Safety of troclosene sodium solution in decontamination of wounds: A prospective clinical and laboratory study.

Debate persists regarding the safety of hypochlorite-containing solutions in the decontamination of infected wounds. In 2006, the Israeli Ministry of Health withdrew licensing approval for troclosene sodium as a wound irrigation solution. The aim of this prospective clinical and laboratory study was to investigate the safety of troclosene sodium solution for decontamination of infected wounds. Troclosene sodium solution was used to treat 30 patients with 35 infected skin wounds of various etiologies and body areas, over a treatment period of 8 days. Data were gathered according to a prospectively designed protocol including general findings, wound-specific observations on Day 1 and Day 8 and laboratory parameters on Day 1 and Day 8. Wound swabs and tissue biopsy for culture were taken on Day 1 and Day 8. Statistical analysis was executed. Tests were 2-sided and p values of <0.05 were considered statistically significant. Eighteen males and 12 females, with 35 infected skin wounds were enrolled. There were no adverse clinical events. No significant changes were observed in general clinical observations. Statistically significant improvements were observed in: pain (p < 0.0001); edema (p < 0.0001); area of wound covered by granulation tissue (p < 0.0001); exudate (p < 0.0001); and erythema (p = 0.002). Prior to treatment, bacteria were demonstrated on microscopy or on culture in 90% of wound samples. On Day 8, this frequency reduced to 40%. There were no abnormal laboratory tests. Serum sodium concentration increased significantly between Day 1 and Day 8, whilst serum concentration of urea and concentrations of thrombocytes, leucocytes and neutrophils showed statistically significant reductions, but all values remained within normal laboratory ranges throughout the study period. Troclosene sodium solution is clinically safe in the management of infected wounds. These findings were presented to the Israel Ministry of Health and as a result, troclosene sodium was re-approved and licensed for decontamination of infected wounds in Israel.

Separate But Not Equal? A Cross-Sectional Study of Segregation by Payor Mix in Academic Primary Care Clinics.

BACKGROUND: At some US Academic Health Centers (AHCs), patients with predominantly Medicaid insurance are seen in one clinic and patients with other insurance are seen in another. The extent of this practice and implications are unknown. OBJECTIVE: To estimate the proportion of AHCs that have at least two primary care internal medicine clinics that differ substantially in proportion of patients with Medicaid and to compare patient demographic, staffing, and operational features. PARTICIPANTS: General internal medicine chiefs and clinic directors at 40 randomly selected US AHCs plus the top 10 AHCs in terms of NIH funding. MAIN MEASURE: An AHC was classified as maintaining clinics that differed substantially in the proportion of patients with Medicaid if any two differed by ≥ 40% (absolute). Other criteria were used for pre-specified secondary analyses (e.g., ≥ 30%). KEY RESULTS: Thirty-nine of 50 AHCs (78%) participated. Four of 39 (10%; 95% CI, 3 to 24%) had two clinics differing by ≥ 40% in the proportion of patients with Medicaid, eight (21%; 95% CI, 9 to 36%) had clinics differing by ≥ 30%, and 15 (38%; 95% CI, 23 to 55%) had clinics differing by ≥ 20%. Clinics with more patients with Medicaid by any of the three criteria were more likely to employ resident physicians as providers of longitudinal care (with faculty supervision) and more likely to have patients who were Black or Hispanic. CONCLUSIONS: Some US AHCs maintain separate clinics defined by the proportion of patients with Medicaid. Clinics with a higher proportion of patients insured by Medicaid are more likely to employ residents (with faculty oversight), feature residents as providers of longitudinal care, and serve patients who are Black and Hispanic. Further research is needed to understand why some AHCs have primary care clinics distinguishable by insurance mix with the goal of ensuring that racism and discrimination are not root causes.

Risk factors associated with accidental fetal skin lacerations during cesarean delivery.

OBJECTIVE: To identify risk factors associated with accidental fetal skin lacerations (AFL) during cesarean section (CS). METHODS: This retrospective cohort study was obtained from the registry of two large medical centers between 2014 and 2019. The study group comprised all newborns identified with AFL. The rates of various potential risk factors were compared between the study group and a group of CS at which no AFL had occurred (the control group). RESULTS: Of the 14 666 CS deliveries, 48 cases of AFL (0.33%) were documented, 52% of these following urgent CS. Compared with the control group (n = 14 618), the only risk factors associated with AFL were premature rupture of membranes (PROM) (odds ratio [OR] 5.38, 95% convidence interval [CI] 2.97-9.74) and meconium-stained amniotic fluid (OR 6.50, 95% CI 2.55-16.54). In subgroup analysis by CS urgency, no significance for these factors was noted in elective CS group; but higher rates of both PROM and meconium-stained amniotic fluid were noted in the AFL during urgent CS (OR 14.23, 95% CI 6.30-32.16 and OR 15.36, (95% CI 5.65-41.75, respectively). CONCLUSIONS: During urgent CS, the surgeon should bear in mind that the presence of PROM or meconium-stained amniotic fluid should prompt extra care and application of preventive measures to decrease the rates of AFL.

Participation in wiki communities: reconsidering their statistical characterization.

Peer production online communities are groups of people that collaboratively engage in the building of common resources such as wikis and open source projects. In such communities, participation is highly unequal: few people concentrate the majority of the workload, while the rest provide irregular and sporadic contributions. The distribution of participation is typically characterized as a power law distribution. However, recent statistical studies on empirical data have challenged the power law dominance in other domains. This work critically examines the assumption that the distribution of participation in wikis follows such distribution. We use statistical tools to analyse over 6,000 wikis from Wikia/Fandom, the largest wiki repository. We study the empirical distribution of each wiki comparing it with different well-known skewed distributions. The results show that the power law performs poorly, surpassed by three others with a more moderated heavy-tail behavior. In particular, the truncated power law is superior to all competing distributions, or superior to some and as good as the rest, in 99.3% of the cases. These findings have implications that can inform a better modeling of participation in peer production, and help to produce more accurate predictions of the tail behavior, which represents the activity and frequency of the core contributors. Thus, we propose to consider the truncated power law as the distribution to characterize participation distribution in wiki communities. Furthermore, the truncated power law parameters provide a meaningful interpretation to characterize the community in terms of the frequency of participation of occasional contributors and how unequal are the group of core contributors. Finally, we found a relationship between the parameters and the productivity of the community and its size. These results open research venues for the characterization of communities in wikis and in online peer production.

Medical Student Patient Outreach to Ensure Continuity of Care During the COVID-19 Pandemic.

Background: In response to the COVID-19 pandemic, the Yale New Haven Health System began rescheduling nonurgent outpatient appointments as virtual visits in March 2020. While Yale New Haven Health expanded its telemedicine infrastructure to accommodate this shift, many appointments were delayed and patients faced considerable uncertainty. Objective: Medical students created the Medical Student Task Force (MSTF) to help ensure continuity of care by calling patients whose appointments were delayed during this transition to telemedicine. Methods: Eighty-five student volunteers called 3765 internal medicine patients with canceled appointments, completing screening for 2197 patients. Volunteers screened for health care needs, assessed preferences for future appointments, and offered emotional support and information about COVID-19. Urgent or emergent patient concerns were triaged and escalated to providers. In this analysis, we used a mixed-methods approach: call information and provider responses were analyzed quantitatively, and patient feedback was analyzed qualitatively via thematic analysis. Results: Ninety-one percent of patients screened found the MSTF calls helpful. Twenty-one percent of patients reported health concerns, with 1% reporting urgent concerns escalated to and addressed by providers. Themes of patient comments included gratitude for outreach and social contact, utility of calls, and well-wishes for health care workers. Conclusions: By calling patients whose appointments had been canceled during a rapid transition to telemedicine, the MSTF helped bridge a potential gap in care by offering patients communication with their care teams, information, and support. We propose that this model could be used in other care systems urgently transitioning to outpatient telemedicine, whether during ongoing outbreaks of COVID-19 or other public health emergencies.

[POSSIBLE REACTION TO SUTURE MATERIALS].

INTRODUCTION: The use of sutures is a common practice in plastic surgical procedures. The potential risk of developing an allergic reaction to suture materials exists. To the best of the authors' knowledge, this is the first case reported in the literature of such a reaction in aesthetic breast surgery. The aim of this review is to raise the awareness of possible allergic and infective or inflammatory reactions to the suture material and to expand the knowledge of the management and interventions which are critical for patient safety and satisfaction. More research is needed to study this challenging topic.

Filopodia and Viruses: An Analysis of Membrane Processes in Entry Mechanisms.

Filopodia are thin, actin rich bundles protruding from cell plasma membranes, serving physiological purposes, such as probing the environment and facilitating cell-to-cell adhesion. Recent studies have highlighted that actively polymerized filopodial-protrusions are exploited during virus entry, trafficking, spread, and the development of clinical pathology of viral diseases. These observations have caused a surge in investigation of the key determinants of filopodial induction and their influence on cell topography including receptor expression for viral entry. It is now very clear that filopodia can provide unique opportunities for many viruses to invade host cells vertically during primary infection, or horizontally during virus spread from cell-to-cell. These emerging concepts can explain the unprecedented ability of viruses to invade both nearby and long-distant host cells, a feature that may directly contribute to viral tropism. In this review, we summarize the significance of filopodia in viral diseases and discuss future therapeutic possibilities to precisely target filopodial-flyovers to prevent or control infectious diseases.

Rivaroxaban-Induced Nontraumatic Spinal Subdural Hematoma: An Uncommon Yet Life-Threatening Complication.

In the last decade, the desire for safer oral anticoagulants (OACs) led to the emergence of newer drugs. Available clinical trials demonstrated a lower risk of OACs-associated life-threatening bleeding events, including intracranial hemorrhage, compared to warfarin. Nontraumatic spinal hematoma is an uncommon yet life-threatening neurosurgical emergency that can be associated with the use of these agents. Rivaroxaban, one of the newly approved OACs, is a direct factor Xa inhibitor. To the best of our knowledge, to date, only two published cases report the incidence of rivaroxaban-induced nontraumatic spinal subdural hematoma (SSDH). Our case is the third one described and the first one to involve the cervicothoracic spine.

Epidermal growth factor receptor tyrosine kinase inhibitors in elderly patients with non-small cell lung cancer.

Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related deaths worldwide. At diagnosis, half of the patients are over 70 years of age, and most present with advanced disease, for which chemotherapy is recommended as first-line treatment. However, the benefit from such therapy is modest and it is at times poorly tolerated. The discovery of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) has significantly impacted the treatment of patients with EGFR mutation-positive advanced NSCLC. These novel agents demonstrate efficacy and a favorably mild toxicity profile. Despite limited data in elderly patients, the largest subpopulation in NSCLC, EGFR-TKIs are considered the standard of care therapy for advanced EGFR-positive disease in the elderly. In this review, we seek to compile the available data about the EGFR-TKIs use in elderly patients with advanced NSCLC, with the hope to better understand its role in this major yet, underrepresented, group of patients.

Lung cancer trends: smoking, obesity, and sex assessed in the Staten Island University's lung cancer patients.

INTRODUCTION: The incidence of lung cancer in the United States decreased by 1.8% from 1991 to 2005 while it increased by 0.5% in females. We assessed whether nonsmokers afflicted with lung cancer at Staten Island University Hospital are disproportionately female in comparison to national averages. We also evaluated different factors including race, histology, and body mass index (BMI) in correlation with smoking history. METHODS: A retrospective chart review was conducted from 2005 to 2011 on 857 patients. Patients were divided into two groups according to their smoking status: current or ever-smokers, and former or never-smokers. A chi-square test for categorical data and multivariate logistic regression analyses was used to study the relation between BMI and the other clinical and demographic data. RESULTS: Forty-nine percent of patients were men and 51% were women with a mean age at diagnosis of 67.8 years. Current smokers were most common (50.2%) followed by ever-smokers (18.2%), former smokers (15.8%) and never-smokers (15.6%). Forty eight percent had stage IV lung cancer upon presentation. Never-smokers with lung cancer were 24 times more likely to be females. However, the proportion of female former smokers (31.6%) was lower than the proportion of male former smokers (68.4%) (P=0.001). There was no significant association between American Joint Committee on Cancer (AJCC) stage, sex, race, and histological type in the two smoking groups. Current/ever-smokers tended to be younger at age of diagnosis (P=0.0003). BMI was lower in the current/ever-smokers (26.8 kg/m(2)) versus former/never-smokers (28.8) in males (P=0.0005). BMI was significantly higher in males (30.26) versus females (25.25) in the never-smoker category (P=0.004). Current smokers, compared to others, had a lower BMI in males (26.4 versus 28.3; P=0.0001) and females (25.5 versus 26.9; P=0.013) but the mean BMI for all groups was in the overweight/obese range. CONCLUSION: Our population of lung cancer patients although demographically distinct, reflects a similar proportion of afflicted nonsmokers to the national population. Smoking is a major risk factor for lung cancer, but there is also a possible direct correlation with BMI that would support obesity as a potential risk factor for lung cancer.

Telephone-based anticoagulation management in the homebound setting: a retrospective observational study.

BACKGROUND: Anticoagulation management is currently performed through anticoagulation clinics or self-managed with or without the help of medical services. Homebound patients are a unique population that cannot utilize anticoagulation clinics or self-testing. Telephone-based anticoagulation management could be an alternative to the traditional methods of monitoring warfarin in this subgroup. The objective of this retrospective, observational study is to investigate the feasibility of warfarin management in homebound patients. METHODS: This study was performed through the use of telephone-based adjustments of warfarin dose based on an international normalized ratio (INR) result. Four hundred forty-eight homebound patients referred to the anticoagulation clinic at Staten Island University Hospital were visited at home by a phlebotomist; a blood sample was drawn for initial laboratory testing. A nurse practitioner then called the patient or designated person to relay the INR result and to direct dosage adjustment. INR results and dosage changes were entered into an electronic medical record and analyzed statistically. RESULTS: The mean percentage of INR values in range was 58.39%. The mean time when the INR was in the therapeutic range was 62.75%. The percent of patients who were therapeutically controlled decreased as the number of medications increased. The complication rate was 4% per patient year, with an equal distribution between bleeding and clotting. These values compared favorably to other studies in which monitoring was performed through anticoagulation clinics or self-monitoring. The cost per visit at our anticoagulation clinic was found to be approximately $300 compared with $82 when utilizing our homebound service. CONCLUSION: Telephone-based management of warfarin therapy in the homebound setting is feasible. It can lower the cost of health care expenditures compared to other modalities of anticoagulation management.

Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review.

Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. They represent about 1.5% of all visceral artery (VAA) aneurysms and are divided into true and pseudoaneurysms depending on the etiologic factors underlying their development. Atherosclerosis and pancreatitis are the two most common risk factors. Making the diagnosis can be complex and often requires the use of Computed Tomography and angiography. The later adds the advantage of being a therapeutic option to prevent or stop bleeding. If this fails, surgery is still regarded as the standard for accomplishing a definite treatment.

A 61-year-old man presented with myopathy, neuropathy, and inflammatory dermatitis responsive to chronic lymphocytic leukemia treatment.

UNLABELLED: The prevalence of paraneoplastic neurologic syndrome in cancer is 0.01%. Neurological syndromes can be seen in chronic lymphocytic leukemia (CLL) and mostly present as either leukemic infiltration of the central nervous system (CNS) or progressive multifocal leukoencephalopathy. To our knowledge, this is the first reported case of combined sensory-motor neuropathy, myopathy, and dermatitis in a patient with CLL. CASE PRESENTATION: A 61-year-old African American man presented with acute dysphagia, rapidly progressive proximal limb-girdle weakness, and dermatitis. He had a white blood cell (WBC) count of 14,600/mm(3), hemoglobin of 11.4 mg/dL, and a platelet count of 165,000/mm(3). Lymphocytes comprised 15% of the total WBC with an absolute lymphocyte count of 2100/mm(3). Metabolic profile was unremarkable except for a serum creatine phosphokinase (CPK) level of 1056 mg/dL. Serum protein electrophoresis, serologic studies for autoimmune, genetic diseases, and paraneoplastic syndromes were all negative. Electrodiagnostic studies revealed sensorimotor neuropathy with mixed axonal and demyelinating features. Muscle biopsy revealed discrete areas of interstitial fibrosis juxtaposed to areas of intact muscle without any inflammation. At that point, a bone marrow biopsy was done because of anemia and slightly elevated mean corpuscular volume of 103. Bone marrow biopsy revealed minimal involvement with CD5/CD19-positive CLL. Flow cytometry demonstrated monoclonal CD5/CD19/CD20/CD23-positive cells, with dim kappa expression, and negative FMC-7 and CD3. This case doesn't meet the criteria for CLL/small lymphocytic lymphoma. However, considering the possibility of paraneoplastic phenomenon for his symptoms, it was decided to start the patient on CLL-directed therapy with Rituximab and Cyclophosphamide. After only two cycles, the patient experienced a dramatic improvement in his muscle strength with disappearance of the rash. CONCLUSION: This case highlights a unique clinical picture of inflammatory dermatitis with electromyography and biopsy findings suggestive of myopathy and combined sensorimotor neuropathy with response to CLL-directed therapy. Also the symptoms started before peripheral lymphocytosis which masked the diagnosis for over a year.

Infective endocarditis complicated by aortic graft infection and osteomyelitis: case report and review of literature.

Primary aortic graft infection early after aortic graft insertion is well described in the literature. Here, we present a unique case of late aortic graft infection 5 years after insertion secondary to mitral valve endocarditis, resulting from cellulitis in a patient with severe venous varicosities. A 63-year-old male presented for severe low back pain, constipation, and low-grade fever. An abdominal computed tomography scan with oral and intravenous contrast showed a normal spine and urinary tract. Blood and urine cultures, done at the same time, grew Staphylococcus aureus. A transesophageal echocardiogram confirmed the diagnosis of endocarditis. Subsequently, a gallium scan showed increased uptake in the vertebral bodies, aortic graft, left patella, and left ankle. After 3 months of antibiotic therapy, the patient's low back pain resolved with normalization of his laboratory values. He remained free of infection at a 2-year follow-up. We reviewed the literature concerning the atypical presentation of infective endocarditis, with a focus on distant metastases at initial presentation, such as osteomyelitis and aortic graft infection, as well as the different treatment modalities. This report describes successful medical treatment with intravenous followed by oral antibiotics for an infected endovascular graft without any surgical intervention.

Allopurinol causing drug rash with eosinophilia and systemic symptoms syndrome: a challenging diagnosis.

BACKGROUND: Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is characterized by cutaneous drug eruption, eosinophilia, and systemic symptoms. The syndrome is difficult to diagnose due to its clinical heterogeneity and long latency period (2-6 weeks). CASE REPORT: This paper describes a 73-year-old man who presented with a rash that started 1 week prior to his presentation. The rash was associated with fever, dyspnea, and cough. He was admitted for pneumonia and started on intravenous antibiotics. After 3 days, he became confused and developed multiorgan dysfunction. Work-up for possible hematologic disorders, autoimmune diseases, and pneumonia was negative. One month prior to the onset of the rash, allopurinol had been prescribed for asymptomatic hyperuricemia. The allopurinol was stopped and corticosteroids were started; 2 days later, the patient became afebrile and the dyspnea resolved. He was diagnosed with DRESS syndrome, which is associated with high mortality. CONCLUSION: The recent introduction of a drug followed by a rash, multiorgan dysfunction, and eosinophilia should raise the suspicion of DRESS syndrome. Early cessation of the introduced drug is key to survival. Clinicians should be aware of this potential adverse reaction when prescribing any new drug, including allopurinol.