -10.8% (95% CI -24.9 to 3.3, p = 0.14). In relation to caries increment, at the enamel level, this was a mean of 2.0 teeth in the fluoride varnish group and 2.8 teeth in the placebo group, a difference of -0.8 (95% CI -2.0 to 0.4, p = 0.19). At the dentine level, caries increment was a mean of 1.8 teeth in the fluoride varnish group and 2.5 in the placebo group, a difference of -0.7 (95% CI -1.9 to 0.4, p = 0.23). Two minor complaints related to taste and appearance of the varnish were recorded and no safety events were reported.

CONCLUSIONS

Whilst no significant difference was found, the authors note that this does not indicate ineffectiveness of fluoride varnish. Re-assessment of the power calculation following study completion demonstrated that a significantly larger sample size would have been indicated, preventing the drawing of any direct conclusions from the results of this study. The use of fluoride varnish amongst this group appears to be safe and overall well tolerated.

Microbial challenge-testing of treatment processes for quantifying stormwater recycling risks and management

Pathogenic microorganisms have been identified as the main human health risks associated with the reuse of treated urban stormwater (runoff from paved and unpaved urban areas). As part of the Smart Water initiative (Victorian Government, Australia), a collaborative evaluation of three existing integrated stormwater recycling systems, and the risks involved in non-potable reuse of treated urban stormwater is being undertaken. Three stormwater recycling systems were selected at urban locations to provide a range of barriers including biofiltration, storage tanks, UV disinfection, a constructed wetland, and retention ponds. Recycled water from each of the systems is used for open space irrigation. In order to adequately undertake exposure assessments, it was necessary to quantify the efficacy of key barriers in each exposure pathway. Given that none of the selected treatment systems had previously been evaluated for their treatment efficiency, experimental work was carried out comprising dry and wet weather monitoring of each system (for a period of 12 months), as well as challenging the barriers with model microbes (for viruses, bacteria and parasitic protozoa) to provide input data for use in Quantitative Microbial Risk Assessment.

Poor efficacy of intradermal administration of recombinant hepatitis B virus immunization in HIV-infected individuals who fail to respond to intramuscular administration of hepatitis B virus vaccine

OBJECTIVE

It is recommended that hepatitis B virus (HBV)-susceptible, HIV-infected persons be immunized for HBV. However, 44-76% of HIV-infected persons fail to respond to a standard series of recombinant HBV vaccine. Intradermal (i.d.) administration of HBV vaccine has been effective in nonresponders to intramuscularly administered vaccine among healthcare workers, haemodialysis patients and renal transplant recipients. We evaluated the immunogenicity of HBV vaccine given by the intradermal route in HIV-infected individuals who failed to respond to two series of HBV vaccine given intramuscularly.

METHODS

Recombinant HBV vaccine [10 microg HBV surface antigen (HBsAg)/mL] was administered as 0.25 mL i.d. every 2 weeks for four doses in 12 HIV-infected adults who failed to respond to six doses of HBV vaccine administered by the intramuscular route. Anti-HBs was tested at least 2 weeks following the fourth dose of i.d. administered vaccine, and if the anti-HBs titre was negative or <30 IU/L, a second series of four i.d. doses were administered every 2 weeks. Anti-HBs was measured at least 2 weeks following the second series of i.d. administered HBV vaccine and 6 and 12 months after the last dose.

RESULTS

Protective levels of anti-HBs (>10 IU/L) were achieved in six subjects (50%) after four doses. Administration of four additional i.d. doses to the six nonresponders did not result in any additional seroconverters. Five of the six responders had no detectable anti-HBs at 12 months after the last dose of i.d. administered vaccine.

CONCLUSIONS

The i.d. route of administration of recombinant HBV vaccine does not appear to be immunogenic in HIV-infected adults who fail to respond to six doses of intramuscularly administered vaccine.

Epidemiology, treatment and outcome of candidemia: a five-year review at three Canadian hospitals

To determine treatment regimens and epidemiological patterns in the occurrence of candidemia, a review of cases occurring from 1992 to 1996 in three large Canadian hospitals, University of Alberta Hospital (UAH) and Royal Alexandra Hospital (RAH), Edmonton, and Foothills Medical Center (FMC), Calgary, was carried out. Cases were detected by reviewing microbiology laboratory records. There were 202 cases in all (UAH 104, FMC 70, RAH 28). For the five study years the candidemia rate was 4.5/10 000 discharges (UAH 7.6, FMC 4.9, and RAH 1.7; P < 0.05 for all interhospital comparisons). The rate remained stable between 1992 and 1995 but rose dramatically in 1996 to 7.6/10 000 (P < 0.01 compared to 1995) as a result of increases at UAH and RAH. Of the 208 species identified, Candida albicans accounted for 135 (65%). During hospitalization 93 (46%) patients died. Species did not influence outcome. Antifungal treatment with fluconazole alone was given to 14% of patients, and increased in frequency throughout the study. No antifungal therapy was given to 47 patients (23%). This group had a much higher mortality (68%) than those who received treatment (39% P < 0.01). Twenty of the untreated patients had already died by the time the blood culture had been reported as growing a yeast. Candidemia rates vary significantly between hospitals and increased in some but not all over the five study years. As many patients with candidemia will have died by the time laboratory diagnosis is made, presumptive antifungal therapy in high-risk patients may be necessary if outcome is to be improved.

Metformin in an HIV-infected patient with protease inhibitor-induced diabetic ketoacidosis

OBJECTIVE

To describe a case of diabetes mellitus and diabetic ketoacidosis in a patient receiving protease inhibitor therapy and to describe the patient's response to treatment with metformin.

CASE SUMMARY

A 49-year-old HIV-positive white man who was receiving indinavir, stavudine, and lamivudine for more than two years presented with shortness of breath and significant weight loss over the previous month. On admission, he had a pH of 7.11 and PaCO2 of 12.9 mm Hg. Laboratory investigations revealed glucose 420 mg/dL, a total carbon dioxide 5 mEq/L, and anion gap of 32. Beta-hydroxybutyrate was 5.9 mmol/L (normal value <0.4 mmol/L). Urine was highly positive for glucose and ketones. The patient was given intravenous fluids and an insulin infusion was started. Five days later, he was discharged on 60 units of insulin per day. Following discharge, efavirenz was substituted for indinavir. Metformin was added and six months following discharge the patient's blood glucose was well controlled with 36 units of insulin per day.

DISCUSSION

New-onset diabetes mellitus has been reported in HIV-infected patients receiving protease inhibitors. To date, diabetic ketoacidosis has been an infrequent acute complication. The mechanism by which protease inhibitors cause diabetes is unclear; however, studies have noted insulin resistance and increased proinsulin. Metformin increases the sensitivity of peripheral tissues to insulin and appeared to be useful in this patient. However, further clinical research is needed.

CONCLUSIONS

Monitoring glucose concentrations in HIV-positive patients receiving protease inhibitors is important to prevent the development of acute complications, including diabetic ketoacidosis. We recommend that these patients have their fasting serum glucose concentration measured at baseline, with follow-up every three months. The role of metformin and the thiazolidinedione antidiabetic agents in the management of protease inhibitor-induced diabetes requires further study.

Intensive chemotherapy and radical resections for primary nonseminomatous mediastinal germ cell tumors

BACKGROUND

Primary nonseminomatous germ cell tumors of the mediastinum (PNSGM), unlike malignancies of gonadal origin, have a poor prognosis. We report a single institutional experience over a 5-year period of PNSGM treated with intensive chemotherapy, followed by radical operation in those who responded to this neoadjuvant regimen.

METHODS

From 1993 to 1998, 20 patients were referred for the management of PNSGM. All were male, with a median age of 30.5 years (range 18 to 48). Eighteen of 20 (90%) presented with symptoms. Most tumors were large, with a median diameter of 10 cm (range 3 to 20 cm). Thirteen patients (65%) had metastatic disease at the time of presentation. Eleven patients had received no prior treatment (initial group) and 9 were referred for salvage therapy after progression of their tumors, following treatment at other facilities (salvage group). All had elevated serum tumor markers (beta hCG and alpha-fetoprotein). Preoperative chemotherapy included alternating cycles of combinations of 3 or more drugs, including cisplatin, bleomycin, etoposide, vincristine, methotrexate, actinomycin, cyclophosphamide, and doxorubicin. An average of 10 cycles of chemotherapy was given to each patient in the initial group, and six to those in the salvage group. Five patients (25%) developed transient renal insufficiency, and 35% developed pulmonary infiltrates related to bleomycin. There were 3 chemotherapy related deaths.

RESULTS

After chemotherapy, 11 patients underwent operation, with 10 complete resections of the residual mediastinal tumors. There were no perioperative deaths. The 2-year survival in the initial group is 72%, and 42% for the salvage group.

CONCLUSIONS

An aggressive, multidisciplinary approach of alternating cycles of chemotherapy, followed by complete surgical resection of all remaining disease in patients whose markers normalize, can be associated with prolonged survival in patients with PNSGM.

Effects of lead, iron, and bismuth alloy shot embedded in the breast muscles of game-farm mallards

Effects of five lead (Pb), iron (Fe), or bismuth (Bi)/tin (Sn) alloy shot embedded in the breast muscles of game-farm mallards (Anas platyrhynchos) were studied from 28 March 1994 through 27 March 1995. We detected no differences in the mean survival times, mean hematocrits, or mean body weights among the three shot types. Connective tissue encapsulated Pb and Bi/Sn shot but only slight changes occurred in tissues surrounding the shot. Recovered Pb and Bi/Sn shot were essentially unchanged in appearance and weight. A thin zone of "oxide" surrounded Fe shot with a slight inflammatory response and a small amount of scarring adjacent to the embedded shot. Fe shot decreased slightly in weight while embedded. Bacterial infections were absent in all dosed ducks. Mean weights of kidneys, livers, and gonads did not vary by type of shot. Kidneys and livers of Bi-dosed ducks had higher concentrations of Bi than in Pb- and Fe-dosed ducks. Muscle and blood showed no differences in Bi concentrations among doses. We found no histological dose-related effects in kidneys, liver, and gonads from the embedded shot.

Central venous catheters as a source of hemodialysis-related bacteremia

OBJECTIVE

To describe investigations into an increase in hemodialysis-related bacteremia that occurred in our hospital in the first 6 months of 1996.

SETTING

Hemodialysis unit in a tertiary-care medical center.

METHODS

Prospective surveillance for hemodialysis bacteremia has been performed for several years. Cases that occurred in 1995 were compared to cases in the first 6 months of 1996. Unit data on dialysis runs and method of dialysis access were used to calculate rates. Nested polymerase chain reaction (PCR) was used to type 18 Staphylococcus aureus isolates from 1996. A case-control study comparing 80 randomly selected hemodialysis patients from 1995 and 1996 was performed to examine infection risk factors.

RESULTS

The hemodialysis bacteremia rate was 1.2 per 1,000 runs in 1995 and 2.8 per 1,000 in the first 6 months of 1996 (P=.0009). The 25 cases in 1995 and 32 in the first half of 1996 were similar in age, gender, means of vascular access, and microbial etiology. Central venous catheter (CVC) access accounted for >90% of cases in both time periods. S aureus was the most common microbial etiology (53% of the 1996 cases). PCR typing of S aureus isolates from 1996 demonstrated five different strains, the most common having six isolates. The use of CVCs as a means of vascular access abruptly increased in the unit in January 1996, from <30% of dialysis runs in 1995 to >40% in 1996 (P<.001), associated with structural changes in healthcare delivery in the region resulting in delays in performing surgical procedures, such as creation of vascular grafts and fistulae.

CONCLUSION

A marked increase in hemodialysis bacteremia occurred in 1996, associated with increased reliance on CVCs for vascular access in hemodialysis patients during a period of healthcare restructuring.

Regionalization of infection prevention and control services in a publicly funded health care system

In 1994 health services in the Edmonton region were consolidated into an integrated network called Capital Health. Infection control professionals in the region met to develop a vision for the future of infection control; the tasks were to prepare a proposal for a regional program, develop indicators for outcome measurements, and standardize guidelines and products. Although regionalization of infection control is a complex process, we have had success with a proactive approach led by infection control professionals.

Bacteremic nosocomial pneumonia. A 7-year experience in one institution

STUDY OBJECT

To describe the epidemiology, microbiology, and outcome of nosocomial pneumonia with secondary bloodstream infection.

DESIGN

Prospective cohort study.

SETTING

Tertiary care Canadian teaching hospital.

PATIENTS

Inpatients.

MEASUREMENT

All inpatient blood cultures were concurrently monitored over an 89 month period. Following chart review, patients experiencing nosocomial bloodstream infection due to pneumonia were identified. A standardized definition of pneumonia was used.

RESULTS

One hundred forty-nine episodes occurred in 145 patients, 0.66/1,000 hospital admissions, 8.4% of all nosocomial bloodstream infections. No change in rate occurred in the study period. Fifty-four percent of episodes developed in one of seven ICUs. Staphylococcus aureus was the most frequently identified etiologic organism (27%). The ICU and non-ICU cases did not differ in etiology. No organism became more prevalent during the study period. Twenty percent of patients died within 1 week of first positive culture; episodes associated with Pseudomonas species had a much higher mortality rate (45%) than other infections (14%) (p = 0.002). The ICU and non-ICU infections had a similar mortality rate.

CONCLUSION

Pneumonia is an important cause of nosocomial bloodstream infection, but it is not increasing in frequency or changing in etiology in our institution. The ICUs are a major contributor to this problem but have the same case short-term mortality rate and microbial etiology as non-ICU cases. Cases associated with Pseudomonas have a much higher mortality rate.

The effect of surgical wound infection on postoperative hospital stay

OBJECTIVE

To determine the effect of surgical wound infection on postoperative duration of hospital stay.

DESIGN

A case-control study nested within a cohort.

SETTING

A tertiary-care hospital.

PATIENTS

Selected from a cohort of 4702 inpatients who underwent surgical procedures over a 12-month period. There were 3602 patients, 1100 having been excluded because of lack of infection associated with a particular surgical procedure, because of "lumping" of procedures under a nonhomogeneous heading or because a procedure was unlikely to be the reason for the patient's hospitalization.

MAIN OUTCOME MEASURE

Postoperative duration of hospital stay.

RESULTS

In the cohort 89 wound infections were identified, 73 of these occurring with procedures selected for study. Five patients were excluded from the study because of data deficiencies, leaving 68 patients who underwent 15 different procedures. These were compared with 136 control patients selected by stratified random sample from a list of patients who underwent the same risk-indexed procedure in the same surgical division. Wound infection patients and controls did not differ in anesthetic risk score or procedure duration. Patients with infection remained in hospital 19.5 days longer than controls (95% confidence interval, range from 11.0 to 27.9 days). Deep-seated infections prolonged the hospital stay more than superficial incisional infections (24.3 versus 13.2 days).

CONCLUSIONS

Surgical wound infection markedly prolonged the duration of hospitalization in the University of Alberta Hospitals, longer than that documented in previous studies in other countries. Maximizing opportunities to prevent wound infection would be beneficial to both patients and hospitals.

Computer simulation of the probability of detecting low volume carcinoma of the prostate with six random systematic core biopsies

OBJECTIVES

Six random systematic core biopsies (SRSCB) of the prostate (biopsies from apex, middle, and base of each lobe) have been commonly used in detection of prostate carcinoma. The objective of this study was to verify the validity of the SRSCB technique in detecting cancer in prostates with low-volume tumor (less than 6 cc).

METHODS

We developed a computer model of the prostate to simulate the SRSCB technique. The data for development of this model were taken from 159 radical prostatectomy specimens in which 112 patients had tumor volumes measured and in which 91 prostates had tumors with volumes less than 6 cc (by whole-mount sectioning).

RESULTS

The simulation shows that only 20.3% of the simulated prostates, with total aggregate tumor volume between 0.034 and 5.1 cc, had a tumor distribution for which the SRSCB technique has a 95% probability of detecting the tumor. In fact, 26.8% had a tumor distribution that was completely disjointed from the six recommended biopsy regions. To compare these results with other possible occurrence, various biases for the angle of biopsy and the distribution of cancer foci were incorporated into the model. Study results should be viewed with the understanding that any simulated model has its limitations. In our simulated model, the shape of the simulated tumor foci (spherical) does not represent all the possible shapes of prostate cancer. However, these results indicate that detection of cancer with biopsies taken from the apex, middle, and base of each lobe of a prostate with tumor volumes of less than 6 cc may not be as effective as it is in prostates with larger tumor volumes or patients with an abnormal digital rectal examination. The study of bias models suggests that the distributional pattern of cancerous foci can have a significant impact on the effectiveness of a given biopsy strategy.

CONCLUSIONS

We concluded that future attempts to improve systematic biopsy strategies for detection of low-volume cancer should include biomechanical characteristics of prostate cancer, including gland volume and tumor distribution. Driven by the conclusions from this idealized model, we have developed a three-dimensional model of the prostate gland from its whole-mount histologic maps. It is anticipated that this continuing investigation will lead to realistic guidelines for improving biopsy techniques.

Disseminated Mycobacterium genavense infection in Canadian AIDS patients

Mycobacterium genavense is a recently described mycobacterial species which thus far has been identified only in persons with advanced HIV disease. It appears to be a rare pathogen with an undefined reservoir. We describe the first two cases of M. genavense infection in Canadian AIDS patients. The clinical presentation of fever and wasting with extremely low CD4 lymphocyte counts was indistinguishable from disseminated M. avium complex (MAC) infection. However, blood cultures in BACTEC 13A medium required a mean of 58 days (range 41-87) to detect growth of M. genavense in contrast to a mean of 10 days for MAC in our laboratory. M. genavense infection is underdiagnosed due to the lack of universal use of BACTEC liquid medium and the use of relatively short incubation times (only 6 weeks) by some laboratories. The value of antimycobacterial therapy for M. genavense is unknown, but anecdotal data suggest that treatment with a regimen appropriate for MAC may be beneficial.

A 3-D reconstruction algorithm for interpolation and extrapolation of planar cross sectional data

A three dimensional (3-D) reconstruction algorithm utilizing both linear interpolation and linear extrapolation was developed for the study of human prostatic cancer. The algorithm was validated by comparing the volumes and shapes of original to reconstructed objects. Synthetic objects of known geometry and wax models with shapes characteristic of prostatic carcinomas were assessed with standard planimetry and by the digital interpolation-extrapolation method. Volume and multifocality measurements obtained by reconstructing excised prostate glands using histologic maps obtained from whole-mount sections were tested. The new algorithm provided greater accuracy in determining tumor volumes than conventional methods. This model provides a basis for mathematical analysis of prostate cancer lesions.

Wound infection in total joint arthroplasty: effect of extended wound surveillance on wound infection rates

OBJECTIVE

To determine the effects of a wound monitoring program on infection rates after total joint arthroplasty.

DESIGN

Case series, comparing postoperative wound infection rates before and after hospital discharge.

SETTING

A university-affiliated tertiary-care hospital.

PATIENTS

A group of 865 patients who underwent primary or revision total hip or knee arthroplasty between September 1989 and September 1991 followed by in-hospital and post-discharge wound monitoring was compared with a baseline group of 204 patients who had undergone an arthroplasty procedure and in-hospital wound monitoring between March and September 1988; only 38 of these patients were selected for post-discharge monitoring.

INTERVENTIONS

In the study group, wounds were monitored every 48 to 72 hours to the time of patient discharge and at 30 days post-discharge. Monthly reports of surgeon-specific and overall infection rates were sent to each surgeon during both baseline and study periods.

MAIN OUTCOME MEASURES

Presence or absence of surgical wound infection.

RESULTS

The initial overall wound infection rate was 9.9%. This decreased to 3.8% in the study group, after the wound monitoring program had been in place for at least 18 months. Post-discharge monitoring accounted for the majority of wound infections diagnosed.

CONCLUSIONS

A wound monitoring program may be an important tool in lowering wound infection rates associated with total joint arthroplasty. Post-discharge monitoring is important in determining true wound infection rates.

Trends and sources of nosocomial fungaemia

Concurrent surveillance of blood culture isolates in a 1000-bed tertiary care hospital over a 7-year period from 1986 to 1993 identified 102 episodes of nosocomial fungaemia, representing 6.6% of all episodes of nosocomial bloodstream infections and 0.49/1000 admissions. No significant change in the frequency, rate, source or microbial aetiology of nosocomial fungaemia occurred over the 7-year period. Candida albicans accounted for 74%, followed by Candida (Torulopsis) glabrata (8%), C. parapsilosis (7%), C. tropicalis (3%), C. lusitaniae (2%), C. krusei, Malassezia furfur Saccharomyces cerevisiae, Hansenula anomala and Cryptococcus albidus (one each). 'Primary' fungaemia, usually attributed to intravascular catheters, was considered to be the source in 65% of cases, with 64% of these patients receiving total parenteral nutrition (TPN). Other important sources of infection included the urinary tract (11%), the gastrointestinal tract (8%) and the respiratory tract (7%). Sixty-four % of patients were in one of the hospital's seven intensive care units (ICUs) when their infection developed, the neonatal ICU and adult medical/surgical ICU each accounting for 21%. Only 7% of cases were associated with neutropenia and another 14% with malignancy or immunosuppression. Death occurred within 7 days of diagnosis of fungaemia in 23 cases. In eight instances, fungaemia was considered the main cause of death. We conclude that in our hospital nosocomial fungaemia is largely caused by C. albicans, occurring in association with intravascular catheter use and TPN in ICU patients. Most cases are not associated with recognized immune defence defects. Fungaemia is associated with a high short-term mortality rate.

Rat microglial interleukin-3

Interleukin-3 (IL-3, multi-CSF) is a growth factor for a variety of hematopoietic progenitor cells. Recently, microglial cells, the resident macrophages of the central nervous system (CNS) have been shown to proliferate in the presence of IL-3 both in vivo and in culture. Data obtained from cultured astrocytes gave rise to the hypothesis that astrocytes synthesize the microglial growth factor. This is the first report identifying rat microglial cells themselves as a source of IL-3. Culture media conditioned by isolated microglia enhanced microglial proliferation above fresh media controls. IL-3 polypeptide was detected in both conditioned media (CM) and in microglial cells by Western blotting and immunoprecipitation. Furthermore, anti-IL-3 antibodies were able to inhibit microglial proliferation induced by conditioned media. mRNAIL-3 was present in single microglial cells as revealed by in situ hybridization. Total RNA prepared from purified microglia yielded a single PCR amplification product. Identity of the PCR product was confirmed by Southern blot hybridization using a cDNAIL-3 probe and by DNA sequencing. Expression of mRNAIL-3 was observed in both absence and presence of lipopolysaccharide, a bacterial endotoxin, that commonly induces expression of inflammatory cytokines and inhibits microglial proliferation. It is concluded that IL-3 expression in ensuring the recruitment of enhanced numbers of immunocompetent cells at sites of lesion. In the light of weak immune reactions in the brain, it is hypothesized that the expression of a characteristic T cell feature in monocyte-derived microglia may be a partial compensation of T cell functions in brain lesions.

Bacteremia due to transplantation of contaminated cryopreserved pancreatic islets

OBJECTIVE

To report two cases of pancreatic islet transplantation-related septicemia, and the results of an investigative protocol to identify potential sources of contamination.

DESIGN

Case series.

SETTING

University hospital clinical investigational islet transplantation program.

RESULTS

The last two of our first seven islet transplantation recipients developed Enterobacter cloacae septicemia within hours of islet infusion. Both had received thawed cryopreserved islet infusions. No source of infection apart from islets could be identified. Pancreas harvesting and islet isolation protocols provided multiple opportunities for contamination. Environmental cultures during a mock islet isolation procedure failed to identify a source of Enterobacter. Previously cryopreserved islet lots were thawed and submitted for culture, 14/47 grew micro-organisms including E. cloacae in four instances. Following revision of protocols for aseptic handling of islets during processing and cryopreservation 55 consecutive pancreata undergoing processing were evaluated; 7 grew micro-organisms on arrival and in 3 cases these persisted through to cryopreservation.

CONCLUSION

Two of seven islet transplantation recipients developed septicemia, likely related to infusion of contaminated cryopreserved islets. Using existing technology, for isolating islets from donor pancreata, recipients will remain at risk for this complication. Prevention should entail strict adherence to aseptic technique, and, possibly, use of surveillance microbial cultures during the islet isolation process.

PI-specific phospholipase C "alpha" from sheep seminal vesicles is a proteolytic fragment of PI-PLC delta

Phosphatidylinositide-specific phospholipase C enzymes (PLCs) catalyze the conversion of the phosphoinositides to biologically important signal transducing molecules. These enzymes may be grouped into "families" which share similar structures and modes of regulation. The existence of a structurally distinct family of PLC termed "alpha" has been recently called into question. In the current paper we show by immunoblotting experiments that PLC "alpha" from sheep seminal vesicles is recognized by monoclonal antibodies raised against the delta 1 isoform of bovine brain PLC, and appears to be derived from a higher molecular weight band at 85 kDa. We also show that antibodies raised against PLC alpha efficiently immunoprecipitate the 85-kDa PLC delta 1 isoform from bovine brain and Chinese hamster lung fibroblasts. These data provide strong evidence that the PLC alpha from sheep seminal vesicles is a proteolytic fragment of PLC delta 1. Thus, there is still no conclusive evidence for a separate "alpha" class of PLC.

Predominance of staphylococcal organisms in infections occurring in a burns intensive care unit

To assess the sites, incidence, and bacteriology of infections in intensive care burn patients, a prospective survey of all admissions to a tertiary care institution burn unit was carried out over a 12-month period. One hundred and sixteen patients were admitted, 106 with a diagnosis of thermal burns. Forty patients developed 90 infections. Only two deaths occurred, one in a patient with sepsis. In order of frequency, pneumonia, burn infection, UTI and primary bacteraemia were most common. Staphylococcal species accounted for a majority of infections at all body sites except UTI (47 per cent of all infections, including 11 of 14 bacteraemic infections). Staph. aureus sepsis was more common in those carrying the organism on admission. Strain typing of paired admission and subsequent clinical isolates in 19 patients with Staph. aureus sepsis indicated that eight (42 per cent) became infected with a strain they carried on admission. Further reductions in septic complications of burns in our center would be best directed at staphylococcal species, particularly Staph. aureus. Both eradication of carrier state, and prevention of acquisition of Staph. aureus strains could be explored.

Intravenous vancomycin usage in a tertiary care hospital

Intravenous vancomycin usage at our institution was examined by a five-month retrospective chart review. Cardiovascular surgery, neurosurgery, and intensive care units accounted for the most use. Sixty courses in 48 patients were reviewed; 42 percent was considered inappropriate, which extrapolated to an annual drug acquisition cost of $51,338. Inappropriate use was categorized as mainly due to documented infection with a beta-lactam sensitive organism in a patient with no history of an allergy (40 percent of inappropriate use) and excessive duration of empiric therapy (28 percent of inappropriate use). Concurrent monitoring by pharmacy staff was felt to be the approach most likely to be effective in modifying this problem.

Rhinofacial zygomycosis caused by Conidiobolus coronatus: a case report including in vitro sensitivity to antimycotic agents

A case of zygomycosis caused by Conidiobolus coronatus, occurring in a 31-year-old priest from the Ivory Coast, is reported. Lesions eventually resolved after 2 1/2 years, during which the patient was variously treated with intravenous amphotericin B and miconazole as well as surgical resection. It is difficult to be certain which, if any, of these treatments contributed to resolution of lesions. A report of in vitro sensitivity data to a variety of antifungal agents is included.

Disseminated histoplasmosis in a nonendemic area

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Axillary skin excision for the treatment of axillary hyperhidrosis

In fourteen patients with axillary hyperhidrosis, good control of sweating has been achieved by resection of a longitudinal ellipse of axillary skin and Z-plasty closure. Axillary scarring has been extensive, but inconspicuous.