Daily gentamicin using ideal body weight demonstrates lower risk of postpartum endometritis and increased chance of successful outcome compared with traditional 8-hour dosing for the treatment of intrapartum chorioamnionitis.

Background: Clinical chorioamnionitis complicates approximately 1-4% of pregnancies overall. Although universal agreement does not exist regarding the antibiotic regimen of choice, most studies have evaluated intravenous ampicillin dosed at 2 g every 6 hours plus gentamicin dosed every 8 hours. Only three studies have examined daily gentamicin for the treatment of intrapartum chorioamnionitis and thus is insufficiently investigated. Objective: This study seeks to determine whether daily dosing of gentamicin using ideal body weight for the treatment of intrapartum chorioamnionitis is more or equivalently efficacious when compared to traditional 8-hour dosing regimens. Materials and methods: We conducted a retrospective cohort study and reviewed charts on all women receiving treatment for intrapartum chorioamnionitis, which included intravenous gentamicin daily dosing calculated using 5 mg/kg ideal body weight or receiving traditional every 8 hours dosing of gentamicin at two large academic centers. Our primary outcomes were resolution of infection following delivery without the development of maternal endometritis and/or neonatal sepsis. Baseline characteristics were compared between dosing groups using Welch two-sample t-tests for continuous variables, uncorrected X2 test and exact binomial 95% confidence intervals. We calculated the risk ratios of each outcome in the ideal versus traditional dosing groups using modified Poisson regression, both crude and adjusted. Adjusted models were controlled for variables determined to be potential confounders, which included BMI, diabetes mellitus, gestational blood pressure >140/90, group ß-Streptococcus status, race, advanced maternal age (>34 y), and parity. Results: The study included 500 patients with 255 patients receiving daily dosing of gentamicin and 245 receiving traditional dosing of gentamicin. Of the patients receiving daily gentamicin compared to traditional dosing, 95.7% (95% CI 94.9-96.6%) achieved the primary outcome versus 92% (95% CI 90.8 - 93.2%), 2.4% (95% CI 1.8-3%) developed endometritis versus 5.6% (4.5-6.7%), 1.6% (95% CI 1.1-2.1%) delivered neonates with sepsis versus 3.3% (CI 2.5-4.1%), and 36.9% required cesarean delivery versus 41.4%. In crude analysis, compared to traditional dosing, IDW daily dosing was associated with a lower risk of postpartum endometritis (RR 0.42, 95% CI 0.16-1.10, p = .032). After adjusting for BMI, diabetes mellitus, gestational blood pressure >140/90, group ß-Streptococcus status, race, advanced maternal age (>34 y), and parity, the IDW daily dosing group had a 5% greater chance of successful outcome (RR 1.05, 95% CI 1.00-1.10, p = .046) and a 64% lower risk of endometritis (RR 0.35, 95% CI 0.15-0.83, p = .017). Conclusion: Daily dosing of gentamicin using ideal body weight is associated with a lower risk of postpartum endometritis and high chance of a successful outcome in the treatment of intrapartum chorioamnionitis compared with traditional 8-hour dosing in our ethnically diverse, urban population and thus may be considered a superior option to every 8 hours dosing regimens.

A Strategy for Role Assignment in Simulation Using Collaborative Cognition.

The purpose of this article is to present an innovative education strategy for role assignment in simulation that encourages collaboration and prioritization, while highlighting critical thinking. BACKGROUND: Traditional methods of role assignment in simulation distribute nursing duties among multiple participants, assigning students as a primary or a secondary nurse or dictating specific tasks such as medication administration, assessment, or documentation. This allows students to divide and conquer, rather than prioritize and delegate. METHOD: In the Two-Heads-Are-Better-Than-One strategy, two students assume the role of one nurse and are instructed to move and act as if they are one person. RESULTS: The Two-Heads-Are-Better-Than-One strategy requires the two students functioning as one nurse to collaborate, discuss differences of opinion, and formulate a plan of care for the simulated patient. CONCLUSION: This innovative approach to role assignment in simulation provides clinical faculty with a unique perspective for assessing critical thinking and clinical reasoning. [J Nurs Educ. 2018;57(11):694-697.].

Earlier Goals of Care Discussions in Hospitalized Terminally Ill Patients and the Quality of End-of-Life Care: A Retrospective Study.

BACKGROUND: The association between physician-directed goals of care discussions (GOCDs) and the use of aggressive interventions in terminally ill patients has not been well characterized in the literature. We examined the associations between the timing of physician-directed GOCDs in terminally ill patients and the use of aggressive interventions, probability of dying in the inpatient setting, and intensive care unit (ICU) utilization. METHODS: This retrospective cohort study included patients admitted to our urban community hospital in 2015 who had a terminal diagnosis on admission and either died on an inpatient unit or were discharged to hospice. The primary independent variable was the number of days from admission to GOCD, expressed as a proportion of the patient's length of stay (LOS). We used robust variance Poisson and zero-inflated negative binomial regression, as appropriate, to estimate the associations between goals of care timing and risk of having an intervention, risk of dying in the inpatient setting, odds of ICU admission, and ICU LOS. RESULTS: A total of 197 cases were included. After adjusting for age, language, gender, insurance, dementia, and decision maker (patient versus surrogate decision maker), later GOCD was significantly associated with greater risk of having an aggressive intervention (risk ratio [RR] = 1.04, 95% confidence interval [CI] = 1.02-1.06), greater risk of death as an inpatient (RR = 1.04, 95% CI = 1.02-1.06), and greater odds of ICU admission (odds ratio = 1.19, 95% CI = 1.02-1.39). CONCLUSION: Later GOCDs were associated with greater risk of aggressive interventions and death as an inpatient and greater odds of ICU admission. Goals of care discussion should be done routinely and early during the hospitalization of terminally ill patients.

Daily dosing of gentamicin using ideal body weight for the treatment of intrapartum chorioamnionitis: a pilot study.

PURPOSE: This study aimed to determine whether daily dosing of gentamicin using ideal body weight in the treatment of chorioamnionitis is effective. MATERIALS AND METHODS: We conducted a prospective observational study and followed all women receiving treatment for chorioamnionitis which included gentamicin daily dosing calculated using 5 mg/kg ideal body weight. Patients were excluded if pathological analysis of placenta did not confirm chorioamnionitis. Our primary outcome was resolution of infection following delivery without the development of maternal endometritis and/or neonatal sepsis. Ninety-five percent confidence intervals for proportions were calculated using exact binomial tests. These patients were retrospectively compared to patients who received treatment for chorioamnionitis which included traditional gentamicin every 8 h. RESULTS: The study included 160 patients. Of the patients receiving daily dosing (n = 80) compared to traditional dosing (n = 80), 96% (95% CI 95.7-97.6%) achieved the primary outcome versus 91% (88.9-93.1%), 2.5% (95% CI 1.2-3.8%) developed endometritis versus 6.3% (4.2-8.4%), 1.3% (95% CI 0.4-2.2%) delivered neonates with sepsis versus 2.5% (1.2-3.8%), and 39% required cesarean delivery (95% CI 46.2-53.8) versus 37% (33.2-40.8%). CONCLUSION: Daily dosing of gentamicin using ideal body weight is effective in successful treatment of chorioamnionitis without development endometritis and/or neonatal sepsis across different ethnicities.

Haemophilus parainfluenzae Endocarditis Associated With Maxillary Sinusitis and Complicated by Cerebral Emboli in a Young Man.

HACEK endocarditis is often difficult to diagnose given the slow-growing characteristics of the organisms involved. Haemophilus parainfluenzae, one of the HACEK organisms, is an uncommon cause of endocarditis. We describe a case of a previously healthy young man with H parainfluenzae endocarditis that was associated with maxillary sinusitis and severe systemic complications, including septic cerebral emboli and mitral valve perforation. Previously reported cases have also described a predilection for younger people, cardiac valve pathology, and a high prevalence of stroke.

Severe headache, neck pain, intermittent cough · Dx?

A 32-year-old Chinese woman sought care from our family medicine clinic because she had a headache, neck pain, and an intermittent cough that had produced white sputum for 7 days. She described the headache as severe and pressure-like, and said that it had progressively worsened over the previous 3 weeks, coinciding with her first trip outside of China to the United States. The patient indicated that she also had occasional vomiting, dizziness, a low-grade fever, chills, night sweats, and increasing fatigue.

Acute Liver Toxicity due to Efavirenz/Emtricitabine/Tenofovir.

The fixed-dose combination of Efavirenz/Emtricitabine/Tenofovir is a first-line agent for the treatment of HIV; however few cases have reported hepatotoxicity associated with the drug. We report a case of Efavirenz/Emtricitabine/Tenofovir-associated hepatotoxicity presenting mainly with hepatocellular injury characterized by extremely elevated aminotransferase levels, which resolved without acute liver failure or need for liver transplant referral.

Myocarditis in a traveler returning from the Dominican Republic: an unusual presentation of dengue fever.

Myocarditis is an uncommon manifestation of dengue fever. We describe a case of a 69-year-old Hispanic male who presented to an emergency room in New York City 3 days after returning from a trip to the Dominican Republic complaining of a 1-day history of chest pain and fever. His first electrocardiogram showed a new left bundle branch block, and initial cardiac enzymes included troponin of 5 ng/dL, creatine kinase-MB of 9 ng/mL, and myoglobin of 234 ng/mL. Dengue fever antibodies were found to be elevated: immunoglobulin M (IgM) titer was 2.48 (reference range < 0.9), and immunoglobulin G (IgG) titer was 4.26 (reference range < 0.9). The patient was diagnosed with myocarditis caused by dengue fever. He improved after 1 week with conservative management in a telemetry unit and was discharged home.

A novel radiation-induced p53 mutation is not implicated in radiation resistance via a dominant-negative effect.

Understanding the mutations that confer radiation resistance is crucial to developing mechanisms to subvert this resistance. Here we describe the creation of a radiation resistant cell line and characterization of a novel p53 mutation. Treatment with 20 Gy radiation was used to induce mutations in the H460 lung cancer cell line; radiation resistance was confirmed by clonogenic assay. Limited sequencing was performed on the resistant cells created and compared to the parent cell line, leading to the identification of a novel mutation (del) at the end of the DNA binding domain of p53. Levels of p53, phospho-p53, p21, total caspase 3 and cleaved caspase 3 in radiation resistant cells and the radiation susceptible (parent) line were compared, all of which were found to be similar. These patterns held true after analysis of p53 overexpression in H460 cells; however, H1299 cells transfected with mutant p53 did not express p21, whereas those given WT p53 produced a significant amount, as expected. A luciferase assay demonstrated the inability of mutant p53 to bind its consensus elements. An MTS assay using H460 and H1299 cells transfected with WT or mutant p53 showed that the novel mutation did not improve cell survival. In summary, functional characterization of a radiation-induced p53 mutation in the H460 lung cancer cell line does not implicate it in the development of radiation resistance.

Effect of a multidisciplinary intervention on central line utilization in an acute care hospital.

BACKGROUND: Many institutions that have adopted evidence-based infection prevention practices have achieved reductions in the rate of central line-associated bloodstream infection (CLABSI) in their intensive care units (ICUs). Few studies have investigated the impact of CLABSI prevention strategies in non-ICU settings, however. This study was conducted to assess whether a multifaceted educational initiative significantly improved health care workers' adherence to clinical practices that have been demonstrated to reduce CLABSI rates. METHODS: This prospective interventional study compared central line utilization and other variables in medical ICU (MICU) and non-ICU settings at an inner city community teaching hospital. The study included 3 phases: preintervention, intervention, and postintervention. RESULTS: A total of 128 central venous catheter (CVC) placements were reviewed. After the intervention, the proportion of patients transferred out of the MICU with a CVC in place decreased significantly (P = .05), and the percentage of patients transitioned from a CVC to a peripherally inserted venous catheter increased (P = .004). The mean duration of CVC use decreased from 8.2 days to 5.7 days (P = .004), which was confirmed by linear regression (P = .003). CONCLUSIONS: Our data indicate that multidisciplinary, evidenced-based educational interventions can significantly improve targeted measures of CVC use. Our program was successfully implemented with limited resources and should be reproducible at other hospitals.

Penicillium marneffei infection in an immunocompromised traveler: a case report and literature review.

Penicillium marneffei has emerged as an important opportunistic pathogen in Southeast Asia during the human immunodeficiency virus (HIV) epidemic. We report a case of disseminated P. marneffei in a person with previously undiagnosed acquired immunodeficiency syndrome (AIDS) who traveled to Southeast Asia, illustrating the importance of considering this diagnosis in immunocompromised travelers.

Knowledge of hepatitis among active drug injectors at a syringe exchange program.

Injecting drug users (IDUs) are at high risk for contracting and spreading viral hepatitis through nonsterile injection practices, unprotected sexual contact, and unsanitary living conditions. We sought to characterize hepatitis knowledge, prior testing, and vaccination history among IDUs at a New York City syringe exchange program (SEP). IDU subjects generally had a poor understanding of viral hepatitis transmission and prevention. We also found low vaccination rates: only 8% reported receiving hepatitis A vaccine and 11%, hepatitis B vaccine. Educating IDUs about risky behaviors and medical preventive interventions, such as vaccines for hepatitis A and B and treatment for hepatitis C, may help prevent disease and reduce transmission. Stronger linkages between health-care centers and SEPs, drug treatment programs, and other service delivery centers where IDUs are encountered may promote hepatitis education and vaccination.

Paecilomyces lilacinus vaginitis in an immuno-competent patient.

Paecilomyces lilacinus, an environmental mold found in soil and vegetation, rarely causes human infection. We report the first case of P. lilacinus isolated from a vaginal culture in a patient with vaginitis.

Impact of monetary incentives on adherence to referral for screening chest x-rays after syringe exchange-based tuberculin skin testing.

INTRODUCTION: Syringe-exchange programs (SEPs) have proven to be valuable sites to conduct tuberculin skin testing among active injection drug users. Chest x-rays (CXRs) are needed to exclude active tuberculosis prior to initiating treatment for latent tuberculosis infection. Adherence of drug users to referral for off-site chest x-rays has been incomplete. Previous cost modeling demonstrated that a monetary incentive to promote adherence could be justified on the cost basis if it had even a modest effect on adherence. METHODS: We compared adherence to referral for chest x-rays among injection drug users undergoing syringe exchange-based tuberculosis screening in New York City before and after the implementation of monetary incentives. RESULTS: From 1995 to 1998, there were 119 IDUs referred for CXRs based on tuberculin skin testing at the SEP. From 1999 to 2001, there were 58 IDUs referred for CXRs with a $25 incentive based on adherence. Adherence to CXR referral within 7 days was 46/58 (79%) among individuals who received the monetary incentive versus 17/119 (14%) prior to the implementation of the monetary incentive (P<.0001; odds ratio [OR]=23; 95% confidence interval [CI]=9.5-57). The median time to obtaining a CXR was significantly shorter among those given the incentive than among those referred without the incentive (2 vs. 11 days, P<.0001). In multivariate logistic regression analysis, use of the incentive was highly independently associated with increased adherence (OR=22.9; 95% CI=10-52). CONCLUSIONS: Monetary incentives are highly effective in increasing adherence to referral for screening CXRs to exclude active tuberculosis after syringe exchange-based tuberculin skin testing. Prior cost modeling demonstrated that monetary incentives could be justified on the cost basis if they had even a modest effect on adherence. The current data demonstrated that monetary incentives are highly effective at increasing adherence in this setting and therefore are justifiable on a cost basis. When health care interventions for drug users require referral off site, monetary incentives may be particularly valuable in promoting adherence.