We report four cases of varicella-zoster virus (VZV)-associated myelopathy in adults. Myelopathy was remitting-exacerbating in two remarkable instances, once acute and once chronic. VZV myelopathy was diagnosed based on the close temporal relationship between rash and onset of myelopathy, and for the first time, by polymerase chain reaction, which revealed VZV DNA in the cerebral spinal fluid of three patients with pleocytosis weeks to months later. Magnetic resonance imaging was abnormal in three of four patients. Although all four patients were treated at some time with intravenous acyclovir, concomitant treatment with steroids and the presence of acquired immunodeficiency syndrome in one patient prevented conclusions about a favorable response to therapy. Myelopathy after VZV infection may be remitting-exacerbating in addition to acute or chronic. Detection of VZV DNA in cerebral spinal fluid months after rash was useful for diagnosis and suggests a role for virus in the pathogenesis of myelopathy.
For over two decades, intraperitoneal administration of vancomycin and an aminoglycoside has been an accepted regimen for the empiric treatment of peritonitis in the peritoneal dialysis patient, until definite identification of the organism has been made. The recent emergence of vancomycin-resistant organisms has been of great concern in many centers. The current treatment recommendation therefore is to use cefazolin in place of vancomycin. We analyzed peritonitis data from January 1, 1996 to June 30, 1997, prior to switching over to cefazolin. Seventy-five percent (27 episodes) in 1997 as compared to 78% in 1996 were due to gram-positive organisms. Twenty-two percent (8 episodes) were due to gram- negative organisms in 1997, 21% in 1996, and 3% (1 episode) due to yeast in 1997, 3% in 1996. Staphylococcus epidermidis (SE) caused 33% of the gram-positive peritonitis episodes in 1997 as compared to 37% in 1996. Twenty-two percent of the gram-positive episodes were due to Staphylococcus aureus (SA) in 1997 and 46% in 1996. Enterococcal infections were 26% in 1997 and 1% in 1996. All of these were confined to only 1 patient. The antibiogram revealed 100% sensitivity of both SA and SE to vancomycin and 100% sensitivity of SA to cefazolin, but only 11% sensitivity of SE to cefazolin. The same patient population had a 48% sensitivity of SE to cefazolin in 1996, showing a sudden and substantial increase in resistance to SE. Even though SE is thought to be a less virulent organism, treating patients with a high probability of being infected by SE with an antibiotic showing 89% resistance is not warranted.
To evaluate the practice of consultations in the community hospital, chart reviews and consultant/surgeon interviews were conducted for 85 consecutive medical preoperative consultations for patients discharged from the Surgical Service. In 78 cases (92%) the authors agreed with the need or reason for the preoperative consultation; the majority were required for the management of chronic medical problems. Continuity of care was considered important by surgeons and consultants. Verbal communication was common, particularly from surgeon to consultant. Brief response time, specific recommendations, focused evaluations, and physician satisfaction with the existing system were the rule. However, 23 preoperative consultations (27%) were judged to be deficient. Compliance with recommendations was high (95%) but other measures of consultation effect were low.
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