Faculty Bibliography

Background: Several molecular methods potentially useful in the detection of Mycobacterium tuberculosis mutations, specifically in rpoB and katG, were compared. Methods and Results: DNA from 24 M. tuberculosis clinical isolates, with mutations associated with resistance to rifampin and/or isoniazid, was analyzed. A 128 bp amplicon, spanning the 81 bp rpoB region containing most mutations leading to rifampin resistance, was analyzed by polymerase chain reaction-single-strand conformation polymorphism (PCR-SSCP) and a recently introduced mutation scanning method, cleavase fragment length polymorphism (CFLP) analysis. Also, a 350 bp amplicon encompassing that region was analyzed by the CFLP method. CFLP analysis of the 350 bp amplicon (23 isolates) identified 14 of 17 mutants; however, CFLP analysis of the 128 bp amplicon accurately identified all mutants as did PCR-SSCP with interpretative difficulty for two codon 513 mutations. CFLP and PCR-restriction fragment length polymorphism (RFLP) analyses of a 623 bp amplicon encompassing katG codons 315 and 463 showed that the CFLP method identified single and dinucleotide codon 315 substitutions with or without codon 463 (CGG-->CTG) changes, whereas PCR-RFLP (MspI) missed one codon 315 polymorphism (AGC-->ACA) in three isolates. Conclusion: Both PCR-SSCP and CFLP analyses were sensitive in identifying all mutations on short sequences in the rpoB mutants. CFLP appears to be more efficient than SSCP and RFLP for the detection of mutations in large amplicons

During an 18-month period in a burn center (January 1995 through June 1996), 109 single-patient MRSA isolates were identified and 102 isolates (94%) were available for DNA fingerprinting. Ninety-nine isolates (97%) carried the mecA polymorph I and Tn554 type E. Pulsed-field electrophoresis (PFGE) identified 8 patterns, of which 60 isolates were of pattern F2. The I:E:F clonal type and a stable drug multidrug resistant phenotype (sensitivity only to trimethoprim/sulfamethoxazole and vancomycin) indicated that these isolates were closely related to the Iberian clone of MRSA, which is widely spread in Europe. The initial source of I:E:F isolates was sputum 49%, blood 23%, wound 16%, urine 7%, and intravascular catheter tip 5%. Fifty-four percent of patients had smoke inhalation injury, and 51/53 required intubation or tracheostomy. Forty-three isolates were considered invasive (positive blood culture). The overall mortality was 30%. Despite infection control measures, the I:E:F clone continued to be recovered from patients during the 18 months of study. This outbreak is the first known report of the Iberian MRSA clone in the United States

BACKGROUND: Intravascular ultrasound (IVUS) imaging parameters have been suggested as criteria to determine coronary lesion significance before intervention. However, there has not been a systematic examination of combined anatomic and physiologic data in the same patients with coronary artery disease. METHODS AND RESULTS: To examine the relation between coronary flow reserve and IVUS parameters, 41 patients with intermediately severe coronary artery stenoses had measurements of coronary flow velocity (0.014-inch Doppler flow wire), coronary flow velocity reserve (CVR) (hyperemic/basal mean flow), IVUS imaging (2.9F, Cardiovascular Imaging Systems, Inc.), and quantitative coronary angiography before intervention. Correlations between physiologic and anatomic parameters were performed by simple regression. Results were also examined by patient subgroups with CVR > 1.8 or < 1.8 to assess differences in IVUS parameters. The angiographic percent diameter stenosis was 52% +/- 17% (range 18% to 95%). Mean CVR was 1.88 +/- 0.56 (range 0.9 to 3.18). IVUS minimal luminal diameter (r = 0.312, p = 0.047) and angiographic percent stenosis (r = 3.05, p = 0.052) were weakly related to poststenotic CVR. Comparing patients with CVR < 1.8, IVUS reference segment area, IVUS lumen area, and angiographic percent diameter stenosis was higher (17.7 +/- 0.3 vs 12.9 +/- 4.4 mm2, p < 0.05; 6.20 +/- 3.76 vs 4.34 +/- 2.00 mm2, p < 0.05; and 60% +/- 14% vs 46% +/- 17%, p < 0.01, respectively) than in the group with CVR > 1.8. CONCLUSIONS: Despite a precise determination of cross-sectional vessel areas and absolute dimensions by IVUS, single tomographic measurements did not correlate well with coronary physiologic responses. These data suggest that the physiologic data may be complementary to anatomic quantitative IVUS, enhancing information for coronary interventional decision making

PURPOSE: To determine the communication difficulties experienced by clinicians in cancer medicine and to develop, implement, and evaluate communication skills training courses. METHODS: One hundred seventy-eight senior clinicians attended 1 1/2- or 3-day residential courses designed to enhance skills development, knowledge acquisition, and personal awareness. Course content included structured feedback, video review of interviews, interactive group demonstrations, and discussion in groups of four led by trained facilitators. The main outcomes were self-rated confidence in key aspects of communication, attitudinal shift toward more patient-centered interviewing, perceived changes in personal practice, and initiation of teaching programs for junior staff. RESULTS: Less than 35% of the participants had received any previous communications training. Time, experience, and seniority had not improved skills; before the course, oncologists expressed difficulty with 998 different communication issues. Primary problems concerned giving complex information, obtaining informed consent, and handling ethnic and cultural differences. Confidence ratings for key communication areas were significantly improved postcourse (P .01). Three months postcourse, 95% of the physicians reported significant changes in their practice of medicine. Seventy-five percent had started new teaching initiatives in communication for junior clinicians. Clinicians showed positive shifts in attitude toward patients' psychosocial needs (P=.0002) and were more patient centered (P=.03). The courses were highly rated and 97% would 'definitely' recommend them to colleagues. CONCLUSION: Oncologists are hampered by inadequate communication skills training and will give up time to correct this. Subjective improvements reported immediately postcourse were maintained at 3 months. Resources for educational initiatives are needed to help both patients and their physicians

BACKGROUND: Porphyria cutanea tarda is known to be associated with HIV infection and hepatitis C virus (HCV). OBJECTIVE: Our purpose was to evaluate whether early infection with HIV, with or without HCV infection, is associated with elevated serum porphyrin levels. METHODS: Serum porphyrin levels were measured in samples obtained from 103 patients with early HIV infection. The results were compared with those of 89 late-stage HIV-positive patients and 78 HIV-negative patients. RESULTS: The highest median porphyrin level was in early-stage HIV-positive/HCV-positive samples, followed in decreasing order by those in early-stage HIV-positive/HCV-negative, late-stage HIV-positive/HCV-positive, late-stage HIV-positive/HCV-negative, HIV-negative/HCV-positive, and HIV-negative/HCV-negative groups. Elevated porphyrin levels were independently associated with early-stage HIV infection (P < .0001) and HCV infection (P = .03). CONCLUSION: This finding suggests abnormal porphyrin metabolism is most noticeable in early-stage HIV infection; it becomes less severe with the progression of HIV disease