Antibiotic failure in a renal transplant patient with Rhodococcus equi infection: an indication for surgical lobectomy.

Rhodococcus equi is an animal pathogen that causes infrequent but challenging infections in immunocompromised individuals, few of which have been described in solid organ transplant recipients. Common clinical presentations include indolent cough, fever, and dyspnea, with necrotizing pneumonia and cavitation. We report a case of a dense right upper lung pneumonia with resultant R. equi bacteremia in a renal transplant recipient. Our patient initially responded to antibiotic treatment with resolution of bacteremia and clinical recovery, followed by interval progression in her right upper lobe consolidation on follow-up computed tomography scans. She underwent lobectomy for definitive therapy with resolution of symptoms. Lobectomy can be utilized in isolated infection after antibiotic failure with excellent clinical outcomes.

Phenological response of tundra plants to background climate variation tested using the International Tundra Experiment.

The rapidly warming temperatures in high-latitude and alpine regions have the potential to alter the phenology of Arctic and alpine plants, affecting processes ranging from food webs to ecosystem trace gas fluxes. The International Tundra Experiment (ITEX) was initiated in 1990 to evaluate the effects of expected rapid changes in temperature on tundra plant phenology, growth and community changes using experimental warming. Here, we used the ITEX control data to test the phenological responses to background temperature variation across sites spanning latitudinal and moisture gradients. The dataset overall did not show an advance in phenology; instead, temperature variability during the years sampled and an absence of warming at some sites resulted in mixed responses. Phenological transitions of high Arctic plants clearly occurred at lower heat sum thresholds than those of low Arctic and alpine plants. However, sensitivity to temperature change was similar among plants from the different climate zones. Plants of different communities and growth forms differed for some phenological responses. Heat sums associated with flowering and greening appear to have increased over time. These results point to a complex suite of changes in plant communities and ecosystem function in high latitudes and elevations as the climate warms.

Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children.

OBJECTIVE: To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury. DESIGN: Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care. SETTING: Five emergency departments in southwest England. PARTICIPANTS: 2127 adults and children presenting to the emergency department with acute elbow injury. INTERVENTION: Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children. MAIN OUTCOME MEASURES: Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days. RESULTS: Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children. CONCLUSION: The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

A decision technology system for health care electronic commerce.

Mounting costs have escalated the pressure on health care providers and payers to improve decision making and control expenses. Transactions to form the needed decision data will routinely flow, often electronically, between the affected parties. Conventional health care information systems facilitate flow, process transactions, and generate useful decision information. Typically, such support is offered through a series of stand-alone systems that lose much useful decision knowledge and wisdom during health care electronic commerce (e-commerce). Integrating the stand-alone functions can enhance the quality and efficiency of the segmented support, create synergistic effects, and augment decision-making performance and value for both providers and payers. This article presents an information system that can provide complete and integrated support for e-commerce-based health care decision making. The article describes health care e-commerce, presents the system, examines the system's potential use and benefits, and draws implications for health care management and practice.

Anesthetic formulation of tumescent solutions.

There is no standard or official recipe for the tumescent anesthetic solutions. The actual concentrations of lidocaine and epinephrine should depend on the areas to be treated and clinical situation. This article discusses the safe usage of tumescent solutions and the proper procedures and precautions to take when mixing these solutions.

Post-tumescent liposuction care. Open drainage and bimodal compression.

The goals of post-liposuction care must be to minimize edema, bruising, and patient discomfort. The postoperative pain and edema resulting from sutured incisions and prolonged post-liposuction compression is an irrational remnant from the days before the tumescent technique. This article discusses various issues involving post-liposuction care.

Pneumatic compression or aspirin prophylaxis against thromboembolism in total hip arthroplasty.

We prospectively studied the use of either aspirin or intermittent pneumatic compression (IPC) as prophylaxis against thromboembolism after 330 consecutive total hip arthroplasties. Duplex ultrasonography of the veins of both lower extremities and ventilation-perfusion lung scans were done preoperatively and 7 to 14 days postoperatively. Eight patients in the IPC group (5%) had asymptomatic deep vein thrombosis; there were no symptomatic thrombi. In the aspirin group, 10 patients (7%) had asymptomatic deep vein thrombosis and two patients (1%) had symptomatic deep vein thrombosis. This difference was not statistically significant. There were no fatal pulmonary emboli in either group. In the IPC group, only one patient had symptomatic pulmonary embolism and 20 patients (22 hips [12%]) had asymptomatic pulmonary embolism. In the aspirin group, two patients (1%) had symptomatic pulmonary embolism and 26 patients (18%) had asymptomatic pulmonary embolism. This difference in asymptomatic pulmonary embolism between the two groups was statistically significant. Both groups had a low incidence of deep vein thrombosis, as shown by Duplex ultrasonography, but IPC was more effective than aspirin in preventing asymptomatic pulmonary embolism after total hip arthroplasty.

Tumescent liposuction and improved postoperative care using Tumescent Liposuction Garments.

The tumescent technique for liposuction, using large volumes of dilute lidocaine and epinephrine infiltrated into subcutaneous fat, has improved safety by eliminating the risks of general anesthesia and the massive blood loss associated with older techniques. This article describes the results of the author's search for ways to optimize patient care after tumescent liposuction. The tumescent technique has dramatically improved postoperative comfort and accelerated recovery time. Using microcannulas and multiple incisions for cannula access, leaving the incisions open without sutures, and wearing a specially designed Tumescent Liposuction (TLG) Garment for compression, patients return to work in 1 to 2 days, and the first postoperative follow-up office visit is 5 to 6 weeks after surgery.