Microbiologic Agents in Parent-reported Neonatal Fever.

We reviewed etiology and outcome of consecutive neonates admitted to a neonatal unit for investigation of parent-reported fever (116 neonates over 24 months). Tympanic temperature was measured at the emergency department (Te) and core temperature at the neonatal unit (Tn). Microbials were isolated in 27 patients (23%); Te and Tn were both <38°C in 13 (48%) of the 27 patients. Microbial isolation was associated with older median age (16.7 vs. 8.0 days, p = 0.004), empirical antibiotic commencement (p = 0.0003) and longer hospital stay (median 8 vs. 4.0 days, p = 0.004). Compared with respiratory viral infection, patients with bacteremia had high C-reactive protein (p = 0.005) and likely to have comorbidity of meningitis (p = 0.077). Te ≥38°C had the highest sensitivity, positive likelihood ratio and positive and negative predictive ratios for bacteremia. Parent-reported fever was associated with a 3% incidence of meningitis, 6% of bacteremia and 9% of urinary tract infection. The majority of neonates with parent-reported fever do not have serious bacterial infection. Nevertheless, recommendations about threshold of antibiotic initiation are difficult, and empirical systemic antibiotic coverage must be commenced in those neonates with Te ≥38°C or elevated C-reactive protein.

Bacillus bloodstream infections in a tertiary perinatal centre: an 8-year study.

BACKGROUND: Isolates of nonanthrax Bacillus species in clinical samples are frequently considered as contaminants. However, there were case reports describing Bacillus sepsis among infants, associated with high mortality and morbidity. METHODS: We performed a retrospective review of the clinical and epidemiological features of Bacillus bacteremia at our neonatal intensive care unit from January 2002 to December 2009. RESULTS: Bacillus bacteremia was considered to be clinically significant in 11 infants. The median gestational age was 30 weeks. All had either central catheters or peripherally inserted arterial lines in situ. The mean neutrophil and lymphocyte counts were 6.73 × 10(9)/L (0.78 to 12.56 × 10(9)/L) and 2.75 × 10(9)/L (0.82 to 6.15 × 10(9)/L), respectively. All 11 infants received intravenous vancomycin, with an average duration of 12.4 days. In general, the earlier the catheter was removed, the quicker the clearance of bacteremia was achieved. All infants survived and were discharged from the hospital. CONCLUSIONS: The growth of Bacillus species in blood cultures cannot simply be regarded as a contaminant. Hematologic parameters are frequently unremarkable at the disease onset. Increased vigilance, early diagnosis, and effective therapy in conjunction with prompt catheter removal are the keys to successful management of Bacillus bacteremia.

The rewarming benefit of anterior torso heat pad application in mildly hypothermic conscious adult trauma patients remains inconclusive.

The rewarming benefit of anterior torso heat pad application in mildly hypothermic conscious adult trauma patients remains inconclusive in this randomized comparative clinical trial. There was no between-group rewarming gain in ear canal temperature when an anterior torso chemical heat pad was compared with blankets. Patient awareness, and favorable perception of, being administered the active intervention (heat pad) could explain the significant improvement in patient-rated cold discomfort discerned with the heat pad. In the context of marginal demonstrated benefit, it would have been informative to ascertain adverse effects related to the heat pad, including burn injury to the chest wall.

Intra-abdominal Rhizopus microsporus infection successfully treated by combined aggressive surgical, antifungal, and iron chelating therapy.

SUMMARY: Zygomycetes are widely distributed in the environment as inhabitants of soil and decaying matter. On rare occasions, these organisms can cause invasive infections in immunocompromised hosts. As zygomycetes are resistant to most conventional antifungal agents, its infection is often fatal. We report 2 cases of unusual intra-abdominal Rhizopus microsporus infection in children with acute leukemia as a result of an unprecedented outbreak due to oral intake of contaminated allopurinol tablets and ready-to-eat food items. Among the 2 patients, one of them survived after aggressive combined surgical, antifungal (AmBisome, Caspofungin, and Posaconazole) and iron chelation therapy.

Difficult diagnosis in the emergency department: hyperemesis in early trimester pregnancy because of incarcerated maternal diaphragmatic hernia.

Hyperemesis gravidarum is a frequent presentation to the ED, which usually resolves with fluid rehydration and antiemetics. Early incarcerated maternal diaphragmatic hernia might be misdiagnosed as relatively benign hyperemesis gravidarum in the first two trimesters of pregnancy. Diagnosis is missed because of non-specific presentation with abdominal pain, nausea and vomiting. Hernias rarely become symptomatic even in latter stages of pregnancy, as the uterus increases in size with each trimester and with raised intra-abdominal pressure from uterine contraction during labour. Symptoms progress with incarceration and strangulation of abdominal contents within the thoracic cavity, compression of the lung and disruption of caval venous return. A woman at 19-week gestation presented with delayed diagnosis of strangulated diaphragmatic hernia, representing the earliest gestation in the published literature when this has occurred. She had repeatedly been misdiagnosed with hyperemesis gravidarum. It is worthwhile considering incarcerated maternal diaphragmatic hernia as an unusual cause of refractory vomiting in pregnancy, when associated with clinically significant upper abdominal pain and progressive respiratory embarrassment. This might occur as early as the mid-second trimester, and without uterine contraction.

Acute pancreatitis related to therapeutic dosing with colchicine: a case report.

BACKGROUND: Colchicine is used in the treatment and prophylaxis of gout. It possesses a narrow therapeutic window, frequently resulting in dose-limiting gastrointestinal side-effects such as diarrhoea and emesis. As colchicine is a cellular anti-mitotic agent, the most serious effects include myelosuppression, myoneuropathy and multiple organ failure. This occurs with intentional overdose or with therapeutic dosing in patients with reduced clearance of colchicine due to pre-existing renal or hepatic impairment. Acute pancreatitis has rarely been reported, and only in association with severe colchicine overdose accompanied by multi-organ failure. CASE PRESENTATION: We report a case of acute pancreatitis without other organ toxicity related to recent commencement of colchicine for acute gout, occurring in an elderly male with pre-existing renal impairment. CONCLUSION: 1) Colchicine should be used with care in elderly patients or patients with impaired renal function.2) Aside from myelosuppression, myoneuropathy and multiple organ failure, colchicine may now be associated with acute pancreatitis even with therapeutic dosing; this has not previously being reported.

Path analysis modeling indicates free transport increases ambulance use for minor indications.

INTRODUCTION: Clinically unnecessary ambulance transport is increasing, diverting limited resources from patients needing ambulance transport. It was anecdotally observed that inappropriate ambulance use increased after abolition of a direct patient cost for ambulance transport. HYPOTHESIS: In July 2003, direct patient fees were abolished in favor of a universally applied ambulance levy, potentially leading to increased ambulance use by patients with low illness acuity and admission rates. METHODS: The influence of age, illness acuity, and need for admission on ambulance use was assessed for 55,397 emergency department attendances in 2002 and 2004. Ambulance users were compared with nonusers in both years and attendances for 2002 compared with 2004 using chi-square test for two groups. Logistic regression provided a multivariate model leading to ambulance use. Path analysis modeling to assess interrelationships between factors associated with ambulance use was developed. RESULTS: Ambulance users in both years were older, had more acute illness, and had greater need for admission compared with nonusers. The odds ratio (OR) of arrival by ambulance in 2004 compared with 2002 was 1.14 (95% confidence interval, [CI], 1.12 to 1.17). In 2002, ambulance users were older (OR, 1.42; 95% CI, 1.40 to 1.43), were more likely to need admission (OR, 2.28; 95% CI, 2.16 to 2.4) and had higher illness acuity (OR, 2.02; 95% CI, 1.94 to 2.09). There was a negative correlation between 2004 and illness acuity. CONCLUSIONS: Ambulance use increased in 2004 after patient transport fees were abolished. Increased use was associated with decreased age, clinical acuity, and admission need. Abolishing direct patient cost stimulates ambulance use, potentially including inappropriate transport. Path analysis to assess the effect of changed funding on ambulance use could be used to the influence of other locally relevant factors contributing to ambulance use.