Notes from the Field: Acute Sulfuryl Fluoride Poisoning in a Family - Florida, August 2015.

On August 19, 2015, the Florida Department of Health (FDOH) was notified by the Florida Poison Information Center Network and a local hospital of possible sulfuryl fluoride poisonings affecting a family in Martin County, in southeastern Florida. Sulfuryl fluoride is a highly toxic (toxicity category I) gas fumigant used for termite control of homes and buildings.* FDOH personnel in Martin County commenced an investigation and identified a family of five (a grandmother, mother, father, son, and daughter) exposed to sulfuryl fluoride after their house was fumigated. The Florida Department of Agriculture and Consumer Services (FDACS), and the U.S. Environmental Protection Agency (EPA) Criminal Investigation Division also conducted an investigation after being notified by FDOH. Medical records were reviewed, and the father was interviewed by FDOH.

Comparison of 3 infrared thermal detection systems and self-report for mass fever screening.

Despite limited evidence regarding their utility, infrared thermal detection systems (ITDS) are increasingly being used for mass fever detection. We compared temperature measurements for 3 ITDS (FLIR ThermoVision A20M [FLIR Systems Inc., Boston, MA, USA], OptoTherm Thermoscreen [OptoTherm Thermal Imaging Systems and Infrared Cameras Inc., Sewickley, PA, USA], and Wahl Fever Alert Imager HSI2000S [Wahl Instruments Inc., Asheville, NC, USA]) with oral temperatures (≥ 100 °F = confirmed fever) and self-reported fever. Of 2,873 patients enrolled, 476 (16.6%) reported a fever, and 64 (2.2%) had a confirmed fever. Self-reported fever had a sensitivity of 75.0%, specificity 84.7%, and positive predictive value 10.1%. At optimal cutoff values for detecting fever, temperature measurements by OptoTherm and FLIR had greater sensitivity (91.0% and 90.0%, respectively) and specificity (86.0% and 80.0%, respectively) than did self-reports. Correlations between ITDS and oral temperatures were similar for OptoTherm (ρ = 0.43) and FLIR (ρ = 0.42) but significantly lower for Wahl (ρ = 0.14; p < 0.001). When compared with oral temperatures, 2 systems (OptoTherm and FLIR) were reasonably accurate for detecting fever and predicted fever better than self-reports.

Laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass in the pediatric population: a MBSAQIP analysis.

BACKGROUND: The growing prevalence of childhood obesity has resulted in an increased number of children and adolescents who undergo bariatric surgery. The safety of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) remains controversial in the pediatric population. OBJECTIVE: To assess the safety of LSG compared with LRYGB in patients aged ≤21 years. SETTING: A retrospective analysis of the 2016 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. METHODS: Patients aged ≤21 years who underwent LSG or LRYGB were identified in the 2016 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. A logistic regression model was used to create a 1:1 propensity-score matched cohort adjusting for age, sex, body mass index, and obesity-related co-morbidities. Unmatched and propensity-score matched analyses were performed to compare baseline characteristics and outcome data between LSG and LRYGB procedure groups. Primary outcomes of interest included 30-day major complications, such as death, reoperation, and anastomotic leak. RESULTS: Of 3571 patients included in our study, 2911 (81.52%) underwent LSG and 660 (18.48%) underwent LRYGB. Patients who underwent LRYGB had an increased body mass index and a higher rate of obesity-related co-morbidities. The LRYGB group had a significantly increased rate of major complications within the first 30 days in both the unmatched cohort (4.55% versus 1.34%, P < .001) and the propensity-score matched cohort (4.57% versus .91%, P < .001). CONCLUSIONS: LSG and LRYGB are both relatively safe to perform in the pediatric population with acceptable complication rates and low mortality. However, LSG demonstrated a significantly decreased rate of major complications in the first 30 days compared with LRYGB.

Differences between low-molecular-weight and unfractionated heparin for venous thromboembolism prevention following ischemic stroke: a metaanalysis.

BACKGROUND: Venous thromboembolism (VTE) remains a major cause of morbidity following stroke. The optimal form of pharmacologic prophylaxis following stroke is unknown. METHODS: We identified randomized trials comparing unfractionated heparin (UFH) to low-molecular-weight heparin (LMWH) for VTE prevention in ischemic stroke patients. We focused on the risk for VTE, pulmonary embolism (PE), bleeding, and mortality as a function of the type of agent used for prophylaxis. Findings were pooled with a random-effects model. RESULTS: We identified three trials including 2,028 patients. Two of the studies were blinded, two studies relied on enoxaparin, while one study utilized certoparin. In two studies, UFH was administered three times a day, while it was administered twice daily in the remaining study. The use of LMWH was associated with a significant risk reduction for any VTE (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.41 to 0.70; p < 0.001). Limiting the analysis to proximal VTEs also indicated that LMWHs were superior (OR with LMWH vs UFH, 0.53; 95% CI, 0.37 to 0.75; p < 0.001). LMWH use led to fewer PEs as well (OR, 0.26; 95% CI, 0.07 to 0.95; p = 0.042). There were no differences in rates of overall bleeding, intracranial hemorrhage, or mortality based on the type of agent employed. Restricting the analysis to the reports employing enoxaparin did not alter our findings. CONCLUSIONS: The prophylactic use of LMWH compared to UFH following ischemic stroke is associated with a reduction in both VTE and PE. This benefit is not associated with an increased incidence of bleeding. Broader use of LMWH for VTE prevention after ischemic stroke is warranted.

Low-molecular weight heparin for deep vein thrombosis prophylaxis in hospitalized medical patients: results from a cost-effectiveness analysis.

Multiple options exist for the prevention of deep vein thrombosis (DVT) in medical inpatients. We sought to determine the cost-effectiveness of low-molecular-weight heparin (LMWH) relative to unfractionated heparin (UFH) for DVT prevention in this setting. We conducted a cost-effectiveness analysis from the perspective of a third-party payer employing a decision model and literature-based estimates for inputs. In the base-case analysis, LMWH had little impact on the rate of DVT. Despite higher acquisition costs, however, LMWHs resulted in net savings. Routine use of LMWH saves approximately US$89 per patient. The lower rate of heparin-induced thrombocytopenia (HIT) with LMWH accounted for this differential. Univariate sensitivity analysis revealed the model was moderately sensitive to the odds ratio of HIT with LMWH and the cost of HIT. Multivariate sensitivity analysis confirmed the LMWH approach dominated financially. 'Worst-case' scenario modeling, where LMWH actually increased the risk for DVT, had little effect on the rate of HIT, and was substantially more costly than UFH, still demonstrated that LMWHs were economically superior. Monte-Carlo simulation indicated the 95% confidence interval around the estimate for savings with LMWH ranged from US$7 to US$373. We conclude that, despite their higher cost, LMWHs for thromboprophylaxis in medical patients result in savings.

Lyme neuroborreliosis presenting as the syndrome of inappropriate antidiuretic hormone secretion.

We describe a case of a patient presenting with the syndrome of inappropriate hormone secretion (SIADH) caused by Lyme neuroborreliosis.

Hypertensive retinopathy associated with use of the ephedra-free weight-loss herbal supplement Hydroxycut.

The use of performance-enhancing and weight-loss supplements is prevalent in the United States, and over the past decade, there has been growing concern with regard to the safety and efficacy of these products. It is well documented that ephedra-based products are associated with adverse reactions, including serious cardiovascular and neurologic injuries. With new restrictions placed on such products, companies are now marketing caffeine-based ephedra-free herbal supplements. Less is known about the potential side effects of these products. We present the case of a 42-year-old, previously healthy man who developed malignant hypertension and hypertensive retinopathy while taking Hydroxycut, a caffeine-based ephedra-free supplement. To our knowledge, this is the first documented case of hypertensive retinopathy associated with the use of Hydroxycut. Given the lack of investigative studies in regard to their safety and efficacy, judicious care should be taken with the use of all herbal supplements, including those designated as ephedra-free.

Levofloxacin for treatment of ventilator-associated pneumonia: a subgroup analysis from a randomized trial.

Ventilator-associated pneumonia (VAP) remains a significant challenge in critical care. We conducted a secondary analysis of a multicenter, prospective, randomized trial comparing levofloxacin (750 mg iv q24h) with imipenem-cilastatin (500-1000 mg iv q6-8h) for treatment of nosocomial pneumonia and focused on the subgroup of patients with VAP. The study cohort included 222 patients, with half (111) of the patients assigned to each treatment group. The patients in both groups were similar with respect to age, severity of illness, and duration of mechanical ventilation before the onset of VAP. Among the intention-to-treat population, clinical success was achieved in 58.6% of patients receiving levofloxacin, compared with 63.1% of patients receiving imipenem-cilastatin (P=.49; 95% confidence interval for the difference, -8.77% to 17.79%). Microbiological success and 28-day mortality rates were also comparable. Multivariate analysis demonstrated that assignment to antibiotic treatment (i.e., levofloxacin vs. imipenem-cilastatin) was not predictive of outcomes, thus suggesting that the treatment regimens were equivalent. Both levofloxacin and imipenem-cilastatin regimens were well tolerated and had similar adverse event profiles.

Should we use etomidate as an induction agent for endotracheal intubation in patients with septic shock?: a critical appraisal.

Etomidate is commonly used for the facilitation of endotracheal intubation. While etomidate possesses multiple qualities that are beneficial in hemodynamically unstable patients who require a sedative or amnestic, its potential to negatively impact corticosteroid production is well-documented. Given the frequency of relative adrenal insufficiency observed in the critically ill and the increasing use of corticosteroids in patients with septic shock, an appraisal of the status of etomidate as an induction agent in patients with evolving or established septic shock is indicated. A review of the relevant literature suggests that its use in this setting may be harmful. It is proposed that, pending the performance of a randomized, controlled clinical trial, considerable caution should accompany its administration in patients with evolving or established septic shock. The potential role for concomitant empiric steroid replacement and the comparability of alternative induction regimens are also discussed.

Transfusion practice and blood stream infections in critically ill patients.

STUDY OBJECTIVE: To examine the relationship between packed RBC (pRBC) transfusion and the development of ICU-acquired bloodstream infections (BSIs) DESIGN: Secondary analysis of a large, prospective, observational study of transfusion practice in critically ill patients. SETTING: A total of 284 adult ICUs in the United States. PATIENTS: Critically ill adults who lacked BSIs both at ICU admission and 48 h after ICU admission. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: BSIs were prospectively tracked in this study, and diagnosis of a new BSI represented the primary end point. Transfusions administered in the ICU prior to development of a BSI were also prospectively recorded. Of 4,892 patients enrolled in this investigation, 3,502 patients lacked BSIs both at ICU admission and 48 h later. Among these individuals, 117 patients (3.3%) had an ICU-acquired BSI. In multivariate analysis adjusting for severity of illness, primary diagnosis, use of mechanical ventilation, placement of central venous catheters, and ICU length of stay, three variables were independently associated with diagnosis of a new BSI: baseline treatment with cephalosporins (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.26 to 2.68), higher sequential organ failure assessment score measured on ICU days 3 to 4 (OR, 1.11; 95% CI, 1.06 to 1.16), and pRBC transfusion (OR, 2.23; 95% CI, 1.43 to 3.52). The relationship between pRBC transfusion and BSI was evident with both small transfusion volumes (OR with 1- to 2-U pRBC transfusion, 1.89; 95% CI, 1.10 to 3.23) and larger transfusion volumes (OR with > 4-U pRBC transfusion, 2.63; 95% CI, 1.52 to 4.53). CONCLUSIONS: pRBC transfusion is associated with subsequent ICU-acquired BSI. Avoiding unnecessary transfusions may decrease the incidence of BSIs.

Meta-analysis: outcomes in patients with suspected pulmonary embolism managed with computed tomographic pulmonary angiography.

BACKGROUND: Spiral computed tomographic pulmonary angiography (CTPA) is increasingly being used in the evaluation of patients with clinically suspected pulmonary embolism (PE). However, CTPA as a definitive diagnostic test may be limited by inadequate sensitivity, especially in instances of isolated subsegmental emboli. PURPOSE: To assess the safety of withholding anticoagulation in patients with suspected PE and negative results on CTPA. DATA SOURCES: All relevant studies identified in MEDLINE (1966 to March 2004) and EMBASE (1974 to 2004) and in bibliographies of key articles. The search was not limited to the English language. STUDY SELECTION: The authors selected all published studies that used CTPA to evaluate suspected PE and reported at least 3 months of follow-up in patients not receiving anticoagulation on the basis of a negative CTPA result. DATA EXTRACTION: Two reviewers independently rated study quality on the basis of predetermined criteria. Data were extracted on participants, CTPA technique, diagnostic studies performed, prevalence of PE, number of patients with negative or indeterminate CTPA results who were followed, and subsequent rates of venous thromboembolism and fatal PE. DATA SYNTHESIS: Twenty-three studies reported on 4657 patients with negative CTPA results who did not receive anticoagulation. The 3-month rate of subsequent venous thromboembolic events was 1.4% (95% CI, 1.1% to 1.8%), and the 3-month rate of fatal PE was 0.51% (CI, 0.33% to 0.76%). LIMITATIONS: The CTPA technology used varied across studies and was not applied uniformly in the same step of diagnostic algorithms. Only 1 study used CTPA as the sole diagnostic test. CONCLUSION: The rate of subsequent venous thromboembolism after negative results on CTPA is similar to that seen after negative results on conventional pulmonary angiography. It appears to be safe to withhold anticoagulation after negative CTPA results.

Potentially ineffective care: time for earnest reexamination.

The rising costs and suboptimal quality throughout the American health care system continue to invite critical inquiry, and practice in the intensive care unit setting is no exception. Due to their relatively large impact, outcomes and costs in critical care are of significant interest to policymakers and health care administrators. Measurement of potentially ineffective care has been proposed as an outcome measure to evaluate critical care delivery, and the Patient Protection and Affordable Care Act affords the opportunity to reshape the care of the critically ill. Given the impetus of the PPACA, systematic formal measurement of potentially ineffective care and its clinical, economic, and societal impact merits timely reconsideration.