A 56-Year-Old Man With Progressive Subacute Hypoxemia.

CASE PRESENTATION: A 56-year-old man with a medical history of diabetes, no prior lung disease, and no tobacco exposure presented with exhaustion and a nonproductive cough 7 days after working in an old farmhouse in Vermont. His friend who worked with him exhibited similar symptoms. He was treated as an outpatient with doxycycline; however, his clinical condition deteriorated and necessitated hospitalization and subsequent intubation.

A 43-Year-Old Woman With Fatigue, Pancytopenia, and Mediastinal Adenopathy.

CASE PRESENTATION: A 43-year-old woman without significant medical history was admitted with fatigue for 2 months. Before her current presentation, she had experienced several weeks of heavy menstrual bleeding and easy bruising. She denied night sweats, weight loss, chills, sore throat, neck swelling, rash, joint pain, cough, fever, or shortness of breath. The patient admitted a 20-year half-pack per day smoking habit that she had not been able to quit. She denied significant occupational or environmental exposures, a family history of malignancy, or current use of medications.

Association of prescription opioid use on mortality and hospital length of stay in the intensive care unit.

OBJECTIVE: Several studies show that chronic opioid dependence leads to higher in-hospital mortality, increased risk of hospital readmissions, and worse outcomes in trauma cases. However, the association of outpatient prescription opioid use on morbidity and mortality has not been adequately evaluated in a critical care setting. The purpose of this study was to determine if there is an association between chronic opioid use and mortality after an ICU admission. DESIGN: A single-center, longitudinal retrospective cohort study of all Intensive Care Unit (ICU) patients admitted to a tertiary-care academic medical center from 2001 to 2012 using the MIMIC-III database. SETTING: Medical Information Mart for Intensive Care III database based in the United States. PATIENTS: Adult patients 18 years and older were included. Exclusion criteria comprised of patients who expired during their hospital stay or presented with overdose; patients with cancer, anoxic brain injury, non-prescription opioid use; or if an accurate medication reconciliation was unable to be obtained. Patients prescribed chronic opioids were compared with those who had not been prescribed opioids in the outpatient setting. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The final sample included a total of 22,385 patients, with 2,621 (11.7%) in the opioid group and 19,764 (88.3%) in the control group. After proceeding with bivariate analyses, statistically significant and clinically relevant differences were identified between opioid and non-opioid users in sex, length of hospital stay, and comorbidities. Opioid use was associated with increased mortality in both the 30-day and 1-year windows with a respective odds ratios of 1.81 (95% CI, 1.63-2.01; p<0.001) and 1.88 (95% CI, 1.77-1.99; p<0.001), respectively. CONCLUSIONS: Chronic opioid usage was associated with increased hospital length of stay and increased mortality at both 30 days and 1 year after ICU admission. Knowledge of this will help providers make better choices in patient care and have a more informed risk-benefits discussion when prescribing opioids for chronic usage.

Delay in Antibiotic Administration Is Associated With Mortality Among Septic Shock Patients With Staphylococcus aureus Bacteremia.

OBJECTIVES: The relationship between the timing of antibiotics and mortality among septic shock patients has not been examined among patients specifically with Staphylococcus aureus bacteremia. DESIGN: Retrospective analysis of a Veterans Affairs S. aureus bacteremia database. SETTING: One-hundred twenty-two hospitals in the Veterans Affairs Health System. PATIENTS: Patients with septic shock and S. aureus bacteremia admitted directly from the emergency department to the ICU from January 1, 2003, to October 1, 2015, were evaluated. INTERVENTIONS: Time to appropriate antibiotic administration and 30-day mortality. MEASUREMENTS AND MAIN RESULTS: A total of 506 patients with S. aureus bacteremia and septic shock were included in the analysis. Thirty-day mortality was 78.1% for the entire cohort and was similar for those participants with methicillin-resistant S. aureus and methicillin-sensitive S. aureus bacteremia. Our multivariate analysis revealed that, as compared with those who received appropriate antibiotics within 1 hour after emergency department presentation, each additional hour that passed before appropriate antibiotics were administered produced an odds ratio of 1.11 (95% CI, 1.02-1.21) of mortality within 30 days. This odds increase equates to an average adjusted mortality increase of 1.3% (95% CI, 0.4-2.2%) for every hour that passes before antibiotics are administered. CONCLUSIONS: The results of this study further support the importance of prompt appropriate antibiotic administration for patients with septic shock. Physicians should consider acting quickly to administer antibiotics with S. aureus coverage to any patient suspected of having septic shock.

Performance of a 25% Inferior Vena Cava Collapsibility in Detecting Fluid Responsiveness When Assessed by Novice Versus Expert Physician Sonologists.

OBJECTIVES: Inferior vena cava collapsibility (cIVC) measured by point-of-care ultrasound (POCUS) has been proposed as a noninvasive means of assessing fluid responsiveness. We aimed to prospectively evaluate the performance of a 25% cIVC cutoff value to detect fluid responsiveness among spontaneously breathing intensive care unit (ICU) patients when assessed with POCUS by novice versus expert physician sonologists. METHODS: Prospective observational study of spontaneously breathing ICU patients. Fluid responsiveness was defined as a >10% increase in cardiac index following a 500 mL fluid bolus, measured by bioreactance. Novice sonologist measured cIVC with POCUS. Their measurements were later compared to an expert physician sonologist who independently reviewed the POCUS images and assessed cIVCs. RESULTS: Of the 85 participants, 44 (52%) were fluid responders. A 25% cIVC cutoff value performed better when assessed by expert sonologists than novice physician sonologists (receiver-operator characteristic curve, ROC = 0.82 [0.74-0.88] vs ROC = 0.69 [0.60-0.77]). CONCLUSIONS: A 25% cIVC cutoff value measured by POCUS detects fluid responsiveness. However, the experience of the physician sonologist affects test performance and should be considered when interpreting and clinically using cIVC to direct intravenous fluid resuscitation.

A Double Whammy: Lactobacillus acidophilus Bacteremia and Subsequent Lactobacillus rhamnosus Prosthetic Valve Infective Endocarditis in an Elderly Diabetic Patient.

The clinical significance of the relatively avirulent organ- ism, Lactobacillus, has been debated in the past. At times misdiagnosed as a contaminant, Lactobacillus has uncommonly been reported to cause intra-abdominal abscesses, peritonitis, meningitis, bacteremia, pneumonia and endocarditis, especially in the population of patients with underlying comorbid conditions including malignancy, diabetes, recent surgery or organ transplantation. We report a case of a 74-year-old male with Lactobacillus bacteremia leading to prosthetic valve infective endocarditis complicated by an aortic root abscess. He was managed with IV antibiotic therapy, ultimately penicillin G, and aortic valve replacement, and completely recovered after a period of rehabilitation. Several factors that predispose to Lactobacillus bacteremia were identified in our patient. This case further supports the proposition that Lactobacillus is not always a contaminant; when pathogenic, underlying disease conditions should be investigated.