Clinical Outcomes of Oral Zinc Therapy in Hepatic Encephalopathy Treatment.

BACKGROUND: Additional therapies for hepatic encephalopathy (HE) treatment are warranted. There are data evaluating the use of zinc for HE; however, clinical outcomes, specifically in the United States, are unknown. OBJECTIVE: To compare 30-day and 1-year all-cause readmission rates in patients with cirrhosis complicated by HE on lactulose and rifaximin to those on lactulose, rifaximin, and zinc. METHODS: This retrospective study included patients admitted with documented cirrhosis and home medications of lactulose and rifaximin, with or without zinc. Patients were stratified into 2 groups: those receiving lactulose and rifaximin for HE (control) and those receiving lactulose, rifaximin, and zinc for HE (treatment). The primary outcomes were 30-day and 1-year all-cause readmission rates. RESULTS: One-hundred fifty-seven patients were included (102 in control group, 55 in treatment group). Regarding 30-day and 1-year all-cause readmission rates, there was no difference between the control and treatment groups. CONCLUSION AND RELEVANCE: This is the first study conducted in the United States evaluating zinc for HE treatment. Zinc did not impact 30-day or 1-year all-cause readmission rates. Further studies are warranted to evaluate the potential benefit of zinc for HE, possibly in correlation with Model for End-stage Liver Disease-Sodium (MELD-Na) scores.

Bedside Nurses' Perceptions of Effective Nurse-Physician Communication in General Medical Units: A Qualitative Study.

Background There is a dearth of research on successful interventions to improve nurse-physician communication (NPC). An important step is identifying what matters to bedside nurses and their perceptions of effective NPC communications and actions. Methods We conducted three focus groups with a total of 19 medical unit nurses across two hospitals in one academic medical center in the United States. Using a convenience sampling strategy, five to eight nurses voluntarily participated in each focus group. The recording was transcribed verbatim and two independent coders performed coding and resolved any discrepancies in codes. Qualitative content analysis was pursued to identify themes and associated quotes. Results The presence of direct communication between physicians and nurses was identified as the first theme and perceived by nurses as very important. Additional themes related to physician communication and attributes emerged including collegiality and respect (e.g., engaging nurses as partners in patient care), attentiveness and responsiveness (e.g., listening carefully and addressing concerns), and directness and support (e.g., backing nurses up in difficult situations). Effective NPC is further facilitated by organizational structure, relationship development separate from patient care, and consistent/timely use of technology. Conclusions Hospital bedside nurses provided valuable insight into improved physician communication and what attributes contribute to more effective NPC. Most importantly, they emphasized the significance of physicians in supporting them with difficult patients.

Deep Venous Aberration.

Deep venous thrombosis is a common medical diagnosis. Estimates suggest 60,000 to 100,000 deaths annually from deep venous thrombosis and related complications in the United States of America. The diagnosis is often straightforward using a combination of clinical features and ultrasonography. Once confirmed, the treatment is straightforward as well - anticoagulation. However, we might come across a case where despite the prescribed treatment, there is little clinical improvement. There could be myriad reasons for this. We wish to share our experience with one such treatment failure and how we were able to narrow down the etiology to an anatomical defect. Eventually, we were able to offer curative treatment with vessel stenting. This case refreshed our medical knowledge and we hope to do the same for our colleagues.

Incidence, predisposing conditions and outcomes of cutaneous mucormycosis: A national database study.

BACKGROUND: The body of evidence on cutaneous mucormycosis is largely derived from case reports or single-centre databases. OBJECTIVES: Our study aimed to describe incidence, predisposing factors and inpatient outcomes of cutaneous mucormycosis in the United States. METHODS: We conducted a population-based retrospective study using the National Inpatient Sample 2016-17 data. Fifty-six discharges had a diagnosis of cutaneous mucormycosis on the International Classification of Diseases, tenth revision. Descriptive analysis was performed for the demographics, predisposing factors, length of stay (LOS), cost and inpatient mortality. The NIS represents 20% of all discharges in the United States, which allowed us to estimate the national incidence of cutaneous mucormycosis. RESULTS: An estimated total of 280 admissions occurred between 2016 and 2017, indicating 3.9 cases per million admissions across the United States. The estimated incidence rate was 0.43 cases per million people per year. Median age was 49.5 (19-59) years, 44.6% were female, and 54.9% were Caucasian. We identified haematologic malignancies (48.2%) and solid organ transplantations (10.7%), often accompanied by skin/soft tissue or post-procedural infections, were the most common predisposing conditions. Median LOS was 15 (6-31) days, median total charges were 187,030 (65,962-446,265) USD, and in-hospital mortality rate was 16.1%. CONCLUSIONS: In current clinical practice, physicians may encounter cutaneous mucormycosis most commonly in severely immunocompromised hosts with haematologic malignancies or transplantations, accompanied by skin/soft tissue or post-procedural infections. A high index of suspicion and prompt tissue sampling in at-risk groups is important to improve the outcomes.

First Documented Case of Percutaneous Endoscopic Gastrostomy (PEG) Tube-Associated Bacterial Peritonitis due to Achromobacter Species with Literature Review.

Introduction. Achromobacter species (spp.) peritonitis has seldom been identified in medical literature. Scarce cases of Achromobacter peritonitis described previously have been correlated with peritoneal dialysis and more sparingly with spontaneous bacterial peritonitis. Achromobacter exhibits intrinsic and acquired resistance, especially in chronic infections, to most antibiotics. This article conducts a literature review of all previously reported Achromobacter spp. peritonitis and describes the first reported case of Achromobacter peritonitis as a complication of percutaneous endoscopic gastrostomy (PEG) tube placement. Discussion. Achromobacter peritonitis as a complication of PEG-tube placement has not been previously reported. In our patients' case, the recently placed PEG-tube with ascitic fluid leakage was identified as the most plausible infection source. Although a rare bacterial peritonitis pathogen, Achromobacter may be associated with wide antimicrobial resistance and unfavorable outcomes. Conclusion. No current guidelines provide significant guidance on treatment of PEG-tube peritonitis regardless of microbial etiology. Infectious Disease Society of America identifies various broad-spectrum antibiotics targeting nosocomial intra-abdominal coverage; some of these antimicrobial selections (such as cefepime and metronidazole combination) may yet be inadequate for widely resistant Achromobacter spp. Recognizably, the common antibiotics utilized for spontaneous bacterial peritonitis, i.e., third generation cephalosporins and fluoroquinolones, to which Achromobacter is resistant and variably susceptible, respectively, would be extensively insufficient. Piperacillin/tazobactam (P/T) and carbapenem were identified to provide the most reliable coverage in vitro; clinically, 5 out of the 8 patients who received either P/T or a carbapenem, or both, eventually experienced clinical improvement.

A Rare Case of Herpes Simplex Virus-2 Hepatitis with Negative Serology.

Herpes simplex virus-2 (HSV2) hepatitis represents a rare but serious complication of HSV2 infection that can progress to acute liver failure (ALF). We describe a case of a pregnant teenager who presented with four days of fever, headache, malaise, nausea, and vomiting. She was initially misdiagnosed with sepsis of unclear source and treated with broad-spectrum antibiotics. Empiric acyclovir was started one week into her hospitalization despite negative serologies while awaiting HSV2 PCR leading to complete resolution of symptoms. Given its high mortality and nonspecific presentation, clinicians should consider HSV hepatitis in all patients with acute hepatitis especially in high-risk population.

A Rare Case of DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) Syndrome with Cholecystitis in a Patient on Levetiracetam.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare idiosyncratic drug reaction with a mortality of up to 10%. As the name suggests, it is characterized by skin rash, eosinophilia, and systemic symptoms resulting from the involvement of visceral organs. We present a case of DRESS in a patient who was on both lamotrigine and levetiracetam, where levetiracetam turned out to be the inciting agent. The interesting features of the case include the onset of symptoms about 70 days after the initiation of levetiracetam, the lack of prominent eosinophilia and the involvement of the gall bladder, which was previously unknown with Levetiracetam. It also reinforces the importance of using the RegiSCAR score in the diagnosis of DRESS. The symptoms resolved over the next few months after drug withdrawal.