Clinical reasoning for performance of transesophageal echocardiography in veterans with Staphylococcus aureus bacteremia.

This study examined physicians' reasoning about obtaining transesophageal echocardiography (TEE) in cases of Staphylococcus aureus bacteremia (SAB). In 221 cases of SAB over 5 years, the most common reasons for not performing TEE were clinical response to antibiotics, negative TTE results, and the expectation that TEE would not change management.

Persistent bacteraemia caused by Staphylococcus aureus in the gall bladder.

Staphylococcus aureusbacteraemia (SAB) remains a complex disease with a high associated morbidity and mortality, especially when it is able to establish an occult nidus safe from antimicrobial eradication. Without rapid identification and intervention, the nidus can cause persistent relapse of disease, morbidity and mortality. Having a high clinical suspicion for the foci of occult S. aureus is important, and awareness of potential sites of infection is critical and can be life-saving.We present a unique case of a 65-year-old man with end-stage renal disease receiving haemodialysis who developed septic shock from SAB. Despite 18 days of appropriate antibiotics, the patient had persistent high-grade bacteraemia until his gall bladder was ultimately percutaneously drained. The day after drainage, he cleared his blood cultures, although he ultimately passed away as he decided to transition his care to focus on comfort measures.

A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback.

PURPOSE: Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns. DESIGN: Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments. RESULTS: The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001). CONCLUSIONS: We successfully implemented a novel high value care curriculum that specifically targets intern physicians.

Trypanosoma brucei infection in a HIV positive Ugandan male.

Human African Trypanosomiasis, or African Sleeping Sickness, is a parasitic infection caused by Trypanosoma brucei (gambiense or rhodesiense), and one of the declared neglected tropical diseases. Sleeping sickness has high fatality rates and is a continued threat in several African countries. We present characteristic clinical and microbiologic features of a fatal case of African Sleeping Sickness in an HIV-infected individual.

Time to clearance of Chlamydia trachomatis ribosomal RNA in women treated for chlamydial infection.

BACKGROUND: The dynamics of chlamydia clearance after treatment administration for chlamydial urogenital infection are unknown. We estimated the time to clearance of Chlamydia trachomatis (CT) ribosomal RNA (rRNA) after administration of azithromycin for cervical chlamydial infection using APTIMA Combo 2 (Gen-Probe, Inc., San Diego, CA, USA). METHODS: A total of 115 women diagnosed with urogenital chlamydial infection, defined as a positive APTIMA urine or endocervical specimen, were enrolled in the present study. Vaginal swabs on the day of treatment (Day 0) and on Days 3, 7, 10 and 14 after treatment with 1 g of azithromycin were self-obtained by participants. Specimens were tested in a single laboratory. Our analysis was limited to women who were CT-confirmed by vaginal swab at baseline, who returned all follow-up swabs, and who reported sexual abstinence during the follow-up period (n = 61). RESULTS: Among 61 participants, 48 (79%) had a negative APTIMA at Day 14. Subjects with a negative APTIMA at each time-point were as follows: 0/61 (0%) on Day 0, 7/61 (12%) on Day 3, 28/61 (46%) on Day 7, 40/61 (66%) on Day 10, and 48/61 (79%) on Day 14. Multiple linear regression analysis predicted time to clearance at 17 days (95% confidence interval, 16-18 days) after administration of azithromycin. Seventeen of the 94 participants (18.1%) who screened positive for chlamydia had a negative vaginal swab on Day 0, indicating possible spontaneous clearance of CT. CONCLUSIONS: After treatment, CT rRNA declined with time. As rRNA was still detectable in 21% of the women 14 days after treatment, APTIMA should not be used as a test-of-cure in the 14-day period following azithromycin administration.

Is spinal tuberculosis contagious?

While pulmonary Mycobacterium tuberculosis infections are recognized for their public health implications, less is known about the infectiousness of extrapulmonary tuberculosis, specifically, spinal tuberculosis or Pott's disease. We present a case of spinal tuberculosis with concomitant active pulmonary tuberculosis in the absence of chest radiographic abnormalities or symptoms, and review the literature regarding infectiousness of concomitant spinal and pulmonary tuberculosis.

Validation of Microcapillary Flow Cytometry for Community-Based CD4+ T Lymphocyte Enumeration in Remote Burkina Faso.

BACKGROUND: CD4+ T lymphocyte enumeration plays a critical role in the initiation and monitoring of HIV-infected patients on antiretroviral therapy. There is an urgent need for low-cost CD4+ enumeration technologies, particularly for use in dry, dusty climates characteristic of many small cities in Sub-Saharan Africa. DESIGN: Cross-sectional study. METHODS: Blood samples from 98 HIV-infected patients followed in a community HIV clinic in Ouahigouya, Burkina Faso were obtained for routine CD4+ T lymphocyte count monitoring. The blood samples were divided into two aliquots, on which parallel CD4+ measurements were performed using microcapillary (Guava EasyCD4) and dedicated (Becton Dickinson FACSCount) CD4+ enumeration systems. Spearman rank correlation coefficient was calculated, and the sensitivity, specificity and positive predictive value (PPV) for EasyCD4 <200 cells/µL were determined compared to the reference standard FACSCount CD4 <200 cells/µL. RESULTS: Mean CD4 counts for the EasyCD4 and FACSCount were 313.75 cells/µL and 303.47 cells/µL, respectively. The Spearman rank correlation coefficient was 0.92 (p<0.001). Median values using EasyCD4 were higher than those with the FACSCount (p=0.004). For a CD4<350 cells/uL, sensitivity of the EasyCD4 was 93.9% (95%CI 85.2-98.3%), specificity was 90.6% (95% CI 75.0-98.0%), and PPV was 95.4% (95%CI 87.1-99.0%). CONCLUSION: Use of the EasyCD4 system was feasible and highly accurate in the harsh conditions of this remote city in Sub-Saharan Africa, demonstrating acceptable sensitivity and specificity compared to a standard operating system. Microcapillary flow cytometry offers a cost-effective alternative for community-based, point-of-care CD4+ testing and could play a substantial role in scaling up HIV care in remote, resource-limited settings.