HIV/AIDS News & Information

Benzalkonium chloride (ВС) is an unreliable disinfectant. A matched case-control study and environmental investigation were conducted to determine the cause of and risk factors for a cluster of postinjection abscesses at a private medical clinic where ВС was used as a disinfectant. Twenty-eight case-patients who had an abscess at the injection site were matched with 126 control patients who had received an intramuscular injection at the clinic on the same day. Risk factors for abscess development in a multivariable logistic model were corticosteroid injection and being female. All case-patients had received a corticosteroid injection from a multidose vial. Cultures of abscesses from 20 of 23 case-patients grew Pseudomonas aeruginosa. Cultures of ВС prepared at the clinic also grew Paeruginosa, suggesting that ВС was the source of infection. Injection site cleaning with ВС did not appear to be the route of infection since use of ВС at the time of injection was not associated with abscess development. A more likely route of infection was injection of contaminated corticosteroid from multidose vials that could have been inoculated with pseudomonads via needle puncture after vial septa were wiped with contaminated ВС. Benzalkonium chloride should not be used to clean injection vial septa or injection sites.

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Results
We mailed 1,030 questionnaires and received responses from 710 (70%) of 1,009 eligible subjects. We excluded 21 subjects who moved without leaving a forwarding address, died, or were no longer in practice. Respondents were predominantly white males with busy practices (Table 2). Respondents had experience with managed care, fee-for-service reimbursement (Table 3), capitation, utilization review, preauthorization by telephone, HMO review, and review by a committee of colleagues. Groups of physicians randomized to receive different versions of the questionnaire did not differ significantly in characteristics.

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In managed care, financial incentives and utilization review create conflicts of interest for physicians. We sought to determine whether these incentives would lead physicians to deny indicated services. We surveyed internists practicing in areas with at least 30% penetration of managed care. Our questionnaire included four scenarios in which a test or referral is indicated according to clearly established practice guidelines. We randomly assigned physicians to receive one of five versions of the questionnaire, which differed only in the type of reimbursement incentive and utilization review that applied to the scenarios. We received responses from 710 (70%) of 1,009 internists. Although physicians underutilized services regardless of incentives in all scenarios, physicians whose questionnaires depicted full capitation said that they would order fewer services than physicians whose questionnaires depicted fee-for-service. In the scenario in which an x-ray of the lumbosacral spine is indicated for a patient with low back pain, 86% of physicians randomized to the full capitation version said that they would order the test compared to 94% in the fee-for-service version. Similarly, physicians randomized to scenarios requiring utilization review said that they would order fewer services than those randomized to scenarios requiring completion of an insurance form. Scenarios depicting managed care incentives caused consistent, modest underutilization compared to fee-for-service scenarioes, although physicians underutilized services under all financial incentives and utilization review. In response, physicians must develop better methods for detecting underutilization and devise programs to increase the provision of indicated services.

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Parathyroid Cyst: An Uncommon Cause of a Palpable Neck Mass and Hypercalcemia

PARATHYROID CYSTS ARE rare lesions arising in the neck and anterior mediastinum. Goris reported the first case in 1905, and since then, fewer than 250 cases have been published in the literature. Parathyroid cysts constitute only 0.6% of all thyroid and parathyroid lesions, but should be considered in the differential diagnosis of anterior neck masses, particularly in the presence of hypercalcemia.

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KETOACIDOSIS is A RARE complication of diabetic pregnancies. It occurred at a rate of 1.73% in a recent series of pregnancies with preexisting, insulin-dependent diabetes. Ketoacidosis is an extremely rare complication of gestational diabetes, as well. In addition, ketoacidosis has been reported in two patients with previously undiagnosed diabetes. We report a case of early diabetic ketoacidosis involving a patient who had had a normal glucose tolerance test (GTT) only 10 days before presentation. generic actos

Case Report
A previously healthy, 23-year-old, gravida II, para I, Asian woman arrived at the obstetrical service in her 36th-week of pregancy, complaining of contractions every three minutes and decreased fetal movement. The patient also admitted to polyuria and polydipsia. She denied nausea, vomiting, fever and chills. She had no signs or symptoms of genitourinary, respiratory, or gastrointestinal infectious processes. Her past medical history was unremarkable. Her past obstetrical history included one prior pregnancy with delivery of malpre-senting twins at 38 weeks by cesarean section. During that pregnancy, routine screening for gestational diabetes had been negative. The present pregnancy had also been unremarkable up to this time. At 15 weeks, the patient had had a 50-gram 1-hour glucose challenge test, which was mildly elevated at 149 mg/dl. (Our facility normally screens patients upon presentation, owing to the prevalence of gestational diabetes in the population served and the fact that much of the population is transient.) A follow-up 100-gram 3-hour GTT was normal at 20 weeks, and at 35 weeks, 10 days prior to her admission, the patient had a second 50-gram 1-hour screening test, which was also normal at 106 mg/dl. Physical examination revealed an alert and oriented patient in no distress. Her vital signs included a blood pressure of 107/57, a pulse of 104, a respiratory rate of 18, and a temperature of 37.3°C. Her abdomen was not tender, there were no localizing signs of infection, and fundal height was in agreement with the estimated gestational age. Cervical examination showed the patient to be in early labor with the vertex presenting. Contractions were coming every two to three minutes.

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NEUROCYSTICERCOSIS is an infection of the central nervous system by the larval forms, or cysticerci, of Taenia solium, the pork tapeworm, which is prevalent primarily in the rural areas of Latin America, Asia, and Africa. The number of cases of neurocysticercosis diagnosed in the United States is rising as a result of the increasing number of immigrants from endemic areas.

There is debate regarding the efficacy of antihelminthic agents in the treatment of neurocysticercosis, because the condition may spontaneously resolve without antihelminthic therapy. Most clinicians, however, recommend treating active neurocysticercosis with antihelminthic agents, using either praziquantel (50 mg/kg/d) or albendazole (15 mg/kg/d). Praziquantel was the first agent used in the United States and is usually the first drug prescribed for this condition. If a patient does not respond to praziquantel, either a repeat course of praziquantel or a trial of albendazole is recommended. No consensus has been reached, however, as to the next course of treatment for patients unresponsive to the standard regimens of praziquantel and canadian albendazole.
Several case reports suggest the use of high-dose praziquantel (100 mg/kg/d) in treating refractory neurocysticercosis. We report a case of neurocysticercosis in which a patient failed to respond to conventional treatments but improved after treatment with high-dose praziquantel. This improvement was assessed during follow-up, using clinical observation, brain magnetic resonance imaging (MRI), and cerebrospinal fluid (CSF) studies.

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Yersinia pseudotuberculosis Bacteremia and Splenic Abscess in a Patient With Non-Insulin-Dependent Diabetes Mellitus

Report of a Case
The patient, a 56-year-old woman with a long history of diet-controlled non-insulin-dependent diabetes mellitus, had a two-week history of fevers, chills, malaise, and loose stools but no abdominal pain. On admission to the hospital, her temperature was 38.5°C. Her abdomen was nontender without hepatosplenomegaly. Her aspartate aminotransferase (AST) level was 103 U per liter; alanine aminotransferase (ALT), 34 U per liter; alkaline phosphatase, 132 U per liter; lactate dehydrogenase (LDH), 1,032 U per liter; leukocyte count, 10.1 X10^9 per liter; platelets, 83X10^9 per liter; and an international normalized ratio, 1.6. A urinalysis showed 4 to 10 leukocytes and many bacteria. A week before her hospital admission, her laboratory values were as follows: AST, 30 U per liter; ALT, 25 U per liter; alkaline phosphatase, 89 U per liter; and LDH, 214 U per liter.

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