DISC: Describing Infections of the Spine treated with Ceftaroline.

OBJECTIVES: Infections of the spine lead to considerable morbidity and a high cost to the global healthcare system. Currently, evidence for using ceftaroline, an advanced-generation cephalosporin active against methicillin-resistant Staphylococcus aureus (MRSA), in spine infections is limited. METHODS: Describing Infections of the Spine treated with Ceftaroline (DISC) is a multicentre, retrospective, cohort study that evaluated ceftaroline for treating spine infections. Patients were included if they were aged ≥18 years, diagnosed with a spine infection and treated with ceftaroline for ≥28 days. A control group was identified with the same inclusion criteria as the study population except they were treated with a comparator antibiotic for ≥28 days. RESULTS: Thirty-seven patients were included each in the ceftaroline and control groups. MRSA was the most commonly identified pathogen. With no differences between groups in age, sex, race or co-morbidities (with the exception of chronic kidney disease), treatment with ceftaroline led to similar clinical success compared with the control group. Multivariate regression analysis did not show a significant difference between the two groups in terms of clinical success after controlling for other covariates (adjusted odds ratio=1.49; P=0.711). More patients who received ceftaroline were discharged to an extended-care or rehabilitation facility than home compared with controls (81% vs. 54%, respectively; P=0.024). Side effects and toxicities were rare, including one case of eosinophilic pneumonia in the ceftaroline group. CONCLUSIONS: Ceftaroline appears to be a safe and effective therapy for infections of the spine, including from MRSA.

Posted emergency department wait times are not always accurate.

OBJECTIVES: Hospitals around the United States are advertising emergency department (ED) wait times. The objective was to measure the difference between publicly posted and actual ED wait times and to compare these between ED site volumes. METHODS: This study was a retrospective consecutive sample of ED patients at one hospital system with four EDs. The wait times of 8,889 patients were included in this analysis. One ED was in a large teaching hospital with 5,000 ED patients per month; the other three were freestanding or community EDs without teaching and with fewer than 2,000 ED patients per month each. The publicly posted ED wait times at the time of patient arrival were recorded and compared to the actual wait times as retrieved from the ED tracking system. The difference between posted and actual wait times for each site was calculated. Separate one-way analysis of variance (ANOVA) tests with post hoc testing were conducted to assess actual wait time and wait time difference between ED sites. RESULTS: Mean and standard deviation (SD) wait time difference at the main ED with a volume of 5,000 patients per month was 31.5 (±61.2) minutes. At the facilities with fewer than 2,000 ED patients per month each, the differences in wait times were 4.2 (±21.8), 8.6 (±23.8), and 1.3 (±11.9) minutes. ANOVA results revealed that the main ED had significantly different actual wait time and wait time differences (p < 0.05) when compared to the other three EDs. CONCLUSIONS: In one hospital system, publicly posted ED wait times show better accuracy in EDs that see 2,000 or fewer patients per month and less accuracy for an ED that sees 5,000 patients per month, likely due to flow confounders.

21-Year-old male with severe coronary atherosclerosis.

Coronary heart disease (CHD) is not limited to middle-aged and elderly individuals; when premature CHD develops in the younger population, it has distinct characteristics in terms of lipid profile, risk factors, and clinical presentation. The following describes a 21-year-old male who presented with stable angina, underwent a full cardiac workup, and was ultimately found to have multivessel CHD. In summary, the presence of mild dyslipidemia, high blood pressure, cigarette smoking, obesity, and a family history was sufficient to induce ischemic heart disease at such a young age. .

Patient preferences in choosing a primary care physician.

BACKGROUND AND AIMS: Studies have identified factors important to patients in consideration of a primary care physician (PCP). Few have explored relevant differences in choosing between family medicine (FM) and internal medicine (IM) physicians. The objective of this study was to identify differences in rating of factors perceived to be important to racially diverse FM and IM patients in the selection of a PCP, and to determine patient knowledge of PCP training. SETTINGS, DESIGN, METHODS, AND MATERIAL: This observational study used self-administered questionnaires to obtain information from adult participants at 2 continuity clinics, FM and IM. Participants rated 16 factors on their importance in selecting a PCP. Demographics and information regarding participants' knowledge of PCP training were collected. STATISTICAL ANALYSES USED AND RESULTS: 857 surveys were completed. Data were analyzed using descriptive statistics, Student t test, χ(2), and multivariate logistic regression. Sixty-five percent and 32% of participants were Caucasian or African American, respectively. Combined responses from both clinics revealed good patient care as the factor ranked highest in importance for selecting a PCP, followed by good communication skills. Forty-eight percent and 35% of FM and IM participants, respectively, did not know whether their PCP was trained in IM or FM. More than 50% of participants were not familiar with the scope of their physicians' practice. CONCLUSIONS: Our results suggest that good patient care and communication are similarly important to all patients, regardless of race. Practices should maintain focus on these qualities, as well as on patient education regarding the relevant differences between FM and IM physicians. Results from this study are consistent with prior research on these issues in more racially homogenous populations.

Perfusion pressures and distal oxygenation in individuals with diabetes undergoing chronic hemodialysis.

BACKGROUND: The number of diabetic patients worldwide was estimated to be approximately 285 million in 2010. Approximately 5% of all diabetic patients have foot ulcers, often preceded by neuropathy and delayed healing resulting from peripheral vascular disease which leads to increased risk of infection. Additionally, there is a concern that blood flow to the feet may be reduced in patients with diabetes, which may be further compounded by changes in lower extremity perfusion pressure during hemodialysis. Current laser Doppler technology provides the opportunity to identify changes in vascularityin a non-invasive fashion. MATERIALS AND METHODS: A prospective, parallel-arm, comparison, pilot study was conducted. A total of 15 patients were enrolled, ten of whom had a documented history of diabetes. All patients required hemodialysis. Peripheral perfusion and oxygenation measurements were obtained before, midway and at the conclusion of three separate dialysis sessions within a 3-week interval for each subject. RESULTS: Preliminary results indicate a significant reduction in toe pressure during and after hemodialysis in the diabetic patient group compared to the non-diabetic group. Significant differences were not found in skin perfusion measurements or in the oxygenation measurements at any time in diabetic and nondiabetic patients undergoing hemodialysis. CONCLUSION: Preliminary results suggest hemodialysis may significantly affect pressure of the lower extremities in diabetic patients. Trends from these data indicate the need to further investigate the effect of hemodialysis on techniques used to heal wounds and ulcers in patients with diabetes.

Waldenström's macroglobulinemia and nephrotic syndrome with membranous nephropathy.

Renal complications of Waldenström's macroglobulinemia (WM) are rarely observed. Nephrotic syndrome in association with WM has most often been secondary to amyloidosis. This article reports a case of WM with nephrotic syndrome as a result of membranous nephropathy with immunoglobulin M (IgM) deposition. A 44-year-old male diagnosed with WM 4 years previously, presented with heavy proteinuria (7.8 g/24 h). Kidney biopsy revealed expanded mesangium, thickened capillary loops and epimembranous spikes, with no significant interstitial inflammation or thickened tubular basement membranes. Immunofluorescence examination demonstrated strong granular staining of IgM and λ chains, with weaker C3 and C1q staining. Electron microscopy showed many subepithelial dense deposits, and fewer large subendothelial dense deposits. Treatment was directed at the patient's WM with maintenance rituximab and fludarabine. Subsequently, decreases were seen in both the patient's serum IgM and serum viscosity. With therapy for WM and the addition of an angiotensin receptor blocker, the patient's proteinuria also improved, from 7.8 g to 4.8 g/24 h. The patient continued to follow up with his hematologist and in 2009 creatinine was 1 mg/dl (76.26 ?mol/l), with a 24 h urine protein excretion of 0.159 g.

Ethanol-based cleanser versus isopropyl alcohol to decontaminate stethoscopes.

Approximately 1 in 20 hospital admissions is complicated by a health care-associated infection. Stethoscopes may play a role in spreading nosocomial infections. The objective of this study was to determine the effectiveness of an ethanol-based cleanser (EBC) compared with isopropyl alcohol pads in reducing bacterial contamination of stethoscope diaphragms. Stethoscopes were cultured from medical professionals on 4 medical floors before and after cleaning with either EBC or isopropyl alcohol pads. The numbers of colony-forming units (cfu) grown were compared between the 2 cleaners and to baseline values. A total of 99 stethoscopes were cultured (49 EBC; 50 isopropyl alcohol), and all were positive for growth. After cleaning, 28.28% of the stethoscopes were growth-free (12 EBC; 16 isopropyl alcohol). Cleaning with EBC and isopropyl alcohol pads significantly reduced the cfu counts (by 92.8% and 92.5%, respectively), but neither was found to be statistically superior (F = 1.22; P = .2721). Cleaning a stethoscope diaphragm using either EBC or isopropyl alcohol led to a significant reduction in bacterial growth in culture. As an extension of the hand, a stethoscope should be cleaned with the same frequency as the hands. The simultaneous cleaning of hands and stethoscope may further increase compliance with current standards.

Case report: anaphylactic reaction to guaifenesin.

Adverse drug reactions lead to a significant number of hospital admissions each year and thus contribute to the overall financial burden of health care. Some of these drug reactions are allergic responses. As the overall predictability of allergic responses to drugs remains low, efforts to improve our understanding of the processes underlying these responses continue as we strive toward the ultimate goal of primary prevention. Allergic reactions range from mild pruritic to severe systemic anaphylactic responses. We report a case of a young healthy man who developed an anaphylactic reaction to an over-the-counter expectorant. A skin test showed that the patient had an immunoglobulin E-mediated allergic response to guaifenesin, one of the components of commonly available cough medications. Our review of published literature showed that this is the first report of a severe allergic response to guaifenesin.

Fibrillary glomerulonephritis with hepatitis C viral infection and hypocomplementemia.

Fibrillary glomerulonephritis (FGN) is a relatively rare cause of renal disease, found in only 0.6-1.5% of native renal biopsies. The pathogenesis of FGN is not well described, and very few associations with disease processes other than hepatitis C virus (HCV) have been made. We describe a case that provides evidence in support of the FGN-HCV association, as well as introduces the association of FGN-HCV and hypocomplementemia. The case is a 53-year-old African-American female demonstrating a classical presentation of FGN complicated by a concomitant HCV infection. Treating an HCV infection with alpha-interferon has been shown to result in subsequent improvement in the nephrotic syndrome and renal function. However, this patient is unique in that she is complicated with hypocomplementemia, creating a complex treatment situation.

Immune mediated neurologic dysfunction as a paraneoplastic syndrome in renal cell carcinoma.

OBJECTIVE: To describe a case of cerebellar ataxia associated with renal cell carcinoma. CASE REPORT: A 53-year-old Caucasian male with a history of Schizophrenia presented with generalized weakness, nausea, vomiting, severe weight loss, and progressively worsening gait difficulty associated with multiple falls. Physical examination revealed profound ataxia with inability to ambulate despite normal strength. The patient also appeared cachectic. A contrast-enhanced CT of the abdomen/pelvis showed a 10.4 x 8.3 cm(2) left renal mass. Histopathology of the tissue revealed morphology consistent with renal cell carcinoma. Paraneoplastic antibodies including anti-Hu, anti-Ma, anti-Ri, and anti-Yo were negative, however, biotinylated serum analysis was positive for hippocampal and cerebellar Purkinje cells. DISCUSSION: The pathogenesis of paraneoplastic neurological syndromes is believed to be associated with antibody and T-cell mediated response to antigens shared between the tumor and neural tissue. Though serum from this patient was negative for well-characterized antibodies, further testing revealed the presence of proteins binding to the hippocampal region of the midbrain and the cerebellum, and to components of the extracellular matrix of the tumor which may suggest partially characterized or as yet uncharacterized antibodies directed against renal cell tumor tissue and the nervous system. This possibility is supported by the observed symptom resolution upon tumor resection. The described case introduces a possible association between an antibody, which may be specific to paraneoplastic neurological syndromes, and renal cell carcinoma.

Retrospective evaluation of a method to predict fresh-frozen plasma dosage in anticoagulated patients.

In the United States, fresh-frozen plasma (FFP) is commonly used for urgent reversal of warfarin; however, dosage recommendations are difficult to find. If validated, a proposed method that uses a nonlinear relationship between international normalized ratio (INR) and clotting factor activity (CFa) would be useful. This study retrospectively evaluated a proposed equation with adult medical inpatients who received FFP for warfarin reversal. For each patient the equation was used to predict the dose of FFP required to achieve the observed change in INR, which was then compared to the actual dose. The equation was considered successful if the predicted dose was within +/-20% of the actual dose. Subgroup analyses included subjects who received concomitant vitamin K; subjects with supratherapeutic INRs (>3); and subjects with significantly elevated INRs (>5). Of the 209 patients screened, 91 met criteria for inclusion in the study. Use of the equation to calculate the predicted dose of FFP was successful in 11 patients (12.1%) with use of actual body weight for prediction and in 23 patients (25.3%) with use of ideal body weight (P = 0.02). The equation performed similarly in all subgroups analyzed. The mean predicted FFP dose was significantly greater than the actual dose in all patients when actual body weight was used (925.2 mL vs. 620.6 mL; P < 0.001). Least-squares regression modeling of repeat INR (converted to CFa) produced a model that accounted for 57% of the variance in repeat INR. The value predicted from the model was closer to the actual CFa than was the value predicted from the published equation in every comparison, but it was statistically different only when actual body weight was used. This study revealed that a published equation for calculation of FFP dose to reverse oral anticoagulation resulted in doses that were significantly higher than the actual dose. Use of ideal body weight improved accuracy but was still not successful for the majority of patients. Until trials are able to prospectively demonstrate the accuracy of a dose-prediction model for FFP, dosing will remain largely empiric.

Use of amifostine, a novel cytoprotective, in alpha-amanitin poisoning.

BACKGROUND: Mortality from ingestions of the mushroom Amanita phalloides remains as high as 20-40% with many surviving patients requiring liver transplantation. A variety of treatments for Amanita ingestion have been evaluated, yet other than supportive measures, no effective therapy has been identified. In addition, an antidote for Amanita toxicity may not be practical due to delayed patient presentation. The drug amifostine was proposed to potentially improve survival from alpha-amanitin toxicity by conferring cytoprotective effects on hepatocytes at risk for cell death. Amifostine is used as a radio--and chemo-protective agent. It protects against lipoperoxidation, interferes with the cross-linking of DNA, and may act by other mechanisms yet to be identified, making it attractive for potentially attenuating ongoing hepatic necrosis. It has not previously been studied in a toxicologic model. STUDY OBJECTIVE: To determine whether amifostine is an effective postexposure therapy for alpha-amanitin, the primary lethal toxin in Amanita phalloides. METHODS: Swiss mice (n = 30 in all groups) were given an approximate LD75 dose of intraperitoneal (i.p.) alpha-amanitin. Amifostine was administered i.p. 6 h after poisoning in three cumulative dosing groups: 250 mg/kg; 500 mg/kg; and 1600 mg/kg. Controls received equal volumes of i.p. sterile 0.9% saline. Mice were monitored and time of death recorded. At day 7, survival was assumed and the remaining mice were euthanized. Qualitative histologic comparisons of hepatic and renal toxicity were performed. RESULTS: At day 7, only 10% of the control mice survived. Survival in the amifostine 250, 500, and 1600 mg/kg groups was 20%, 20%, and 3%, respectively. No statistically significant differences were detected in Kaplan-Meier survival between the control group and those receiving 250 or 500 mg/kg; however, there was a statistically significant decrease in survival for the group receiving 1600 mg/kg (p = 0.0002). CONCLUSION: No survival benefit was seen with cumulative doses between 250 and 500 mg/kg; however, higher doses may result in subsequent toxicity and decreased survival.

The effect of various insufflation gases on tumor implantation in an animal model.

OBJECTIVE: The expanded use of laparoscopy has led to reports of tumor dissemination and spread to laparoscopic port sites. We previously showed that carbon dioxide insufflation produced tumor dissemination compared with laparotomy. It is unknown whether the type of gas used influences this dissemination. Although carbon dioxide is commonly used during laparoscopy, helium and nitrous oxide could be used. This study was undertaken to compare the effects of carbon dioxide, helium, and nitrous oxide gas on tumor spread in an animal model to determine whether the type of gas used for the pneumoperitoneum would affect tumor spread. STUDY DESIGN: Viable MATB mammary adenocarcinoma cells were injected into the peritoneal cavity of Fisher 344 rats (1 x 10(5) cells/rat). The animals were then divided into three groups. Four 18-gauge angiocaths were inserted into each of four quadrants of the peritoneal cavity, and induction of pneumoperitoneum with helium, nitrous oxide, or carbon dioxide gas was done at approximately 7 mm Hg for 2 hours. Animals were killed at 7 days and the ventral peritoneal wall and abdominal cavity were examined for evidence of tumor formation. Tumor implants were counted for each of the four quadrants on the anterior peritoneal wall and for the total abdominal cavity. RESULTS: A total of 39 rats were studied with 13 animals per group. The total number of implants was calculated for the groups: carbon dioxide, n = 57; helium, n = 62; nitrous oxide, n = 66. There was no significant difference in the total number of implants according to the type of gas or the size of implants. When implants that were <5 mm were analyzed, the four quadrants of the anterior peritoneum showed a random difference in tumor disbursement between one quadrant in the helium (n = 15) and one quadrant in the nitrous group (n = 23). However, when the three gasses were compared with all four quadrants, there was no statistical significance (carbon dioxide, n = 35; helium, n = 38; nitrous oxide, n = 44). CONCLUSION: There is no difference in tumor implantation when with use of carbon dioxide, helium, or nitrous oxide gas in an animal model. Thus, carbon dioxide insufflation does not appear to increase tumor spread compared with other gasses.