Oritavancin vs Standard of Care for Treatment of Nonendovascular Gram-Positive Bloodstream Infections.

Background: Data is limited comparing oritavancin (ORT) to the standard-of-care (SOC) for the treatment gram-positive blood stream infections (BSI). Methods: This was a retrospective study of all patients in the Veteran's Affairs Health Care System treated with at least 1 dose of oritavancin or at least 5 days of vancomycin, daptomycin, ceftaroline, ampicillin, ampicillin-sulbactam, nafcillin, oxacillin, or cefazolin for a documented gram-positive BSI from 1 January 2015 to 30 June 2021. Patients with polymicrobial blood cultures or positive cultures from other sites were included if the organisms were sensitive to the incident antimicrobial; no concomitant antimicrobials could be used once the incident agent was started. Individuals were also excluded if they were diagnosed with endocarditis, had a neutrophil count 96-hours of treatment before the incident antimicrobial was started.The primary composite outcome was clinical failure, defined as all-cause mortality within 30-days from the end of therapy, or blood cultures positive for the incident organisms ≥72 hours after administration of the first dose and ≤30 days after the administration of the final dose of the study antimicrobial, or any drug or line-related readmissions within 30-days of hospital discharge. Results: Two hundred-forty patients were identified for screening with 96 meeting criteria (27 in ORT and 69 in SOC groups). Baseline characteristics were generally balanced between groups except more patients in the ORT group received >96-hours of treatment before the incident antimicrobial was started (70.3% (19/27) vs 13.04% 9/69); P < .001). The pathogen most prevalent was methicillin susceptible Staphylococcus aureus (MSSA) (ORT 33.3% (9/27) vs SOC 46.4% (32/69)). Clinical failure occurred in 7.4% (2/27) in the ORT group and 17.4% (12/69) in SOC (P = .34). No components of the primary outcome were significantly different between groups, but AKI did occur more commonly in the SOC group (27.5% (19/69) vs 3.7% (1/27); P = .01). Conclusions: ORT appears to be a safe and effective option when directly compared to the SOC for non-endocarditis BSIs.

Evaluation of Thrombocytopenia in Patients Receiving Percutaneous Mechanical Circulatory Support With an Impella Device.

Evaluate the time course of thrombocytopenia in patients with Impella devices (Abiomed, Danvers, MA). DESIGN: This was a retrospective, multicenter review of electronic medical records at a large hospital system from April 2018 to August 2020. SETTING: Electronic medical records of patients at SSM Health hospitals were reviewed. PATIENTS: Patients 18-89 years old admitted to an SSM Health hospital from April 2018 to August 2020 who received greater than or equal to 24 hours of percutaneous mechanical circulatory support (pMCS) with an Impella device were included. Exclusion criteria were use of other pMCS devices, history of heparin-induced thrombocytopenia (HIT), and presence of device upon transfer from an outside hospital. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ninety-three patients were included. The median duration of pMCS was 63.5 hours. Thrombocytopenia occurred in 86% of patients and was evident 24 hours after device placement. The platelet nadir occurred 84 hours after device placement. Platelet recovery occurred 86.5 hours after device removal. The duration of thrombocytopenia was 156 hours. Signs of hemolysis were present in 44.09% of patients, were evident 12-24 hours after device placement, and resolved after device removal. CONCLUSIONS: Thrombocytopenia occurred in the majority of patients and was evident 24 hours after device placement. The time course of thrombocytopenia mirrored that of hemolysis.

The implications of an incidental chronic lymphocytic leukaemia in a resection specimen for colorectal adenocarcinoma.

BACKGROUND: Colorectal cancer and B cell chronic lymphocytic leukaemia (CLL) have a significant incidence, which are increasing with the aging population. Evidence has been presented in the literature to suggest that the synchronous presentation of colorectal cancer and B cell CLL may be more than simply coincidental for these two common malignancies. We report an unusual case of a presumed B cell CLL diagnosed on the basis of histological analysis of lymph nodes recovered from a resection specimen for rectal adenocarcinoma. We considered aetiological factors which may have linked the synchronous diagnosis of the two malignancies and the potential implications for the natural history of the two malignancies on one another. CASE PRESENTATION: A 70-year-old male underwent low anterior resection with total mesorectal excision for a rectal adenocarcinoma. His co-morbid conditions were chronic obstructive airways disease and ischaemic heart disease. General examination revealed no lymphadenopathy. Full blood count, urea and electrolytes and liver function tests were all within normal limits. As well as confirming a pT3 N1 adenocarcinoma, histological analysis showed lymph nodes with an infiltrate of small lymphoid cells. Immunohistochemical studies showed these cells to be in keeping with B cell CLL. CONCLUSION: Whilst unable to identify any common aetiological factors in the two malignancies in our patient, immunosuppression and genetic abnormalities have been identified as possible bases for an observed epidemiological association between colorectal cancer and haematological malignancies. Examples such as our case of synchronous diagnosis of two malignancies in a patient are likely to increase with the aging population. The potential affects of one malignancy on the natural history of the other warrants further study. In our case, we considered that slow progression of the B cell CLL may increase the risk of recurrent rectal adenocarcinoma.

Enhancing the Enhanced Recovery Program in Colorectal Surgery - Use of Extended-Release Epidural Morphine (DepoDur®).

PURPOSE: DepoDur® is a single-dose extended-release morphine injection into the epidural space. It is not commonly used, but has many advantages over traditional analgesic regimens. We analyzed a number of these advantages in our case series in the context of the colorectal enhanced recovery program (ERP) and aimed to show that the ERP could be further enhanced by using DepoDur®. METHODS: We conducted a prospective audit of all patients undergoing open and laparoscopic colorectal procedures where DepoDur® was used between July 2010 and April 2012. Validated pain scores were used, and primary outcome measures were resting and dynamic pain, mobilization, and need for additional analgesia. RESULTS: Two hundred eighty patients were included in the case series. Good pain control was seen at 24 and 48 hours. Eighty-one percent of the patients required simple analgesia alone at 24 hours, and 62% required simple analgesia (paracetamol +/- nonsteroidal anti-inflammatory drugs) alone at 48 hours. Only a minority required additional oramorph and patient-controlled analgesia at 24 and 48 hours (19% at 24 hours and 38% at 48 hours). Seventy-nine percent of the patients were mobilized at 24 hours, and 88% of the patients were mobilized at 48 hours. CONCLUSION: DepoDur® is an effective alternative to conventional pain management techniques and may have a role in further enhancing the ERP.

A case of gallstone-induced small bowel necrosis masquerading as clinical appendicitis.

Cholecysto-duodenal fistula and gallstone ileus are well-recognised complications of gallstone disease. However, small bowel necrosis is a rare complication of gallstone disease. We describe a case of gallstone-induced ileal necrosis presenting with symptoms and signs resembling acute appendicitis. A 79-year-old woman presented to the surgical team with central abdominal pain which subsequently shifted to the right iliac fossa. Clinically, the patient had localised perotinism in the right iliac fossa with high inflammatory markers. Abdominal radiography showed no diagnostic features. Initial clinical impression was that of acute appendicitis. Given that this diagnosis was unlikely in a patient of this age, an abdominal CT scan was performed. The CT scan showed evidence of a large gallstone causing small bowel obstruction in the presence of a cholecysto-duodenal fistula. At surgery, she was found to have an area of necrosis with a pin-point perforation at the site of impaction of the gallstone in the proximal ileum. This occurred secondarily to pressure necrosis from the gallstone impacting at a site where the small bowel diameter narrows in transition from jejunum to ileum. A limited small bowel resection was performed with an uncomplicated postoperative course. This case report draws attention to a rare complication of gallstone disease which presents with a clinical picture similar to acute appendicitis. Preoperative investigation for an elderly patient who presents with an acute abdomen should include an abdominal CT scan to diagnose any rare disease processes which otherwise may not be suspected.

Post-operative neutrophil-lymphocyte ratio predicts complications following colorectal surgery.

INTRODUCTION: The neutrophil-lymphocyte ratio (NLR) correlates with serial organ dysfunction scores in colorectal surgical patients in critical care units. We hypothesised that the NLR on the first day after an elective colorectal resection would identify patients at increased risk of subsequent complications. METHODS: With Ethics Committee approval, 100 patients were recruited to a prospective cohort study. Pre-operative test results and the full blood count on the first post-operative day were noted for all patients. The development of any pre-defined post-operative complications was recorded. RESULTS: Elective colorectal resection was associated with an increase in mean NLR from 3.5 to 11.6 (p<0.001). Thirty patients developed at least one predefined complication. Patients with an NLR > or =9.3 on the first post-operative day had a significantly greater risk of complications (likelihood ratio 2.12; 95% confidence interval 1.366-3.253). Twenty-two patients had a white cell count > or =11 on the first post-operative day but this was not associated with a significantly increased risk of complications (likelihood ratio 1.94; 95% confidence interval 0.94-3.9). CONCLUSION: NLR > or =9.3 on the first post-operative day is associated with an increased risk of complications. This simple derivation of routinely available data helps to identify patients at high-risk of complications, allowing targeted preventive measures.