In-Hospital Mortality Following Open and Closed Long Bone Fracture: A Comparative Study.

BACKGROUND: Open fracture is a serious orthopaedic injury that can lead to significant patient morbidity and mortality. There is limited data on the mortality risk for open compared to closed long bone fracture. METHODS: The Nationwide Inpatient Sample was used to identify all patients who were admitted with a long bone fracture in the United States between 1998 and 2010. Cox proportional hazards regression modeling was used to calculate the hazard ratio (HR) and 95% confidence interval (CI) of mortality. RESULTS: After adjusting for age, gender, race, insurance, and comorbidities, the HR of mortality was 2.89 (95% CI, 2.56-3.28; p<0.001) for open compared to closed fracture. Stratified by anatomical site, the HR of mortality for open compared to fracture was 3.43 for femur (95% CI, 2.78-4.23; p<0.001), 2.81 for tibia or fibula (95% CI, 2.17-3.64; p<0.001), 2.54 for humerus (95% CI, 1.81-3.56; p<0.001), and 1.56 for radius or ulna (95% CI, 1.10-2.23; p=0.014). CONCLUSIONS: This data suggests that open fracture carries a worse prognosis compared to closed fracture at the same anatomical site.

Relationship between the Soluble F11 Receptor and Annexin A5 in African Americans Patients with Type-2 Diabetes Mellitus.

Type 2 diabetes mellitus (T2DM) is characterized by endothelial dysfunction, increased thrombogenicity, and inflammation. The soluble human F11 receptor (sF11R) and annexin A5 (ANXA5) play crucial roles in inflammatory thrombosis and atherosclerosis. We examined the relationship between circulating sF11R and ANXA5 and their impact on endothelial function. The study included 125 patients with T2DM. Plasma levels of sF11R and ANXA5 were quantified by ELISA. Microvascular function was assessed using the vascular reactivity index (VRI). Large artery stiffness was assessed by carotid-femoral pulse wave velocity (PWV). Carotid intima-media thickness (CIMT) was assessed by B-mode ultrasound imaging. The mean age of patients in the study was 59.7 ± 7.8 years, 78% had hypertension, 76% had dyslipidemia, and 12% had CKD. sF11R correlated positively with ANXA5 levels (ß = 0.250, p = 0.005), and correlated inversely with VRI and total nitic oxide (NO), (ß = −0.201, p = 0.024; ß = −0.357, p = 0.0001, respectively). Multivariate regression analysis revealed that sF11R was independently associated with ANXA5 in the total population and in patients with HbA1c > 6.5% (ß = 0.366, p = 0.007; ß = 0.425, p = 0.0001, respectively). sF11R and ANXA5 were not associated with vascular outcome, suggesting that they may not be reliable markers of vascular dysfunction in diabetes. The clinical significance of sF11R/ANXA5 association in diabetes warrants further investigation in a larger population.

Association between nitrated lipoproteins and vascular function in type 2 diabetes.

Higher levels of nitrated lipoproteins (NT-HDL and NT-LDL) were found in blood and atherosclerotic plaques of patients with coronary artery disease. We aimed to examine the relationship between plasma NT-HDL and NT-LDL and diabetic vascular dysfunction. The study included 125 African-American patients with T2DM. NT-HDL and NT-LDL were quantified by ELISA. Microvascular function was assessed by vascular reactivity index (VRI). Large artery stiffness was assessed by carotid-femoral pulse wave velocity (PWV). Carotid intima-media thickness (CIMT) was assessed by B-mode ultrasound imaging. In univariate analysis, NT-HDL was associated with VRI in total population and in patients with HbA1c more than or equal to 7.0 percent (beta= -0.178, p= 0.034; beta = -0.265, p= 0.042; respectively). In contrast, NT-LDL was associated with CIMT in total population and in patients with HbA1c more than 7.0 percent (beta = -0.205, p= 0.022; beta = -0.244, p= 0.042; respectively). Multivariable-adjusted regression analysis demonstrated that NT-HDL independently predicted VRI outcome in total population and in well-controlled patients (beta = -0.282, p= 0.014; beta = -0.400, p= 0.035, respectively). These results suggest that NT-HDL could be used as marker to identify diabetic patients at risk of developing early microvascular complications.

Dissociative Identity Disorder CPAP Adherence: An Uncommon Factor in Obstructive Sleep Apnea.

ABSTRACT: We present a case of a patient with dissociative identity disorder and symptomatic sleep apnea who was treated with continuous positive airway pressure (CPAP). CPAP use depended upon which personality the patient exhibited but apnea reduction did not. This case illustrates in one individual how personality can positively or negatively affect CPAP adherence.

Impact of contact and droplet precautions on the incidence of hospital-acquired methicillin-resistant Staphylococcus aureus infection.

OBJECTIVE: To evaluate the efficacy of contact and droplet precautions in reducing the incidence of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections. DESIGN: Before-after study.Setting. A 439-bed, university-affiliated community hospital. METHODS: To identify inpatients infected or colonized with MRSA, we conducted surveillance of S. aureus isolates recovered from clinical culture and processed by the hospital's clinical microbiology laboratory. We then reviewed patient records for all individuals from whom MRSA was recovered. The rates of hospital-acquired MRSA infection were tabulated for each area where patients received nursing care. After a baseline period, contact and droplet precautions were implemented in all intensive care units (ICUs). Reductions in the incidence of hospital-acquired MRSA infection in ICUs led to the implementation of contact precautions in non-ICU patient care areas (hereafter, "non-ICU areas"), as well. Droplet precautions were discontinued. An analysis comparing the rates of hospital-acquired MRSA infection during different intervention periods was performed. RESULTS: The combined baseline rate of hospital-acquired MRSA infection was 10.0 infections per 1,000 patient-days in the medical ICU (MICU) and surgical ICU (SICU) and 0.7 infections per 1,000 patient-days in other ICUs. Following the implementation of contact and droplet precautions, combined rates of hospital-acquired MRSA infection in the MICU and SICU decreased to 4.3 infections per 1,000 patient-days (95% confidence interval [CI], 0.17-0.97; P=.03). There was no significant change in hospital-acquired MRSA infection rates in other ICUs. After the discontinuation of droplet precautions, the combined rate in the MICU and SICU decreased further to 2.5 infections per 1,000 patient-days. This finding was not significant (P=.43). In the non-ICU areas that had a high incidence of hospital-acquired MRSA infection, the rate prior to implementation of contact precautions was 1.3 infections per 1,000 patient-days. After the implementation of contact precautions, the rate in these areas decreased to 0.9 infections per 1,000 patient-days (95% CI, 0.47-0.94; P=.02). CONCLUSION: The implementation of contact precautions significantly decreased the rate of hospital-acquired MRSA infection, and discontinuation of droplet precautions in the ICUs led to a further reduction. Additional studies evaluating specific infection control strategies are needed.

Desoximetasone 0.25% and tacrolimus 0.1% ointments versus tacrolimus alone in the treatment of atopic dermatitis.

Long-term in vitro compatibility of desoximetasone and tacrolimus ointments prompted the current trial in humans. We aimed to evaluate the efficacy of twice-daily simultaneous application of desoximetasone and tacrolimus in the treatment of atopic dermatitis versus tacrolimus monotherapy. Eighty-two subjects were treated in this multicenter, single-group, double-blinded, paired, 3-week follow-up clinical study of desoximetasone 0.25% and tacrolimus 0. 1% ointments versus tacrolimus 0.1% ointment and vehicle. Subjects were treated twice daily for 21 days or until clearing. Safety and efficacy were assessed at days 3, 7, 14, and 21. The combination of desoximetasone and tacrolimus ointment was superior to tacrolimus alone (P=.0002) in treating atopic dermatitis as measured by the summary of the scores for erythema, lichenification, pruritus, scaling/dryness, and oozing/crusting. Of note, pruritus at the application site was diminished in subjects treated with desoximetasone and tacrolimus together compared with tacrolimus alone (P=.04). Combination treatment with desoximetasone and tacrolimus offered increased efficacy and tolerability over tacrolimus alone in patients with atopic dermatitis.

Increased mortality associated with a clonal outbreak of ceftazidime-resistant Klebsiella pneumoniae: a case-control study.

OBJECTIVES: To determine risk factors for ceftazidime-resistant Klebsiella pneumoniae infection and the effect of ceftazidime-resistant K. pneumoniae infection on mortality during an isolated outbreak. DESIGN: Case-control investigation using clinical and molecular epidemiology and prospective analysis of infection control interventions. SETTING: Surgical intensive care unit of a university-affiliated community hospital. PATIENTS: Fourteen case-patients infected with ceftazidime-resistant K. pneumoniae and 14 control-patients. RESULTS: Ten of 14 case-patients had identical strains by pulsed-field gel electrophoresis. Broad-spectrum antibiotic therapy before admission to the unit was strongly predictive of subsequent ceftazidime-resistant K. pneumoniae infection. In addition, patients with ceftazidime-resistant K. pneumoniae infection experienced increased mortality (odds ratio, 3.77). CONCLUSIONS: Cephalosporin restriction has been shown to decrease the incidence of nosocomial ceftazidime-resistant K. pneumoniae. However, isolated clonal outbreaks may occur due to lapses in infection control practices. Reinstatement of strict handwashing, thorough environmental cleaning, and repeat education led to termination of the outbreak. A distinct correlation between ceftazidime-resistant K. pneumoniae infection and mortality supports the important influence of antibiotic resistance on the outcome of serious bacterial infections.

Quinolone-resistant Haemophilus influenzae in a long-term care facility: clinical and molecular epidemiology.

We describe a clonal outbreak of quinolone-resistant Haemophilus influenzae (QRHI) from an affiliated long-term care facility (LTCF-A); the outbreak was associated with the clinical use of levofloxacin, which was determined to be a risk factor for acquisition of QRHI. The minimum inhibitory concentration to which 90% of isolates were susceptible (MIC90), as determined by broth microdilution, was >4 microg/mL for levofloxacin, >2 microg/mL for moxifloxacin, >2 microg/mL for gatifloxacin, and 8 microg/mL for gemifloxacin. The MIC90, as determined by Etest (AB Biodisk), was >32 microg/mL for levofloxacin, ciprofloxacin, moxifloxacin, and gatifloxacin. Having been a resident at LTCF-A and having chronic obstructive pulmonary disease were significant risk factors for acquisition of QRHI at our 500-bed hospital (New York Hospital Queens). All QRHI isolates were found to be genetically related by pulsed-field gel electrophoresis, were nontypeable, were susceptible to ceftriaxone and azithromycin, and were negative for beta -lactamase production. Emphasis on patient contact and respiratory isolation and placing colonized or infected patients in cohorts yielded a marked reduction in the prevalence of QRHI at LTCF-A.

Sleep and reported daytime sleepiness in normal subjects: the Sleep Heart Health Study.

STUDY OBJECTIVES: To describe the distribution of nocturnal sleep characteristics and reports of daytime sleepiness in a large well-defined group of healthy adults. DESIGN: The Sleep Heart Health Study is a multicenter study examining sleep and cardiopulmonary parameters through nocturnal polysomnography in adults enrolled in geographically distinct cardiovascular cohorts. SETTING: Community setting. PARTICIPANTS: 470 subjects enrolled in the Sleep Heart Health Study (n = 6440) were selected as a 'normative' group based on screening of health conditions and daily habits that could interfere with sleep. MEASUREMENTS AND RESULTS: Home-based nocturnal polysomnography was obtained on all participants and centrally scored for sleep and respiratory parameters. Demographic and health-related data were obtained and updated at the time of the home visit. Sleep efficiency decreased by 1.6% for each 10 years of increased age. Sleep time decreased by 0.1 hours (6.0 minutes) for each 10-year age increase and was longer in women. The arousal index increased by 0.8 for each 10-year increase in age and was lower by 1.4 in women. Women had a lower mean percentage of stage 1 and stage 2 sleep. Mean percentage of slow-wave sleep was higher in women (by 6.7%). Percentage of slow-wave sleep decreased with increased age for men only (by 1.9% for each 10-year age change). CONCLUSIONS: Data suggest a clear lessening in the quantity and quality of sleep with age that appears to be more rapid in males compared to females.

Early administration of antibiotics does not shorten time to clinical stability in patients with moderate-to-severe community-acquired pneumonia.

STUDY OBJECTIVE: To determine if there is a statistically significant difference in the time to clinical stability (TCS) between those patients with moderate-to-severe (MTS) community-acquired pneumonia (CAP) who received their antibiotics within 4 h and those who received their antibiotics after 4 h. DESIGN: Prospective observational study. SETTING: A large metropolitan teaching institution with 62,000 annual emergency department visits from May 1999 through January 2001. PATIENTS: Patients were > or = 21 year with MTS CAP as defined by the Pneumonia Patient Outcomes Research Team (PORT). INTERVENTIONS: Triage-to-needle time (group 1, 0 to 240 min; group 2, 241 to 480 min; and group 3, > 480 min) was the independent variable, and TCS was the dependent variable. Our hypothesis was that door-to-needle time < 4 h would result in TCS reduction of 0.5 days. MEASUREMENTS: Statistical analysis was performed using the two-tailed Student t test, analysis of variance, and multiple linear regression; p < 0.05 was considered significant. RESULTS: Four hundred nine patients with MTS CAP achieved clinical stability during their hospital stay. Fifty-four percent of patients received antibiotics within 4 h. The mean time to receiving antibiotics was 131.46 min (2.19 h) in group 1, 335.52 min (5.59 h) in group 2, and 783.98 min (13.07 h) in group 3. Mean TCS was 3.19 days in group 1, 3.16 days in group 2, and 3.29 days in group 3. There were no statistically significant differences in TCS between the study groups. CONCLUSION: The administration of antibiotics within 4 h does not reduce the TCS in adult patients with MTS-CAP, as defined by the PORT group. Future studies using other physiologic parameters should be explored.

Intrapartum fetal stimulation tests: a meta-analysis.

OBJECTIVE: To assess the performance of stimulation tests for the prediction of intrapartum fetal acidemia. DATA SOURCES: We conducted a MEDLINE (Internet Grateful Med) literature review from 1966 to 2000 using the terms "fetal scalp pH," "fetal scalp stimulation," and "fetal acoustic stimulation." STUDY SELECTION: Articles were included if sensitivity, specificity, and predictive values for intrapartum fetal acidemia could be calculated. Reactivity was a fetal heart rate (FHR) acceleration of 15 beats per minute for 15 seconds. Likelihood ratio and 95% confidence intervals (CIs) for four different fetal provocations were calculated using the Cochrane collaboration 2000 Review Manager 4.1. This permitted an estimate of the degree of confidence surrounding the point estimate of the likelihood ratio for the presence or absence of acidemia given a positive or negative test. The likelihood ratio is a stable predictive property of any test because it combines information from both sensitivity and specificity, is independent of prevalence, and avoids the limitations of traditional predictive values. TABULATION, INTEGRATION, AND RESULTS: Eleven of 512 articles met criteria for inclusion and included four stimulation tests - fetal scalp puncture, Allis clamp scalp stimulation, vibroacoustic stimulation, and digital scalp stimulation. Pooled likelihood ratio and 95% CIs were similar among the four different stimulation tests. Each test was very useful at predicting both the lack of and the presence of fetal acidemia. Likelihood ratio and 95% CIs for the prediction of fetal acidemia given a positive test were: scalp puncture 8.54 (CI 1.28, 56.96), Allis clamp 10.4 (CI 1.47, 73.61), vibroacoustic stimulation 5.06 (CI 2.69, 9.50), and digital 15.68 (CI 3.22, 76.24). For a negative test, these were: scalp puncture 0.12 (CI 0.02, 0.78), Allis clamp 0.10 (CI 0.01, 0.68), vibroacoustic stimulation 0.20 (CI 0.11, 0.37), and digital 0.06 (CI 0.01, 0.31). CONCLUSION: Intrapartum stimulation tests appear to be useful to rule out fetal acidemia in the setting of a nonreassuring FHR pattern. Our data reveal the degree of confidence around the estimate of the likelihood ratio of a stimulation test. The very low negative likelihood ratios warrant the use of these tests when a nonreassuring intrapartum FHR pattern appears. Because these tests are less than perfect, caution is advised; careful continued monitoring with repeat testing during the course of labor should be performed as long as suspicious FHR patterns persist. Fetal scalp pH should be determined whenever possible after a positive stimulation test (lack of acceleration).

Effect of interferon-alpha2b therapy on St. Louis viral meningoencephalitis: clinical and laboratory results of a pilot study.

The safety and potential efficacy of interferon (IFN)-alpha2b were determined for 15 patients during an outbreak of meningoencephalitis due to St. Louis encephalitis (SLE) virus. Clinical and laboratory results were compared with those of 17 untreated patients who were admitted to the same hospital during this nonrandomized preliminary trial. Quadriplegia, quadriparesis, or respiratory insufficiency persisted after the first week of hospitalization, for 11 of 17 untreated patients and for only 2 of 15 treated patients. These complications existed after the second week of hospitalization for 5 of the 17 untreated patients and for 1 of the 15 treated patients. Transient neutropenia and/or mild hepatitis occurred in 11 treated patients. Early initiation of IFN-alpha2b therapy may reduce the severity and duration of complications due to previously untreatable flavivirus meningoencephalitis. A prospective randomized controlled trial is warranted.

Effectiveness of Selective Use of Intravenous Pyelography in Patients Presenting to the Emergency Department with Ureteral Colic.

OBJECTIVE: To determine whether IV pyelography (IVP) is required routinely for all patients presenting to the ED with ureteral colic. METHODS: A randomized prospective study was conducted with 2 patient groups-a routine IVP group, in which all patients underwent IVP, and a selective IVP group, in which patients were treated, observed, and released without undergoing IVP unless they experienced continued symptoms. The study was performed in a large university-affiliated, community hospital ED. Participants were patients aged 18-65 years with signs and symptoms consistent with ureteral colic. RESULTS: Among the 40 patients enrolled in the routine IVP group, 26 had positive studies, 8 of which necessitated hospitalization. Among the 41 patients randomized to the selective IVP group, there were only 19 IVPs performed, of which 6 were positive and 4 necessitated hospitalization. Compared with the routine IVP group, there were 54% fewer FVPs performed and a 51 % lower admission rate in the selective IVP group. Despite the fact that fewer IVPs were performed in the selective IVP group, clinical outcomes in the 2 groups were similar, without significant complication in either group. CONCLUSIONS: IVPs do not need to be routinely performed for all patients presenting to the ED with ureteral colic. The decision to perform an IVP may be dictated by symptoms that persist after initial evaluation and treatment.