High risk and low prevalence diseases: Guillain-Barré syndrome.

INTRODUCTION: Guillain-Barré syndrome (GBS) is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of GBS, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: GBS is a rare immune-mediated neurologic disorder with peripheral nerve injury. It most commonly presents weeks after a bacterial or viral infection, though there are a variety of associated inciting events. The diagnosis is challenging and often subtle, as only 25-30% of patients are diagnosed on their initial healthcare visit. Clinicians should consider GBS in patients with progressive ascending weakness involving the lower extremities associated with hyporeflexia, but the cranial nerves, respiratory system, and autonomic system may be involved. While the ED diagnosis should be based on clinical assessment, further evaluation includes laboratory testing, cerebrospinal fluid (CSF) analysis, and potentially neuroimaging. Not all patients demonstrate albumino-cytological dissociation on CSF testing. Several criteria exist to assist with diagnosis, including the National Institute of Neurological Disorders and Stroke criteria and the Brighton criteria. Management focuses first on assessment of the patient's hemodynamic and respiratory status, which may require emergent intervention. Significant fluctuations in heart rate and blood pressure may occur, and respiratory muscle weakness may result in the need for airway protection. Neurology consultation is recommended, and definitive treatment includes PLEX or IVIG. CONCLUSIONS: An understanding of GBS can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

A retrospective cohort study assessing acute kidney injury and renal recovery among septic patients empirically treated with vancomycin piperacillin-tazobactam versus vancomycin cefepime.

Vancomycin plus piperacillin-tazobactam (VPT) is a commonly used antimicrobial regimen for septic patients. VPT is more nephrotoxic than other regimens such as vancomycin plus cefepime (VC) when given over several days. This risk of nephrotoxicity is less clear when VPT is given for initial empiric therapy in sepsis and de-escalated quickly based on evolving clinical information. The objective of this study was to assess nephrotoxicity among septic patients empirically treated with either VPT or VC at initial clinical presentation. We conducted a retrospective study of septic patients who received VPT or VC within 12 h of presentation to the emergency department. The primary outcomes were acute kidney injury (AKI) and renal recovery 72 h after presentation. For the total of 418 patients, 306 received VPT and 112 received VC. Rates of AKI at 72 h were 15.2% for VPT patients and 11.0% for VC patients [p = 0.44]. Among patients with AKI at presentation, 16.3% of VPT patients had AKI at 72 h compared to 8.9% of VC patients [p = 0.19]. Among those without AKI at presentation, 14.2% VPT patients and 16.7% VC patients had AKI at 72 h [p = 0.71]. Renal recovery rates for patients with AKI at presentation were 42.3% for VPT patients versus 40.3% for VC patients [p = 0.78]. In-hospital renal replacement therapy occurred in 6.2% VPT patients and 0.9% VC patients [p = 0.024]. Therefore, initial empiric therapy with VPT in sepsis may not confer increased risk of AKI when de-escalated appropriately.

Predictors of new-onset atrial fibrillation in geriatric trauma patients.

INTRODUCTION: Geriatric patients (age >65) comprise a growing segment of the trauma population. New-onset atrial fibrillation may occur after injury, complicating clinical management and resulting in significant morbidity and mortality. This study was undertaken to identify clinical and demographic factors associated with new-onset atrial fibrillation among geriatric trauma patients. METHODS: In this case control study, eligible participants included admitted trauma patients age 65 and older who developed new-onset atrial fibrillation during the hospitalization. Controls were admitted trauma patients who were matched for age and injury severity score, who did not develop atrial fibrillation. We evaluated the associations between new-onset atrial fibrillation and clinical characteristics, including patient demographics, health behaviors, chronic medical conditions, and course of care. RESULTS: Data were available for 63 cases and 25 controls. Patients who developed atrial fibrillation were more likely to be male, compared to controls (49% versus 24%; odds ratio 3.0[1.0, 8.9]). Other demographic and clinical factors were not associated with new-onset atrial fibrillation, including mechanism of injury, co-morbid medical conditions, drug or alcohol use, surgical procedures, and intravenous fluid administration. CONCLUSIONS: Male geriatric trauma patients were at higher risk for developing new-onset atrial fibrillation. Other demographic and clinical factors were not associated with new-onset atrial fibrillation.