Impact on Patient Management of a Novel Host Response Test for Distinguishing Bacterial and Viral Infections: Real World Evidence from the Urgent Care Setting.

Antibiotic overuse and underuse are prevalent in urgent care settings, driven in part by diagnostic uncertainty. A host-based test for distinguishing bacterial and viral infections (MeMed BV) has been clinically validated previously. Here we examined how BV impacts antibiotic prescription in a real-world setting. The intention to treat with antibiotics before the receipt of a BV result was compared with practice after the receipt of a BV result at three urgent care centers. The analysis included 152 patients, 57.9% children and 50.7% female. In total, 131 (86.2%) had a bacterial or viral BV result. Physicians were uncertain about prescription for 38 (29.0%) patients and for 30 (78.9%) of these cases, subsequently acted in accordance with the BV result. Physicians intended to prescribe antibiotics to 39 (29.8%) patients, of whom 17 (43.6%) had bacterial BV results. Among the remaining 22 patients with viral BV results, antibiotic prescriptions were reduced by 40.9%. Overall, the physician prescribed in accordance with BV results in 81.7% of all cases (p < 0.05). In total, the physicians reported that BV supported or altered their decision making in 87.0% of cases (p < 0.05). BV impacts patient management in real-world settings, supporting appropriate antibiotic use.

Continuous glucose monitoring in patients undergoing cardiac surgery.

OBJECTIVES: Hyperglycemia is a prominent feature among patients exposed to major stress such as in cardiac surgery. The implementation of a continuous glucose monitoring system (CGMS) for glucose monitoring during cardiac surgery was assessed. SUBJECTS AND METHODS: Fifty-nine consecutive patients who underwent cardiac surgery were monitored by CGMS. Patients' fluid glucose content, drug requirements, and hemodynamic and physiologic parameters were evaluated. RESULTS: Of the 59 patients, 32 completed the monitoring with CGMS. Patients were divided into three groups: diabetes patients, patients without diabetes history who developed significant hyperglycemia perioperatively, and patients who did not develop hyperglycemia. Hyperglycemia was most frequently observed postoperatively. Hyperglycemic patients required significantly more insulin (81±40 vs. 34±37 units, P=0.005) and experienced an increased early complication rate, although this difference was not significant. CGMS erroneously detected late-phase operative and immediate postoperative hypoglycemia in approximately one-third of patients as reflected from venous blood sample measurements. CONCLUSIONS: CGMS enables close monitoring and optimal control of blood glucose among patients undergoing major cardiac surgery, although its reliability is limited during the cardiac surgery phase and in the early postoperative period, because of incorrect hypoglycemic readings.

Prehospital care of orthopedic injuries.

Orthopedic injuries are predominant among combat casualties, and carry the potential for significant morbidity. An expert consensus process (Prehospital care of military orthopedic trauma: A consensus meeting, Israel Defense Forces Medical Corps, May 2003) was used to create guidelines for the treatment of these injuries by military prehospital providers. The consensus treatment guidelines developed by experienced orthopedic trauma personnel from leading trauma centers in Israel are presented in this paper. For victims with open fractures, the first priority is hemorrhage control. Splinting, irrigation, and wound care should be performed while waiting for transport, or, in any scenario, in the case of an isolated limb injury. The use of traction splints was advocated for both the rapid transport scenario (up to one hour from the time of injury to arrival at the hospital) and the delayed transport scenario. In the urban setting, traction splints may not be necessary. Any victim experiencing pelvic pain following a high-energy mechanism of injury should be presumed to have an unstable pelvic fracture, and a sheet should be tied around the pelvis. The panel agreed that field-reduction of dislocations should be avoided by the medical officer unless it is anticipated that the patient will need to go through a long evacuation chain and the medical officer is familiar with specific reduction techniques.

Application of a cuirass and institution of biphasic extra-thoracic ventilation by gear-protected physicians.

OBJECTIVES: To evaluate the speed by which cuirass application, followed by biphasic extra-thoracic ventilation, can be instituted by full anti-chemical protective gear-wearing physicians. MATERIALS AND METHODS: Ten physicians of variable subspecialties applied a cuirass on an adult volunteer and instituted biphasic extra-thoracic ventilation, using the RTX respirator (Medivent, London, UK). Endotracheal (ET) intubation and manual ventilation of a mannequin and its ventilation was comparatively assessed. Performances were conducted in a prospective, crossover, randomized manner. Times to successful applications as well as failure rates were recorded. RESULTS: Cuirass application was performed more rapidly (102 +/- 9 s, 177 +/- 31 s, respectively, P <.01) and with a slightly lower failure rate than ET intubation. CONCLUSIONS: Physicians wearing full anti-chemical protective gear applied the cuirass and instituted biphasic extra-thoracic ventilation faster than ET intubation and manual positive pressure ventilation. Extra-thoracic ventilation should be further evaluated as an option for emergent respiratory support during toxic mass casualty events.

Supraglottic devices: a possible role in prehospital toxic mass casualty event?

Rapidly progressive respiratory failure is the leading cause of death from inhalation of toxic chemical warfare agents. In an expected chaotic scenario, direct laryngoscopic tracheal intubation is unlikely to be easily and quickly performed due to shortage of medical personnel experienced with laryngoscopy and/or reduced dexterity imposed by the protective gear worn by the caregivers. Supraglottic devices have increasingly been used for emergent airway control in prehospital settings, thus avoiding the need for laryngoscopy. This review summarizes Medline English literature search on supraglottic devices and their use in the prehospital setting or in mass casualty event focusing on their potential role for emergent airway control in the setup of toxic inhalation.