Faculty Bibliography

Background. Healthcare personnel's (HCP) gloves and gowns are frequently contaminated with antibiotic-resistant bacteria in the intensive care unit (ICU). Guidelines recommend contact precautions for patients with methicillin-resistant Staphylococcus aureus (MRSA); however, this approach remains controversial. This study aimed to identify which patients are more likely to transfer MRSA to HCP gloves or gowns and to identify HCP interactions more likely to lead to glove or gown contamination. Methods. In a multicenter cohort study of MRSA colonized patients, we observed HCP-patient interactions and cultured HCP's gloves and gowns before doffing. We also assessed the association between bacterial burden and contamination by sampling patients' anterior nares, perianal area, chest, and arm. Results. We enrolled 402 MRSA-colonized patients and observed 3,982 HCP interactions. MRSA contamination of HCP gloves and gown occurred in 14.3% and 5.9% of interactions, respectively. Contamination of either gloves or gown occurred in 16.2% of interactions. Occupational/physical therapists had the highest rates of contamination (OR: 6.96 [95% CI: 3.51-13.79]), followed by respiratory therapists (OR: 5.34 [95% CI: 3.04- 9.39]) when compared with the "Other" category. Touching the patient was associated with higher contamination (OR: 2.59 [95% CI: 1.04-6.51]) when compared with touching nothing in the room. Touching only the environment was not associated with glove or gown contamination (OR: 1.13 [95% CI: 0.43, 3.00]) when compared with touching nothing. Touching the endotracheal tube (OR: 1.75 [95% CI: 1.38-2.19]), bedding (OR: 1.43 [95% CI: 1.20-1.70]) and bathing a patient (OR: 1.32 [95% CI: 1.01-1.75]) increased odds of contamination when compared with not having such contacts (Figures 1 and 2). We found an association between increasing bacterial burden in the patient's nares, perianal area, and chest skin and glove or gown contamination. Conclusion. Contamination of HCP gloves and gowns with MRSA occurs frequently when caring for ICU patients. We identified interactions that are high-risk for transmission. Hospitals may consider optimizing contact precautions by using less precautions for low-risk interactions and more precautions for high-risk interactions. (Figure Presented)

Black women have a lower incidence of vertebral and hip fractures than white women, possibly due to differences in skeletal and mineral metabolism. One suggested mechanism is that blacks have decreased skeletal sensitivity to parathyroid hormone (PTH). To test this hypothesis, we infused h(1-34)PTH in healthy premenopausal black (n = 15) and white (n = 18) women over 24 h and measured serum and urine indices of bone turnover and calcium metabolism throughout the infusion. At baseline, the mean 25-hydroxyvitamin D (25(OH)D) concentration was significantly lower in black women (46%). There were also nearly significant trends toward higher PTH and lower urinary calcium and pyridinoline levels in black women. During infusion, there were no racial differences in the mean (1-34)PTH levels achieved or in resultant elevations of serum calcium or 1,25-dihydroxyvitamin D (1,25(OH)2D) levels. Endogenous parathyroid suppression (measured by (1-84)PTH levels) was also similar between blacks and whites. There was an initial decline in urinary calcium/creatinine in both groups with a greater reduction in black women early in the infusion period (p < 0.05 at 8 h). Furthermore, blacks had lower levels of urinary calcium/creatinine throughout the infusion (p < 0.05 group difference). Bone formation markers (carboxy-terminal propeptide of type I procollagen and osteocalcin) decreased within 8 h and continued to decline throughout the infusion with no distinguishable racial differences (p < 0.05 time trend for both). The most dramatic difference between black and white women in response to PTH infusion was represented by the bone resorption markers. Three separate metabolites of bone resorption (cross-linked N-telopeptide of type I collagen, cross-linked C-telopeptide of type I collagen, and free pyridinoline) all showed substantially greater elevations in white (mean peak increments 399, 725, and 43%) compared with black women (mean peak increments 317, 369, and 17%) during the infusion (p < 0.05 group differences for all three variables). These data strongly suggest that blacks have decreased skeletal sensitivity to the acute resorptive effects of increased PTH. This finding indicates that calcium homeostasis may be accomplished in blacks (during times of relative calcium deficiency) by greater conservation of calcium from nonskeletal sources (most likely renal) with relative preservation of skeletal tissue. These differences in calcium economy could account, at least in part, for the increased bone mass and lower incidence of osteoporotic fractures in black women.

While noninvasive studies of bone mass and turnover in blacks and whites abound, histologic evaluations are very rare. We have performed a comparative bone histomorphometric study of iliac biopsies from 55 healthy, premenopausal women including 21 blacks (mean age 33.4 + 1.2 years) and 34 whites (mean age 32.5 + 0.8 years) of comparable age, weight, body composition, education, and lifestyle. Biochemical indices of mineral metabolism: parathyroid hormone, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, serum ionized calcium, serum phosphorus, and urinary calcium/creatinine were measured in the fasting state. Blacks had lower 25-hydroxyvitamin D (315 +/- 3.36 vs. 63.21 +/- 3.79 nmol/l, p = 0.0001). Histomorphometric indices of bone volume, structure, and connectivity were not different between groups. The following indices of bone remodeling were also similar in both groups: eroded perimeter, osteoid width, mineralizing perimeter, tissue-based bone formation rate, osteoid maturation time, active formation period, and activation frequency. However, osteoid perimeter (black [B] = 15.85 +/- 1.30 vs. white [W] = 9.49 +/- 0.70%, p = 0.0002), osteoid area (B = 2.55 +/- 0.32 vs. W = 1.39 +/- 0.12%, p = 0.003), single-labeled perimeter (B = 5.46 +/- 0.54 vs. W = 4.04 +/- 0.33%, p = 0.03), mineralization lag time (B = 38.18 +/- 4.04 vs. W = 21.83 +/- 1.60 days, p < 0.009), and total formation period (B = 148.15 +/- 19.70 vs. W = 84.04 +/- 7.62 days, p = 0.0056) were higher in blacks than in whites. The quiescent perimeter (B = 76.91 +/- 1.40 vs. W = 84.25 +/- 0.91%, p = 0.0001), mineral apposition rate (B = 0.70 +/- 0.02 vs. W = 0.75 +/- 0.02 micron/day, p = 0.066), mineralizing osteoid perimeter (B = 0.49 +/- 0.04 vs. W = 0.75 +/- 0.04%, p = 0.0001) and adjusted apposition rate (B = 0.35 +/- 0.04 vs. W = 0.58 +/- 0.04 micron3/micron2/day, p = 0.0001) were all lower in blacks than in whites. These results indicate that there are no differences in bone volume, microstructure, or turnover between black and white premenopausal women. However, there are significant differences in the mechanism of bone formation between the two groups, with a lower rate of mineralized matrix apposition within each remodeling unit and a longer total formation period in blacks than in whites. The differences appear to the result of more frequent and/or longer inactive periods in the life span of the bone formation units in blacks. These differences may allow a greater overall deposition of bone mineral in black women and therefore help explain a higher bone mass and perhaps better bone quality in black than white women.

BACKGROUND: Neisseria gonorrhoeae is one of the most common organisms associated with pelvic disease in a woman of reproductive age. CASE: We present an unusual case of cerebrospinal fluid infection with N. gonorrhoeae in a woman with a ventriculoperitoneal shunt who complained of abdominal pain. Her shunt was removed and after adequate antibiotic therapy, it was re-inserted. CONCLUSION: Sexually active women, especially those with ventriculoperitoneal shunts, should be encouraged to use a barrier method of contraception, and should have a pelvic examination as part of their evaluation when they present with complaints of abdominal pain.

Objective: To determine the effects of elevated endogenous E-2 levels on in vitro platelet function in patients undergoing controlled ovarian hyperstimulation (COH). Design: Women with normal ovulatory cycles and patients undergoing COH on cycle day 3 and near ovulation (preovulatory follicles were at least 16 mm in diameter) were studied. Serum E-2, Thrombostat 4000, (V. d. Goltz, Seeon, Germany), von Willebrand factor antigen (vWF-Ag), and platelet aggregation and adenosine triphosphate (ATP) release to adenosine diphosphate (ADP), collagen (COL), and arachidonic acid (AA) were measured. Setting: University-based outpatient infertility clinic. Patient(s): Twenty-two consenting infertile women undergoing COH cycles and 14 women with documented ovulatory cycles. Main Outcome Measure(s): Whole blood platelet aggregation with ADP, COL, AA, and Thrombostat 4000. Result(s): Estradiol levels rose significantly at peak times (P = 0.011). No changes were noted in in vitro platelet function measured by the Thrombostat 4000 and by whole blood platelet aggregation with ADP and AA and in ATP release with ADP, COL, or AA. Aggregation with collagen was increased because of likely elevations in vWF-Ag levels. Conclusion(s): No significant changes in in vitro platelet function were noted in 19 women undergoing COH with E-2 levels two to three times that observed in oral contraceptive or hormone replacement therapy users, suggesting no increased risk for arterial thromboembolism. (C) 1997 by American Society for Reproductive Medicine.