Variability in Glycemic Control with Temperature Transitions during Therapeutic Hypothermia.

PURPOSE: Patients treated with therapeutic hypothermia (TH) and continuous insulin may be at increased risk of hyperglycemia or hypoglycemia, particularly during temperature transitions. This study aimed to evaluate frequency of glucose excursions during each phase of TH and to characterize glycemic control patterns in relation to survival. METHODS: Patients admitted to a tertiary care hospital for circulatory arrest and treated with both therapeutic hypothermia and protocol-based continuous insulin between January 2010 and June 2013 were included. Glucose measures, insulin, and temperatures were collected through 24 hours after rewarming. RESULTS: 24 of 26 patients experienced glycemic excursions. Hyperglycemic excursions were more frequent during initiation versus remaining phases (36.3%, 4.3%, 2.5%, and 4.0%, p = 0.002). Hypoglycemia occurred most often during rewarming (0%, 7.7%, 23.1%, and 3.8%, p = 0.02). Patients who experienced hypoglycemia had higher insulin doses prior to rewarming (16.2 versus 2.1 units/hr, p = 0.03). Glucose variation was highest during hypothermia and trended higher in nonsurvivors compared to survivors (13.38 versus 9.16, p = 0.09). Frequency of excursions was also higher in nonsurvivors (32.3% versus 19.8%, p = 0.045). CONCLUSIONS: Glycemic excursions are common and occur more often in nonsurvivors. Excursions differ by phase but risk of hypoglycemia is increased during rewarming.

A 58-Year-Old Female with Progressive Cough and Right Shoulder Pain.

Cavitary pneumonia in immunocompromised patients is a challenging entity. Establishing accurate diagnosis and starting effective antibiotics are essential steps towards improving outcome. A 58-year-old stem cell transplant patient was admitted to the hospital with necrotizing pneumonia caused by nocardia. The disease progressed despite of aggrieve antimicrobial therapy. Nocardiosis continues to be a difficult disease to diagnose and treat.

The yield of stool testing in hospital-onset diarrhea: Has evidence changed practice?

INTRODUCTION: Aside from examination for Clostridium difficile, the yield of stool testing in hospital-onset diarrhea is poor. Clinical practice guidelines discourage overzealous stool testing in patients with diarrhea that develops after the third hospital day. However, the adoption of this recommendation into clinical practice is limited. Furthermore, the effect of microbiology laboratory improvements on hospital-onset diarrhea testing is largely unknown. METHODS: A retrospective cohort study was conducted in a university-affiliated community-hospital and included all adult inpatients who developed diarrhea after hospitalization. RESULTS: 132 adult patients (53% female) developed diarrhea after hospitalization in 2013. The cohort's mean age was 55.6 years. 46.2% of patients developed diarrhea in the first 3 days of hospitalization. Testing for parasites was negative in all examined 67 samples. Testing for C. difficile was positive in 13 cases (10.8%) out of 120 tested samples. Testing for other pathogens was positive in 1 sample (Campylobacter) out of 129 samples. Stool samples tested in the first 3 days of hospitalization were more likely to be positive (64.3 vs 35.7%, p = 0.1). Change in management was reported in 9 out of 14 patients (64.3%) with positive stool testing compared with 31 out of 118 patients (26.3%) with negative stool testing, p = 0.01. CONCLUSION: Despite improvements in stool samples' testing, the yield continues to be low, especially in hospital-onset diarrhea past the third hospital day. Physicians' embracement of the '3-day rule' continues to be poor.

Epidemiological characteristics, hospital course and outcome of snakebite victims in West Texas.

INTRODUCTION: Numerous snakebites are reported every spring and summer in the United States especially in the Southwestern part of the country. This is usually associated with significant morbidity but fatalities are rare. Most victims are male and the majority of bites are on the extremities. METHODS: A search for all cases coded with a discharge diagnosis of snakebite injury revealed 90 patients admitted to Northwest Texas Hospital, the trauma center in Amarillo, Texas, between January 2002 and December 2012. These charts were retrospectively reviewed and data extracted including patient demographics, severity of snakebite, treatment given, and ultimate outcome. RESULTS: Ninety patients were admitted to the hospital due to snakebite. It was a rattlesnake in 83 cases. The mean age of the victims was 29.7 years and 74 of them were male. Fifty-one bites were on the upper extremities, thirty-eight bites were on the lower extremities and one bite was on the abdominal wall. About 95% of the lower extremity bites were moderate or severe compared to 74.5% of the upper extremity bites, Cramer's coefficient 0.3, p=0.02. Thirty-one patients had complications and twenty patients required surgical intervention. Eighty-eight patients received a median of 10 vials of antivenin that was well tolerated. Median hospital length of stay was 3 days. None of the patients died. CONCLUSION: Rattlesnake bites cause significant morbidity although mortality is rare. Early administration of antivenin and appropriate supportive measures and monitoring for complications with surgical intervention when needed leads to improved patient outcomes.

A 47-year-old stem cell transplant recipient with fever, cough and chest pain.

Infections and malignancies are among the most serious complications that follow organ or stem cell transplantation. They may have a mild course, and nonspecific and overlapping manifestations. The present article describes a case of symptomatic nodular pulmonary disease that complicated hematopoietic stem cell transplantation. It was diagnosed to be post-transplant lymphoproliferative disorder, a potential sequela of immunosuppression and a very difficult entity to treat in profoundly immunosuppressed patients.

Staphylococcus lugdunensis gluteal abscess in a patient with end stage renal disease on hemodialysis.

A 57-year-old end stage renal disease patient on hemodialysis (HD) presented with sepsis secondary to right buttock abscess and overlying cellulitis. She was started on broad-spectrum antibiotic therapy and underwent incision and drainage with marked improvement. Her cultures grew methicillin-resistant Staphylococcus lugdunensis. This bacterium is more virulent than other coagulase negative staphylococci and has been implicated in causing a variety of serious infections but it has been underreported as a cause of skin infections in HD patients and possible other patient populations.

Cardiovascular Complications of HIV-Associated Immune Dysfunction.

Prolonged survival in HIV infection is accompanied by an increased frequency of non-HIV-related comorbidities. It is suggested that cardiovascular diseases (CVD) occur earlier among HIV-positive patients compared with HIV-negative patients, and at a higher rate. Several factors have been proposed which can be categorized into traditional and nontraditional risk factors. Immune dysfunction is a nontraditional risk factor that contributes significantly to cardiovascular pathology. Markers of inflammation are elevated in HIV-infected patients, and elevations in markers such as high-sensitivity C-reactive protein, D-dimer, and interleukin-6 (IL-6) have been associated with increased risk for cardiovascular disease. However, the data currently suggest the most practical advice is to start antiretroviral therapy early and to manage traditional risk factors for CVD aggressively. A better understanding of the mechanisms of CVD in this population and further efforts to modify chronic inflammation remain an important research area.

Round pneumonia in an elderly woman.

KEY CLINICAL MESSAGE: We describe a case of pneumococcal round pneumonia in an elderly smoker and it demonstrates the role of inflammatory biomarkers and follow-up imaging in ruling out more ominous diagnoses.

Comparing the auscultatory accuracy of health care professionals using three different brands of stethoscopes on a simulator.

BACKGROUND: It is considered standard practice to use disposable or patient-dedicated stethoscopes to prevent cross-contamination between patients in contact precautions and others in their vicinity. The literature offers very little information regarding the quality of currently used stethoscopes. This study assessed the fidelity with which acoustics were perceived by a broad range of health care professionals using three brands of stethoscopes. METHODS: This prospective study used a simulation center and volunteer health care professionals to test the sound quality offered by three brands of commonly used stethoscopes. The volunteer's proficiency in identifying five basic ausculatory sounds (wheezing, stridor, crackles, holosystolic murmur, and hyperdynamic bowel sounds) was tested, as well. RESULTS: A total of 84 health care professionals (ten attending physicians, 35 resident physicians, and 39 intensive care unit [ICU] nurses) participated in the study. The higher-end stethoscope was more reliable than lower-end stethoscopes in facilitating the diagnosis of the auscultatory sounds, especially stridor and crackles. Our volunteers detected all tested sounds correctly in about 69% of cases. As expected, attending physicians performed the best, followed by resident physicians and subsequently ICU nurses. Neither years of experience nor background noise seemed to affect performance. Postgraduate training continues to offer very little to improve our trainees' auscultation skills. CONCLUSION: The results of this study indicate that using low-end stethoscopes to care for patients in contact precautions could compromise identifying important auscultatory findings. Furthermore, there continues to be an opportunity to improve our physicians and ICU nurses' auscultation skills.

Safety and feasibility of antibiotic de-escalation in bacteremic pneumonia.

BACKGROUND: Antibiotic de-escalation is a potential strategy advocated to conserve the effectiveness of broad-spectrum antibiotics. The aim of this study was to examine the safety and feasibility of antibiotic de-escalation in patients admitted with bacteremic pneumonia. METHODS: A retrospective chart review was done for patients with bacteremic pneumonia admitted to Northwest Texas Hospital in Amarillo, TX, USA, during 2008. Antibiotic de-escalation was defined as changing the empiric antibiotic regimen to a culture-directed single agent with a narrower spectrum than the original regimen. RESULTS: Sixty-eight patients were admitted with bacteremic pneumonia. Eight patients were not eligible for de-escalation. Among the 60 patients who were eligible for de-escalation, the treating physicians failed to de-escalate antibiotics in 27 cases (45.0%). Discharge to a long-term care facility predicted failure to de-escalate antibiotics, while an infectious diseases consultation was significantly associated with antibiotic de-escalation. The average daily cost of antibacterial therapy in the de-escalation group was $25.7 compared with $61.6 in the group where de-escalation was not implemented. The difference in mean length of hospital stay and mortality between the two groups was not statistically significant. CONCLUSION: Antibiotic de-escalation is a safe management strategy but unfortunately is not widely adopted. Although bacterial resistance poses a significant threat and is rising, antimicrobial de-escalation has emerged as a potential intervention that can conserve the effectiveness of broad-spectrum antibiotics without compromising the patient's outcome. This practice is becoming important in the face of slow development of new anti-infective agents.

The effect of a nurse-led multidisciplinary team on ventilator-associated pneumonia rates.

Background. Ventilator-associated pneumonia (VAP) is a worrisome, yet potentially preventable threat in critically ill patients. Evidence-based clinical practices targeting the prevention of VAP have proven effective, but the most optimal methods to ensure consistent implementation and compliance remain unknown. Methods. A retrospective study of the trend in VAP rates in a community-hospital's open medical intensive care unit (MICU) after the enactment of a nurse-led VAP prevention team. The period of the study was between April 1, 2009, and September 30, 2012. The team rounded on mechanically ventilated patients every Tuesday and Thursday. They ensured adherence to the evidence-based VAP prevention. A separate and independent infection control team monitored VAP rates. Results. Across the study period, mean VAP rate was 3.20/1000 ventilator days ±5.71 SD. Throughout the study time frame, there was an average monthly reduction in VAP rate of 0.27/1000 ventilator days, P < 0.001 (CI: -0.40--0.13). Conclusion. A nurse-led interdisciplinary team dedicated to VAP prevention rounding twice a week to ensure adherence with a VAP prevention bundle lowered VAP rates in a community-hospital open MICU. The team had interdepartmental and administrative support and addressed any deficiencies in the VAP prevention bundle components actively.