Elderly and their companion animals, cause for pleasure or for harm, a case report of a non-bite Pasteurella multocida bacteremia in an 85-year-old woman with a fatal outcome.

We present a case of an elderly woman suffering from Pasteurella multocida (P. multocida) bacteremia, without obvious bite marks, but owning a pet dog. Although the patient was not immunocompromised, and prompt treatment with intravenous antibiotics was initiated, she developed severe septic shock with multiple organ failure and died. In healthy individuals, an infection caused by these bacteria is easy to treat and often harmless, whereas in elderly serious complications can occur. We believe this report of a fatal outcome of a P. multocida bacteremia in a non-immunocompromised, but elderly patient is important, given the growing cohort of elderly pet-owners seeking medical care. A greater awareness of this zoonosis and its potentially fatal outcome is warranted.

The development and appraisal of a tool designed to find patients harmed by falsely labelled, falsified (counterfeit) medicines.

BACKGROUND: Falsely labelled, falsified (counterfeit) medicines (FFCm's) are produced or distributed illegally and can harm patients. Although the occurrence of FFCm's is increasing in Europe, harm is rarely reported. The European Directorate for the Quality of Medicines & Health-Care (EDQM) has therefore coordinated the development and validation of a screening tool. METHODS: The tool consists of a questionnaire referring to a watch-list of FFCm's identified in Europe, including symptoms of their use and individual risk factors, and a scoring form. To refine the questionnaire and reference method, a pilot-study was performed in 105 self-reported users of watch-list medicines. Subsequently, the tool was validated under "real-life conditions" in 371 patients in 5 ambulatory and in-patient care sites ("sub-studies"). The physicians participating in the study scored the patients and classified their risk of harm as "unlikely" or "probable" (cut-off level: presence of ≥2 of 5 risk factors). They assessed all medical records retrospectively (independent reference method) to validate the risk classification and documented their perception of the tool's value. RESULTS: In 3 ambulatory care sites (180 patients), the tool correctly classified 5 patients as harmed by FFCm's. The positive and negative likelihood ratios (LR+/LR-) and the discrimination power were calculated for two cut-off levels: a) 1 site (50 patients): presence of two risk factors (at 10% estimated health care system contamination with FFCm's): LR + 4.9/LR-0, post-test probability: 35%; b) 2 sites (130 patients): presence of three risk factors (at 5% estimated prevalence of use of non-prescribed medicines (FFCm's) by certain risk groups): LR + 9.7/LR-0, post-test probability: 33%. In 2 in-patient care sites (191 patients), no patient was confirmed as harmed by FFCm's. The physicians perceived the tool as valuable for finding harm, and as an information source regarding risk factors. CONCLUSIONS: This "decision aid" is a systematic tool which helps find in medical practice patients harmed by FFCm's. This study supports its value in ambulatory care in regions with health care system contamination and in certain risk groups. The establishment of systematic communication between authorities and the medical community concerning FFCm's, current patterns of use and case reports may sustain positive public health impacts.

Mobile Medical Teams are Often Over-Qualified.

BACKGROUND AND IMPORTANCE: Emergency department (ED) staff in Belgium is simultaneously involved in patient care in the ED and in prehospital interventions as part of a Mobile Medical Team (MMT) or a Paramedic Intervention Team (PIT). There is a growing concern that the MMT is often over-qualified for the prehospital interventions they are dispatched to, while their absence from the ED results in insufficient human resources there. OBJECTIVE: The current study aims to investigate whether this perception is correct in the EDs of two different regions, while also examining the differences between a two-tiered (2T) and a three-tiered (3T) Emergency Medical Services (EMS) region. METHODS: A specially developed and pre-tested registration form was completed by physicians and nurses before and after each MMT intervention. The form included information on the composition of the MMT, the perceived need for MMT intervention pre-departure from the ED, the subjective appreciation of the need for the MMT after an intervention, and the therapeutic intervention(s) performed, in order to obtain a more objective appreciation of the actual need for an MMT. Data from a 2T and a 3T region were analyzed to rate the appropriateness of the interventions. RESULTS: Although the 2T and 3T regions showed differences regarding MMT composition, dispatching, and logistics, the outcome of the study was identical in both regions. Before the intervention, physicians and nurses estimated that the MMT intervention would not be necessary in 37.7% of cases. However, following the intervention, it was subjectively deemed unnecessary in 65.7% of cases. Based on therapeutic interventions performed, the MMT was viewed as being over-qualified for carrying these out in 85.6% of cases. Post-intervention, the initial prediction that the MMT was over-qualified for the call was confirmed by the same physicians and nurses in 87.6% of cases, whilst their prediction was correct in 92.8% of cases in terms of the intervention that was carried out. CONCLUSION: In two different Belgian regions, the MMT is over-qualified in a vast majority of interventions. Physicians and nurses within the MMT can generally already predict that the MMT is over-qualified when leaving the ED. These findings suggest that there may be significant opportunities to improve the efficacy of human resources in the ED once there are less interventions carried out by an over-qualified MMT.

Clostridium myonecrosis - a rare and underdiagnosed condition in the elderly: a case with severe skipping lesions and an overview of treatment guidelines.

We present an unusual and severe case of spontaneous clostridial myonecrosis (SCM) in an elderly patient, with severe skipping lesions spread throughout the body. CT imaging, combined with postmortem available blood cultures, confirmed the diagnosis. We noted an underrepresentation of SCM in the cohort of elderly patients (≥ 85 years), upon a review of case reports in the literature over the last decade. Given the worldwide demographic change resulting in an increase in the number of visits to emergency departments for this age group, it is likely that SCM is underdiagnosed in these elderly patients. This case report aims to increase awareness among emergency physicians to recognize the disease as well as to provide a treatment guideline, in order to provide better care and outcome.

Presumed mass illness following a pyridine fumes incident: environmental contamination versus mass hysteria.

This case study is based on a chemical spill in a warehouse in Belgium. Two victims were hospitalized, and a confluence of symptoms among the warehouse personnel had to be managed medically. An on-scene medical station and medical management team were deployed. A total of 51 victims were examined. Medical, political, and labor management arguments occurred. Medical findings and results from a thorough investigation helped prevent a presumed illness epidemic. The primary goals of the medical management of victims must include ensuring the health and safety of the personnel involved.

A case of group A streptococcal meningitis following acute otitis media.

Group A streptococcal meningitis is less common than other forms of meningitis; however, the occurrence of this infection is associated with high mortality and morbidity. Early recognition and a prompt treatment are therefore essential. We review one case of an Asian women admitted with group A streptococcal meningitis as a complication of otitis media.

Sudden drooling and supine gagging: an important emergency?

We describe a case of an eupnoeic patient complaining of a foreign body sensation in his mouth and throat, with sudden drooling and supine gagging. This condition was caused by an isolated uvular angioedema (Quincke's oedema). As this uvular hydrops did not decrease with initial standard therapy for angioedema, epinephrin was applied directly on the swollen uvula, causing it to shrink very rapidly. Isolated uvular oedema is a potentially life-threatening condition with risk of sudden upper airway obstruction, and should therefore be recognized and treated as soon as possible. As described in this case, its initial presentation can consist of gagging and drooling without dyspnoea, thus causing a real challenge for triage and diagnosis.

A vertebral artery dissection with basilar artery occlusion in a child.

This paper presents the case report of an 11-year-old boy with an acute dissection with thrombosis of the left vertebral artery and thrombosis of the basilar artery. The patient was treated with acute systemic thrombolysis, followed by intra-arterial thrombolysis, without any clinical improvement, showing left hemiplegia, bilateral clonus, hyperreflexia, and impaired consciousness. MRI indicated persistent thrombosis of the arteria basilaris with edema and ischemia of the right brainstem. Heparinization for 72 hours, followed by a two-week LMWH treatment and subsequent oral warfarin therapy, resulted in a lasting improvement of the symptoms. Vertebral artery dissection after minor trauma is rare in children. While acute basilar artery occlusion as a complication is even more infrequent, it is potentially fatal, which means that prompt diagnosis and treatment are imperative. The lack of class I recommendation guidelines for children regarding treatment of vertebral artery dissection and basilar artery occlusion means that initial and follow-up management both require a multidisciplinary approach to coordinate emergency, critical care, interventional radiology, and child neurology services.