Faculty Bibliography

There is a high prevalence of bacterial infections in long term care facilities (4.4 to 16.2%). This, together with the fact that antimicrobial resistance is a big concern in current medical practice, makes infection control so important in nursing home care. This article covers the mechanisms of antibacterial resistance and focuses on 4 major antibacterial-resistant bacteria. Vancomycin is the treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA). Colonisation with MRSA is not uncommon in nursing homes and eradication is probably not necessary. Any clinically important enterococcal infection should be tested for high-level resistance. An infectious disease consultation should be sought for vancomycin-resistant enterococcal infections. Gram-negative bacilli have developed multi-resistance. Susceptibility testing can identify the most appropriate therapy. Multiresistance should also be considered when treating Streptococcus pneumoniae. Overall, handwashing is highly recommended. Barrier precautions, minimising hospitalisations and avoiding unnecessary personnel rotation can reduce the chance of resistance spread.

Repeatedly noncompliant tuberculosis patients (who are often homeless or substance users) are once again being forcibly detained. Health officials intend that confinement be used only when "less restrictive alternatives" have failed. Past programs of detention can inform current efforts. In 1949, Seattle's Firland Sanatorium established a locked ward. Although initially intended only for active public health threats, the ward was eventually used to maintain order among Firland's alcoholic patients. That is, the staff detained alcoholics--regardless of their infectivity or compliance with medications--for breaking sanatorium rules. In this manner, maintaining institutional order became a legitimate reason for invoking public health powers. Although new detention regulations strive to protect patients' civil liberties, attention must also be paid to the day-to-day implementation of coercive measures. When public health language is used to justify administrative or institutional requirements, disadvantaged patients may be stigmatized.

The increasing emphasis in medicine on treating the whole patient has focused attention of the association between emotions and disease. However, physicians have long studied the connection between mind and body. One particularly interesting researcher in this area was Thomas Holmes, a charismatic and iconoclastic Seattle physician who studied the association between stress and tuberculosis in the 1950s. Although lacking the sophistication of modern biostatistics, several of Holmes' studies suggested that persons who had experienced stressful situations, such as divorce, death of a spouse, or loss of a job, were more likely to develop tuberculosis and less likely to recover from it. Holmes consciously used the same scientific methods as his peers, devising a numeric scale that quantified stressful events and doing prospective studies with control groups. Yet, he also emphasized the need to understand each patient's story and to view his or her tuberculosis as the culmination of a life of emotional hardship. Although Holmes' work was rudimentary, his basic supposition may have been correct. Recent research, benefiting from advances in both immunology and biostatistics, suggests that stress may lead to decreased immune function and thus to clinical disease. As studies of stress and disease become more statistically sophisticated, it will be important to retain Holmes' emphasis on understanding the lives of individual patients.

We have detected new clues to the composition and function of 'Transfer Factor' using the direct Leucocyte Migration Inhibition (LMI) test as an in vitro assay of Dialysates of Leucocyte Extracts (DLE). This approach has revealed two opposing antigen-specific activities to be present in the same > 3500 < 12,000 DA dialysis fraction - one activity is possessed of Inducer/Helper function (Inducer Factor). The opposing activity is possessed of Suppressor function (Suppressor Factor). When non-immune leucocyte populations are cultured with Inducer Factor they acquire the capacity to respond to specific antigen and inhibition of migration occurs. This conversion to reactivity is antigen-specific and dose-dependent. When immune leucocyte populations are cultured with Suppressor Factor their response to specific antigen is blocked and Inhibition of Migration is prevented

The case of a 35-year-old woman who reported to Siegel with abnormal and sometimes missing periods is recounted. The diagnosis was premature menopause