Bloodstream infections and setting of onset in persons with spinal cord injury and disorder.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: Health-care-associated (HCA) bloodstream infection (BSI) has been shown to be a distinct epidemiologic category in the general adult population, but few studies have examined specific patient populations. The objective of this study was to assess characteristics associated with BSI that occurred in the hospital (hospital-acquired, HA BSI), from health-care contact outside the hospital (HCA BSI) or in the community (community-acquired, CA BSI) in veterans with spinal cord injury and disorder (SCI&D). SETTING: Two United States Department of Veterans Affairs hospitals. METHODS: All patients with SCI&D with a positive blood culture admitted to study hospitals over a 7-year period (1 October 1997 to 30 September 2004). Demographics, medical characteristics and causative organisms were collected. RESULTS: Four hundred and thirteen episodes of BSI occurred in 226 patients, with a rate of 7.2 BSI episodes per 100 admissions: 267 (64.7%) were HA BSI, 110 (26.6%) were HCA BSI and 36 (8.7%) were CA BSI. Antibiotic resistance was more common in those with HA BSI (65.5%) compared with that in those with HCA (49.1%, P=0.001) and CA BSI (22.2%, P<0.0001). Methicillin resistance in Staphylococcus aureus was highly prevalent; HA BSI (84.5%), HCA BSI (60.6%) and CA BSI (33.3%). CONCLUSION: HCA BSI comprises one-quarter of all BSIs in hospitalized patients with SCI&D. Although those with HCA and CA BSI share similarities, several differences in medical characteristics and causal microorganism are noted. Treatment and management strategies for HCA and CA infections need to vary.

A computerized model for home glucose monitoring proficiency testing: efficacy of an innovative testing program.

PURPOSE: A newly instituted computerized system for proficiency testing of home glucose monitoring was evaluated comparing accuracy of patient determination of glucose with serum values measured in the laboratory. METHODS: Patients returning for routine blood glucose testing ordered by their care provider brought their glucose monitoring equipment to the laboratory. They performed a finger-stick glucose check in the laboratory while the laboratory phlebotomist drew blood for glucose determination; both results were computer analyzed. Patients with a 25% or less variation from the laboratory were considered proficient, while those with greater than 25% variation were defined as nonproficient. RESULTS: Over a 19-month period, 300 of the 3208 patients notified about the study completed proficiency testing at least once. Using the defined proficiency of 25% variation or less, 12% of the participants were nonproficient. Using a variation of 15% or less, 31% of patients were nonproficient. CONCLUSIONS: An annual methodology evaluation such as the one in this study should become a standard of care to identify patients for remedial classes to correct the source of error. The goal must be to meet or exceed the American Diabetes Association standard of 15% total error in home glucose monitoring.

Monitoring for undertransfusion.

BACKGROUND: Most published reviews and audits of blood and blood component transfusion have focused on the issue of overtransfusion and on the inappropriate use of red cell components. There is growing concern that efforts to curb unnecessary transfusions may result in a trend toward undertransfusion of patients. There is little published information that addresses this issue or the magnitude of this practice. STUDY DESIGN AND METHODS: Undertransfusion was evaluated by examining the transfusion records from a 3-month period for 55 patients who met the study criteria of having either a hemoglobin level < 7 g per dL or a platelet count of < 10 x 10(9) per L. If the identified patient did not receive a transfusion within 24 hours of the reported hemoglobin level or platelet count, the medical record was reviewed by a resident physician. RESULTS: A total of 213 individual hemoglobin levels and platelet counts, representing the 55 patients, met our transfusion criteria. All except 8 of the identified patients received red cells and/or platelet transfusions. Reasons for not transfusing red cells included the patient's response to nutritional support and iron supplementation, refusal of blood, and noncompliance. Reasons for not transfusing platelets included falsely low platelet count because of platelet clumping in vitro, contraindication based on clinical diagnosis (e.g., immune thrombocytopenic purpura), and the patient's death before transfusion. CONCLUSION: Red cell and platelet transfusions were appropriately ordered for all patients who met the transfusion criteria. Undertransfusion is not a problem at this institution according to the criteria established. It is recommended that other institutions expand their blood utilization audits to include investigation for evidence of undertransfusion. Further research regarding the issue of undertransfusion is warranted and could be expanded to include other components.

Performance of the Coumatrak system in a large anticoagulation clinic.

There is a need to monitor anticoagulation accurately, inexpensively, and rapidly. The accuracy and precision of a simple fingerstick method was studied in a large outpatient anticoagulation clinic using the Coumatrak method. The Coumatrak apparatus has been studied in the home setting, and three recent reports suggest that it is practical, accurate, and possibly superior to the standard method. These results differ from recently published studies. This technique was found to be less than acceptable in precision and accuracy. This method requires further study before it can be recommended for wide-spread use in making decisions for patient care.

A feedback system for reducing excessive laboratory tests.

At the James A. Haley Veterans Hospital in Tampa, Fla, a program has been implemented to reduce the amount of potentially excessive laboratory testing. The major program components are a set of test frequency guidelines and a system of feedback to resident physicians that compares their test ordering patterns against the predetermined guidelines. The guidelines are analyte specific and differentiate between normal and abnormal test values reported during 1-day and 7-day time periods. The feedback process includes both systematic reporting of objective data and individual and group education and counseling sessions related to the appropriate use of laboratory tests. A reduction in the percentage of tests that fell outside the guidelines (outliers) was achieved following implementation of the program.

Blood biochemical characteristics of cattle at sea level and at moderately high altitude (3,000 m).

We investigated the biochemical composition of blood from Holstein cows, native breed (criollas), and cows descended from fighting bulls (Vacas de lidia) raised at an altitude of 3,000 m (moderately high altitude, MHA), and compared the results with those from Holsteins and cows of similar genetic ancestry as the criollas (scrub cows), both raised at sea level (SL), to determine blood biochemical values characteristic of adaptation to high altitude. Only potassium and calcium concentrations were similar among groups. Glucose concentration was lower in MHA cows, with the exception of Vacas de lidia. Serum bicarbonate concentration was lower in MHA cows; this finding can be explained by hyperventilation in the hypoxic environment. Serum magnesium concentration was lower in SL and MHA Holsteins than in other groups. Serum phosphate concentration was lower in scrub cows, MHA Holsteins, and criollas than in other groups. Cholesterol concentrations were lower in SL Holsteins, whereas triglycerides were higher in scrub cows and MHA Vacas de lidia. Concentration of high-density lipoprotein was significantly greater in Vacas de lidia and less in MHA criollas than in the other groups. Uric acid and total protein were higher in MHA groups. Using radioimmunoassay for human proteins, thyroxine-binding globulin was undetectable. Total and free thyroxine and free triiodothyronine were higher in scrub cows, followed by Vacas de lidia; lower values were detected in SL and MHA Holsteins and MHA criollas.

Hypercalcemia as a clinical prodrome to lymphoma.

A 73-year-old man was admitted for evaluation of unexplained hypercalcemia and was found to have a large-cell non-Hodgkin's lymphoma with stage IV disease. Treatment with cyclophosphamide, doxorubicin (Adriamycin), vincristine sulfate, and prednisone chemotherapy returned his calcium levels to normal. Hypercalcemia with lymphoma is rare, and persistent evaluation for malignancy is essential.

Chromomycosis in a steroid-dependent patient with chronic obstructive pulmonary disease.

Cutaneous chromomycosis developed in an elderly man with steroid-dependent chronic obstructive pulmonary disease. This patient had no history of foreign travel. Chromomycosis acquired in the United States is rare and may be seen in immunosuppressed patients, as exemplified by this case. Satisfactory response was observed in this patient with surgical debridement and continuing oral ketoconazole therapy.

Drug induced morphologic changes in the liver.

The pathologic evaluation of hepatic changes secondary to drug ingestion is a difficult task because of the limited histologic response of the liver to hepatotoxins. The majority of these pharmacologic agents produce cholestasis, hepatitis, or both. Some drugs will produce damage if given for a sufficient time and in sufficient amount; this reaction is termed predictable. Other agents cause injury only in a small number of individuals; this reaction is unrelated to dosage or duration of administration and is termed unpredictable. In time, after discontinuing the offending agent, morphologic alterations of the liver and clinical findings will revert to normal except in certain conditions. Some drugs will produce cirrhosis as a sequelae while others may progress to chronic hepatitis. The accurate and complete evaluation of hepatic morphology requires a thorough clinical history since the histologic changes of certain illnesses may mimic the changes of drug-induced hepatic damage. For the clinician, drug-induced hepatic injury is important because of the central function the liver plays in drug metabolism and its susceptibility to damage.

Microcomputer reporting and information system for microbiology.

A computerized reporting and information system for microbiology employing a relatively inexpensive microcomputer is described. A comprehensive approach to accessioning and result entry for microbiology is presented. A daily laboratory worklist is generated for each work area, providing the responsible technologist with information on previously processed specimens. Manipulation of patient and specimen information permits the performance of various functions, including the generation of billing reports, workload statistics, quality-control summaries, epidemiologic surveys, and cumulative reports. The employment of many user-definable data lexicons allows optimal use of disk space while affording rapid information retrieval. Data file maintenance is automatically accomplished by the system, requiring no user intervention.

Quality-control statistical interpretation by microcomputer.

A comprehensive summary report of quality-control data is of great value in monitoring the accuracy and precision of the clinical chemistry laboratory. This report allows a retrospective appraisal alerting laboratory personnel to possible test control material degradation or instrument malfunction. A microcomputer-based program package is described, designed to reduce the errors and lengthy preparation inherent in the manual generation of such a report. Quality-control summary data is automatically compared with a predefined set of statistical criteria, and any aberrant values are flagged, thus eliminating subjective and nonuniform data interpretation. Statistical comparisons include: number of control points, delta mean, delta standard deviation, standard deviation index, and F-ratio. The summary report is well accepted by the laboratory staff, and its incorporation into the decision-making process allows for an efficient, critical, and uniformly rigorous examination of analytic proficiency.

Workload recording by microcomputer.

Workload recording as designed by the College of American Pathologists has proven to be an invaluable aid in the assessment of overall laboratory operation. The administrative information derived from the compilation of these workload statistics is utilized to provide effective and these workload statistics is utilized to provide effective and efficient laboratory management. A microcomputer-based system for the pathology department that permits the accumulation of daily raw workoad data is descirbed. A monthly cummulative summary report is subsequently produced, complete with computer-derived College of American Pathologists workload units.

Pathology accessioning and retrieval system with encoding by computer (PARSEC). A microcomputer-based system for anatomic pathology featuring automated SNOP coding and multiple administrative functions.

A pathology accessioning and retrieval system with encoding by computer (PARSEC) has been developed, employing a relatively inexpensive microcomputer. PARSEC performs a variety of administrative functions for anatomic pathology, including accessioning of surgical specimens, storage of patient demographic information, editing, retrieval, and archiving of patient data, as well as CAP (college of American Pathologists) workload units, billing, and inventory functions for histopathology. In addition, appropriate gross and microscopic descriptions and pathologic diagnoses can be entered into the system by a text editor. Automatic assignment of SNOP (Systematized Nomenclature of Pathology) codes, is accomplished via an online SNOP lexicon, allowing the ultimate generation of completed surgical pathology reports. The data base management system employed makes optimum use of disk storage space, while permitting rapid data retrieval. Data file maintenance is automatically accomplished by the system, requiring no user intervention.

Lymphoepithelioid cellular lymphoma (Lennert's lymphoma) in association with malignant lymphoma, histiocytic type.

The present case is unusual in that it demonstrates the presence of the histologic pattern of Lennert's lymphoma in a patient who had a 14-year history of recurrent reticulum cell sarcoma (histiocytic lymphoma). This particular lesion also exhibits clinical and pathologic similarities to angioimmunoblastic lymphadenopathy and malignant lymphoma of peripheral T-lymphocyte origin. Whether the appearance of Lennert's lymphoma in this patient represents a regression of the previous reticulum cell sarcoma (histiocytic lymphoma) to a more benign form, a response to therapy, an alteration in the immune system, or a new lymphoreticular malignancy remains to be answered.