Cardiac Arrhythmias Resulting from a Peripherally Inserted Central Catheter: Two Cases and a Review of the Literature.

We present two cases of patients being treated for diabetic ketoacidosis in the intensive care unit who experienced cardiac arrhythmia secondary to peripherally inserted central catheters (PICCs). In one instance, the patient became bradycardic and experienced related loss of consciousness, ultimately requiring cardiopulmonary resuscitation. In the second case, the patient experienced an episode of nonsustained ventricular tachycardia. We explore the various types of arrhythmias that have been reported secondary to central venous catheters, as well as factors that place patients at an increased risk for arrhythmia while undergoing PICC insertion. Furthermore, we look at the literature for methods to improve the insertion of PICC lines by decreasing the risk of catheter over-insertion as well as the effects of training for PICC placement.

Streptococcus Gordonii Empyema: A Case Report and Review of Empyema.

Streptococcus gordonii (S. gordonii) is a pioneer oral bacteria that is recognized as an agent of bacterial endocarditis. However, an extensive review of the literature revealed no reported case of S. gordonii causing empyema. We present a case of a 65-year-old male who presented with respiratory distress. Physical examination revealed several dental caries with decreased breath sounds in the bibasilar regions. A computed tomography (CT) scan of the chest and abdomen demonstrated left-sided pleural effusion and a 4.3 cm x 2.8 cm splenic abscess. He received intravenous (IV) antibiotics, and his blood cultures remained negative. Drainage of the splenic abscess grew S. gordonii. A CT-guided thoracentesis yielded 450 ml of exudative fluid. Pleural fluid cultures grew S. gordonii. A CT scan of the head and neck ruled out an intra-oral abscess. He received six weeks of IV penicillin with a follow-up CT scan showing resolution of both the splenic abscess and the left parapneumonic effusion.

Forgotten but Not Gone! Syphilis Induced Tenosynovitis.

Objective. Tenosynovitis, inflammation of a tendon and its synovial sheath, is a rare manifestation of secondary syphilis and if diagnosed early is reversible. Background. A 52-year-old male with past medical history of untreated syphilis presented with gradual onset of swelling and pain of the right fourth metacarpophalangeal joint (MCP). He reported a history of painless penile lesions after having sexual intercourse with a new partner approximately five months ago which was treated with sulfamethoxazole/trimethoprim. An RPR done at that time came back positive with a high titer; however, patient was lost to follow-up. On examination, patient had an edematous, nonerythematous right fourth proximal interphalangeal (PIP) joint. Urgent irrigation, debridement, and exploration of the right hand into the tendon sheath were performed. With his history of syphillis, an RPR was done, which was reactive with a titer of 1 : 64. A confirmatory FTA-ABS test was completed, rendering a positive result. Based on his history of untreated syphilis, dormancy followed by clinical scenario of swelling of the right fourth finger, and a high RPR titer, he was diagnosed with secondary syphilis manifesting as tenosynovitis.

Evaluating a prediction model for infant hearing loss.

OBJECTIVES/HYPOTHESIS: The objective of this study was to determine whether a prognostic model using risk factors for hearing loss could predict the chance that infants who failed a newborn hearing screen would subsequently be found to have hearing loss diagnosed by auditory brainstem response testing. STUDY DESIGN: Individual retrospective case-control study. METHODS: We studied 229 infants with hearing loss compared with 458 infants with normal hearing. All infants had undergone natural sleep or sedated auditory brainstem response, predominantly for not passing a newborn hearing screen. Risk factors, birth history, and other information were extracted via medical record review. Multiple logistic regression analyses identified independent predictors of hearing loss. RESULTS: Four risk factors were independently predictive of hearing loss diagnosed by sleep or sedated auditory brainstem response: prematurity, 5-minute APGAR score ≤ 6, intracranial complication, and craniofacial abnormality. A prognostic model developed from these risk factors was associated with a 15% rate of hearing loss in stage I, 52% rate of hearing loss in stage II, and 96% rate of hearing loss in stage III. CONCLUSIONS: The presence of any one of four independently predictive risk factors in infants who did not pass newborn hearing screen was associated with a 50% rate of hearing loss; having three or more was associated with a 90% rate of hearing loss. Knowing that an infant is at high risk of hearing loss can motivate parents to follow up with diagnostic auditory brainstem response testing so that early identification can lead to early intervention.

Magnetic resonance imaging of the pediatric liver: benign and malignant masses.

Hepatic neoplasms constitute approximately 5% to 6% of all pediatric intra-abdominal masses, most of which are malignant. When compared with traditional multiphase computed tomography protocols that are often used in adults, magnetic resonance (MR) imaging is particularly desirable for evaluating liver lesions in children because of the lack of ionizing radiation and superb soft tissue contrast resolution. The goal of this article is to discuss common benign and malignant pediatric hepatic lesions and their key MR imaging findings. Particular emphasis is placed on the utility of new hepatocyte-specific contrast agents to narrow the differential diagnosis.

Quantifying clinical HPV4 dose inefficiencies in a safety net population.

PURPOSE: HPV4 is the most expensive vaccine requiring three appropriately timed doses to provide maximal efficacy against two oncogenic HPV types. The primary purpose of this study is to quantify the use of HPV4 vaccine in a safety net health care system in terms of its inefficiencies. METHODS: A retrospective study of HPV4 dosing from 2006-2009, among females 10-26 years old who sought care in a safety net health care system was conducted to determine dose usage patterns among those at highest risk for cervical cancer. Dose descriptors abstracted from the electronic medical record (EMR) included timing and number in series as well as characteristics of the person to whom and visit at which the dose was given. Dose inefficiencies were separated into "less than three doses" and "mistimed doses" for analysis. RESULTS: The majority (66%) of HPV4 doses administered were insufficient to induce the maximal immune response necessary for HPV infection prevention. Among on-time doses, 58% were singleton or doublet doses. Mistimed doses accounted for 19% of all doses administered with late intervals being more common than early intervals among those receiving more than one dose (9% vs. 4%, p<0.001). Third doses were mistimed twice as often as second doses (10% vs. 5%, p<0.001). Black women were more likely to have a mistimed second dose and Hispanic women more likely to have a mistimed third dose compared to white women (OR = 1.70 (95% CI: 1.11, 2.61 and 2.44 (1.19, 5.00), respectively). The HPV4-only visit type at which HPV4 was initiated was the most significant predictor of on-time doublet completion. CONCLUSIONS: In a safety net health care system the large inefficiencies associated with HPV4 vaccination must be addressed in order to maximize our patient's cervical cancer prevention.