Fusobacterium nucleatum endocarditis: a case report and literature review.

Fusobacteria is anaerobic gram-negative rods, which frequently colonize the oral cavity and can rarely cause deadly diseases in humans. The two most commonly found in this group of bacteria are fusobacterium necrophorum and fusobacterium nucleatum. Only a handful of cases of endocarditis due to fusobacterium have been reported. We describe an 86-year-old male who had a recent tooth extraction presenting to the emergency department with weakness lightheadedness, and pain in his right elbow. He had a low-grade fever of 100.8°. The patient was discharged home but came back less than 24 hours with a fever of 102° and chills and again after the second discharge with sepsis of unknown origin. A week after initial blood cultures were drawn, fusobacterium nucleatum grew in one of two sets and his transesophageal echocardiogram revealed vegetation on his mitral valve. The patient was then successfully treated with a six weeks course of ampicillin-sulbactam. This case is followed by a review of the literature.

Opioid prescription patterns in a children's hospital from 2012 to 2016.

STUDY OBJECTIVE: Pain management is a widely discussed topic, especially in the setting of the current opioid epidemic. Previous studies have shown that the use of opioids increased in the adult population. We aimed to look at the use of narcotic and non-narcotic pain medications at a large pediatric hospital to discern if patterns of pediatric pain management changed over time. METHODS: 58,402 analgesic prescriptions of patients 0-21 years of age were analyzed from May 2012 to November 2016. A logistic regression model was fitted to examine the association of age, sex, primary diagnosis, and the length of hospital stay with probability of opioid prescription. RESULTS: 36,560 patients aged 0-21 years (mean: 10.5, median: 11.0, and standard deviation (SD): 7.42) received analgesic pain medications. 21,847 (59.8 percent) patients were prescribed more than one analgesic. There was a male predominance in patients <15 years of age; however, in adolescents >16 years, females constituted 57.1 percent of patients. Data also showed a statistically significant reduction of opioid prescriptions from 2012 to 2016 (p < 0.001). Age and length of hospital stay were directly associated with opioid prescription (p < 0.001). CONCLUSION: Data show that there is a decrease in overall opioid prescriptions among pediatric patients, which may be secondary to new Food and Drug Administration regulations and increased awareness of morbidity associated with opioid use. Not surprisingly, increased hospital stay and increase in age lead to more analgesic prescriptions. Further investigation is needed to determine the differences within opioid prescription patterns.

Analysis of pediatric opioid analgesics prescribed in a large pediatric hospital over a 5-year period.

OBJECTIVE: In this study, we aim to look at opioid prescription patterns in a large pediatric hospital with an emphasis on opioid potency as measured by morphine milligram equivalents (MMEs) to understand physician response to safe prescribing regulations and new research on opioid use in pediatrics. DESIGN: Analgesic prescriptions in a pediatric hospital in California from 2012 to 2016 were included. Prescriptions that contained any type of opioid medication were analyzed total MME in each prescription, and medication prescribed. The MME for each opioid was assigned to the prescription and presented as mean ± standard deviation (SD). Statistical analysis was performed by using IBM SPSS statistics version 25. SETTING: A pediatric hospital in California. PARTICIPANTS: All pediatric patients receiving analgesic prescriptions from a single institution between 2012 and 2016. MAIN OUTCOME MEASURE: Relative frequency of different opioid medications -prescribed. RESULTS: Of the 14,194 total opioid prescriptions, hydrocodone (11,247), codeine (2,117), and tramadol (411) were most prescribed. The relative frequency of opioid prescription decreased from 2012 to 2016 due to the decreased prescription of hydrocodone and codeine. Despite the decreased relative frequency of opioid prescription, the mean MME of prescribed opioids increased. CONCLUSION: The study demonstrated that recent efforts to limit pediatric exposure to opioids have been effective. However, recommendations limiting the use of weak opioids (codeine and tramadol) have caused an increase in average prescribed opioid potency. This may be a contributing factor to the overall increase in opioid-related pediatric hospitalizations. Revision of prescription guidelines for hydrocodone (MME = 1) may protect pediatric patients from unnecessary opioid exposure.

Racial disparities in opioid prescriptions for fractures in the pediatric population.

BACKGROUND AND OBJECTIVES: Racial disparities have been well documented in literature regarding pain management. However, few studies have focused on its effect in the pediatric population. This study seeks to examine the relationship between race and opioid prescription patterns for children with fractures. METHODS: A retrospective study was conducted by reviewing all analgesic prescriptions of discharged pediatric patients (ages 0-21, median 10 years) from a large children's hospital over a five-year period. Multiple logistic regression analysis was applied to examine racial differences in opioid prescriptions for patients with long bone fractures after adjusting for sex, age, length of stay, and payer type. RESULTS: 58,402 analgesic prescriptions were reviewed in this study; 5061 were given for the primary discharge diagnosis of "fracture" of any bone. Overall, 52% of analgesics prescribed for this diagnosis were opioid medications. The relative frequency of opioid prescriptions was 48.7% in Hispanic White patients and 63.1% in non-Hispanic White patients. The odds ratio for non-Hispanic White patients to be prescribed an opioid medication was 1.44 (CI 1.20-1.73) compared to Black patients and to Hispanic White patients after adjustment for sex, age, length of hospital stay, and payer type. The same racial disparity pattern was observed in patients regardless of long bone fracture location. CONCLUSIONS: Racial bias is suggested in opioid prescription patterns, even in the pediatric population, which may have untoward negative downstream effects. This study delineates the need for improved and standardized methods to adequately treat pain and reduce variations in prescriber habits.

A study of biophysical profile of inguinal skin: An implication for health and disease.

CONTEXT: Inguinal skin is prone to various infectious dermatological conditions such as erythrasma, intertrigo, hidradenitis suppurativa, folliculitis, dermatophytic infection, and various sexually transmitted diseases, as compared to the skin elsewhere. AIM: Our study attempts to compare the biophysical profile parameters (BPPs) of the genital skin with that of the rest of the body, while taking skin of the upper back as control. It also attempts to find out if there is a difference in BPPs of the two sites and that how the change in the BPPs, bring about change in microbiome and make inguinal skin more prone to infections. MATERIALS AND METHODS: This was a hospital-based comparative study conducted over 976 patients (600 males and 376 females) of age group 18-60 years, where BPP parameters such as hydration, skin pH, transepidermal water loss (TEWL), and sebum content were measured over the skin of the upper back and right inguinal region, and the results were summarized and presented as proportions (%). Chi-square test was used to compare abnormal findings. P ≤ 0.05 was taken as statistically significant. MedCalc 16.4 version software was used for all statistical calculations. RESULTS: Significant difference was noted in skin pH and TEWL, where P value came out to be <0.05, which was statistically significant, whereas there was minimal difference in sebum content and skin hydration in both the areas, in males and females. CONCLUSION: Raised skin pH disturbs organization of lipid bilayers (disturbed barrier), decreases lipid processing (impaired SC cohesion), and increases serine protease activity (reduced AMP). Increased TEWL (defect in physical barrier) and decreased hydration predispose the genital skin to infections. Use of pH buffered solutions (3-4), barrier repair creams containing ceramides, and barrier protective creams with dimethicone can help prevent these inguinal dermatoses.

Skin Surface pH in Acne Vulgaris: Insights from an Observational Study and Review of the Literature.

OBJECTIVE: Recurrent and chronic course of acne vulgaris, despite effect-proven therapies, point to an underfocused aspect in its pathogenesis and management. This study aims to assess in subjects with and without acne, the skin surface pH, a parameter that cumulatively represents functioning of various units of skin, including the barrier. METHODS: A total of 200 patients with acne and 200 age- and sex-matched controls were included. Under basal conditions, facial skin pH was derived from five sites using a skin pH-meter. The relation between skin pH and acne was evaluated according to sex. RESULTS: There were more subjects with normal skin pH in the control group compared to the case group, and the majority of acne occurrences in the case group were related to high skin pH (p=0.000). Mean pH among cases was higher than normal reference value (pH 4.5-5.5 for women, 4-5.5 for men) and that of controls p (<0.001). No significant association was observed between sex and skin pH in either cases or controls (p>0.05). CONCLUSION: Increased facial skin pH in patients with acne at basal conditions mirrors a chronic state of stratum corneum instability, which could be predisposing individuals to acne occurrence and/or recurrences. It could possibly be a common domain via which the classical pathomechanisms might be acting in acne. Integrating measures that maintain stratum corneum pH during therapy might prove worthwhile.

Modified transjugular approach for percutaneous atrial septal defect closure.

Femoral venous route is routinely used for percutaneous closure of atrial septal defects (ASDs). However, a situation may arise where transfemoral approach is not feasible. We describe a successful transjugular closure of a moderate-sized ASD in a 49-year-old symptomatic man with interrupted inferior vena cava, using a novel deployment technique, which helped in overcoming difficulties such as maintaining stable sheath position and minimizing risk of air embolism.

Determinants of Pediatric Psychiatry Length of Stay in 2 Urban Emergency Departments.

OBJECTIVES: Pediatric mental illness poses a significant burden with an overall prevalence of approximately 10%. Increasingly, children with mental disorders seek care in the emergency department (ED). However, the ED is not an ideal setting. Pediatric mental health patients receive limited treatment and experience significantly longer length of stay (LOS) than other patients seen in the ED. This study examines patient and hospital factors associated with LOS and prolonged LOS (PLOS). METHODS: This is a retrospective chart review of patients between the ages of 3 and 17 presenting at 2 participating urban EDs with a psychiatric diagnosis from May 2010 to May 2012. RESULTS: This study includes 939 patients with an average age of 14.1 years and a median LOS of 295 minutes. The diagnosis was the strongest predictor of LOS and PLOS. Patients with a psychotic disorder or suicide attempt or ideation experienced a longer LOS, 35% and 55% increases, respectively, and an increased odds of PLOS (odds ratio, 3.07 and 8.36, respectively). Patient sex, previous history of self-harm, and the daily census were associated with both a longer LOS and PLOS. Ethnicity, site of admission, and year of admission were only associated with LOS. CONCLUSIONS: Diagnosis-specific management factors are the primary determinant of LOS. However, some patient characteristics and hospital operational factors are also associated with LOS. Organizational reforms and an evaluation of the required human and material resources are necessary to improve access to and availability of pediatric mental health care.

Neuroblastoma presenting as persistent postprandial emesis in a neonate.

Early identification and treatment of neuroblastoma, the most common malignant solid tumor in infants, (Atkinson et al. AJR Am J Roentgenol. 1986;146:113-117; Nuchtern. Semin Pediatr Surg. 2006;15:10-16; Lanzkowsky. Manual of Pediatric Hematology and Oncology. 4th ed. Burlington, MA: Elsevier Academic Press; 2005:530-547) can improve prognosis of this illness. Benign emesis as an initial presentation of infantile neuroblastoma is rare (Isaacs. Fetal Pediatr Pathol. 2007;26:177-184). We report a case of a 17-day-old healthy male who presented to the emergency department with persistent, nonprojectile emesis after feedings. A diagnosis of nonresectable stage IV thoracoabdominal neuroblastoma with invasion to the spine was made. We concluded that oncological processes, such as neuroblastoma, should be included in the differential diagnosis of persistent emesis in the neonatal period. Emergency physicians may have the opportunity to detect neuroblastoma earlier by contemplating a broader differential diagnosis of a vomiting infant and initiating the appropriate workup in the emergency department.

Chest pain unit using thrombolysis in myocardial infarction score risk stratification: an impact on the length of stay and cost savings.

BACKGROUND: Despite the fact that studies have demonstrated cost-effectiveness of chest pain observation units (CPOUs) in emergency departments, they have not been widely implemented. Thrombolysis in Myocardial Infarction (TIMI) score is an easy and reliable tool, but none of the prior studies have used it for risk stratification in CPOUs. We propose to study the impact of CPOU using TIMI risk stratification model on the length of stay (LOS) and cost savings. METHODS: We studied 777 patients with chest pain admitted to our hospital from July 2010 to June 2011. The patients with a TIMI score of 0 to 2 were observed for 12 hours, those with a score of 3 to 4 were observed for 20 hours, and the ones with a score >4 were deemed appropriate for admission. We calculated the cost differences between the actual admissions and the CPOU. RESULTS: A total of 39.1% of patients had a TIMI score of 0, 31.1% had a TIMI score of 1, 18.1% had a TIMI score of 2, 9.2% and 2.5% had TIMI scores of 3 and 4, respectively. The expected LOS based on this model was 418.5 days versus the actual LOS of 1324 days. The cost of CPOU was estimated to be $1,979,977. However, the actual cost was $3,216,809. Hence, the annual cost savings were estimated to be $1,236,832. CONCLUSION: CPOU using TIMI score is an easy and reliable risk stratification tool for patients with chest pain in the emergency department and can significantly reduce the LOS, hence saving millions of dollars in this economic crisis.

HDAC inhibitor M344 suppresses MCF-7 breast cancer cell proliferation.

Histone deacetylase (HDAC) inhibitors represent a novel class of drugs that selectively induce cell cycle arrest and apoptosis in transformed cells. This study examined, for the first time, the effects of the relatively new HDAC inhibitor, M344 [4-dimethylamino-N-(6-hydroxycarbamoylhexyl)-benzamide], on the proliferation of MCF-7 breast cancer cells. MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assays revealed significant concentration- and time-dependent decreases in MCF-7 cell proliferation following treatment with M344 (1-100µM). In contrast to the significant induction of p21(waf1/cip1) mRNA expression following treatment with M344 (10µM) for 1 or 3 days, there was a significant decrease in p53 mRNA expression, although p53 protein levels were unchanged. Similar treatment with M344 also induced expression of the pro-apoptotic genes, Puma and Bax, together with the morphological features of apoptosis, in MCF-7 cells. The results of this study reinforce previous findings indicating that HDAC inhibitors are an important group of oncostatic drugs, and show that M344 is a potent suppressor of breast cancer cell proliferation.

Esophageal coin removal by emergency physicians: a continuous quality improvement project incorporating rapid sequence intubation.

OBJECTIVE: The objective of this study was to describe our experience removing esophageal coins from children in a tertiary care pediatric emergency department over a 4-year period. METHODS: We retrospectively reviewed a continuous quality improvement data set spanning October 1, 2004, through September 30, 2008. RESULTS: In 96 of 101 cases (95%), emergency physicians successfully retrieved the coin. The median age of the children was 19 months (interquartile range [IQR] 13-43 months; range 4 months-12.8 years). The median time to removal of coin from initiation of intubation was 8 minutes (IQR 4-14 minutes; range 1-60 minutes). Coins were extracted using forceps only in 56 cases, whereas forceps and a Foley catheter were used in the remainder. Succinylcholine and etomidate were used in almost all cases for rapid sequence intubation prior to coin removal. Complications were identified in 46 cases: minor bleeding (13), lip laceration (7), multiple attempts (5), hypoxia (3), accidental extubation (3), dental injuries (3), bradycardia (2), coin advanced (1), right main-stem bronchus intubation (1), and other (8). CONCLUSIONS: Emergency physicians successfully removed esophageal coins following rapid sequence intubation in most cases. Our approach may be considered for the management of pediatric esophageal coins, particularly in an academic pediatric emergency department.

Procedural pain management patterns in academic pediatric emergency departments.

OBJECTIVES: To describe the current state of the art for pain and sedation management for five common pediatric emergency department (ED) procedure scenarios. METHODS: Fellowship directors of U.S. EDs with a pediatric emergency medicine fellowship training program were surveyed by mail and asked to choose the one most commonly used pain or sedation management option for five clinical scenarios: facial laceration repair, cranial computed tomography in a toddler, closed fracture reduction, neonatal lumbar puncture, and intravenous catheter insertion. Results were analyzed by using descriptive statistics, and the differences between high and low volume departments were compared by using a chi-square test. RESULTS: Thirty-eight of 51 fellowship programs responded (75%). The majority of respondents were fellowship directors (76%). Topical anesthetics were most commonly reported as used for a simple facial laceration (84%), whereas ketamine sedation was most popular for fracture reduction (86%). Pain management for the other scenarios was more variable. More than half of the respondents (53%) would not sedate at all for cranial computed tomography, and only 38% reported use of pharmacologic pain management for intravenous catheter insertion. The majority (74%) reported use of anesthetic (topical or injected local) for neonatal lumbar puncture. High volume departments were more likely to use pain management for intravenous catheter insertions. CONCLUSIONS: Pain and sedation management methods for pediatric procedures continue to evolve. Despite gains, there is still room for improvement, particularly regarding intravenous catheter insertions.