Case of a Giant Appendicolith.

Appendicoliths are calcified deposits located within the appendiceal lumen, usually measuring less than 1 cm in diameter. Appendicoliths greater than 2 cm in the largest diameter are uncommon and referred to as giant appendicoliths. Generally, patients with giant appendicoliths are asymptomatic, with these being detected incidentally on X-ray or computed tomography (CT). However, the presence of appendicoliths has been shown to be associated with an increased risk of developing appendicitis and is associated with more severe appendicitis. There is an increased incidence of appendicoliths in retrocecal appendices. This case report is of an adult male patient who presented with a three-day history of right iliac fossa pain, nausea, and decreased appetite. CT of the abdomen and pelvis showed acute appendicitis secondary to a calcified 3.1 cm giant appendicolith. Open appendicectomy was subsequently performed as the patient's financial constraints hindered a laparoscopic approach. The clinical outcome was successful with no postoperative complications, and the patient was discharged the following day. The patient was reviewed six weeks post-laparotomy with no complaints and was discharged from the surgical outpatient clinic.

Pathogenic arsenal of Pseudomonas aeruginosa: an update on virulence factors.

The emergence of Pseudomonas aeruginosa as a potential threat in persistent infections can be attributed to the plethora of virulence factors expressed by it. This review discusses the various virulence factors that help this pathogen to establish an infection and regulatory systems controlling these virulence factors. Cell-associated virulence factors such as flagella, type IV pili and non-pilus adhesins have been reviewed. Extracellular virulence factors have also been explained. Quorum-sensing systems present in P. aeruginosa play a cardinal role in regulating the expression of virulence factors. The identification of novel virulence factors in hypervirulent strains indicate that the expression of virulence is dynamic and constantly evolving. An understanding of this is critical for the better clinical management of infections.

More Specialties, Fewer Problems: Using Collaborative Competency Between Infectious Diseases, Podiatry, and Pathology to Improve the Care of Patients with Diabetic Foot Osteomyelitis.

BACKGROUND: Diabetic foot osteomyelitis is a common infection where treatment involves multiple services, including infectious diseases, podiatry, and pathology. Despite its ubiquity in the hospital, consensus on much of its management is lacking. METHODS: Representatives from infectious diseases, podiatry, and pathology interested in quality improvement developed multidisciplinary institutional recommendations culminating in an educational intervention describing optimal diagnostic and therapeutic approaches to diabetic foot osteomyelitis (DFO). Knowledge acquisition was assessed by preintervention and postintervention surveys. Inpatients with forefoot DFO were retrospectively reviewed before and after intervention to assess frequency of recommended diagnostic and therapeutic maneuvers, including appropriate definition of surgical bone margins, definitive histopathology reports, and unnecessary intravenous antibiotics or prolonged antibiotic courses. RESULTS: A postintervention survey revealed significant improvements in knowledge of antibiotic treatment duration and the role of oral antibiotics in managing DFO. There were 104 consecutive patients in the preintervention cohort (April 1, 2018, to April 1, 2019) and 32 patients in the postintervention cohort (November 5, 2019, to March 1, 2020), the latter truncated by changes in hospital practice during the coronavirus disease 2019 pandemic. Noncategorizable or equivocal disease reports decreased from before intervention to after intervention (27.0% versus 3.3%, respectively; P = .006). We observed nonsignificant improvement in correct bone margin definition (74.0% versus 87.5%; P = .11), unnecessary peripherally inserted central catheter line placement (18.3% versus 9.4%; P = .23), and unnecessary prolonged antibiotics (21.9% versus 5.0%; P = .10). In addition, by working as an interdisciplinary group, many solvable misunderstandings were identified, and processes were adjusted to improve the quality of care provided to these patients. CONCLUSIONS: This quality improvement initiative regarding management of DFO led to improved provider knowledge and collaborative competency between these three departments, improvements in definitive pathology reports, and nonsignificant improvement in several other clinical endpoints. Creating collaborative competency may be an effective local strategy to improve knowledge of diabetic foot infection and may generalize to other common multidisciplinary conditions.

Beyond the Superficial: Disseminated Trichophyton rubrum Infection in a Kidney Transplant Recipient.

Superficial dermatophyte infections are common in the general population and are readily treated with topical antifungals. Deeper invasion is rare, and dissemination to visceral organs is extremely uncommon. We describe a 66-year-old renal transplant recipient who developed disseminated Trichophyton rubrum infection while undergoing treatment for acute humoral rejection. The infection presented as a facial rash with subsequent dissemination to the lungs and chest wall. All sites of infection improved with combination administration of oral posaconazole and terbinafine. In this work, we review the available literature regarding management of disseminated Trichophyton infection and discuss therapeutic interventions for disseminated dermatophytosis in immunosuppressed hosts.

Surgical cure of clarithromycin resistant Mycobacterium chelonae breast implant infection: A case report and review of the literature.

Clusters of patients who obtain cosmetic surgeries abroad have developed surgical site infections due to rapid growing non-tuberculous mycobacteria (NTM). These are usually treated with a combination of surgery and months of anti-mycobacterial therapy, but poor outcomes, including permanent scarring are common. We present a case of a 36-year-old female who developed a clarithromycin-resistant M. chelonae (CRMC) infection after undergoing breast augmentation in the Dominican Republic. She underwent debridement and explant of her silicone implants, but due to a series of complications including discordant antimicrobial susceptibility testing profiles, GI side effects, and then pregnancy, she was unable to receive typical multidrug anti-mycobacterial therapy after surgery. She received close clinical follow up and demonstrated full recovery without any evidence of recurrence of infection at 9 months of follow up. We searched the literature for cases of NTM surgical site infection after breast surgery. To our knowledge, this is the first case report of confirmed NTM breast implant infection being cured with surgery alone, and only the second report of clarithromycin resistant M. chelonae in a patient without disseminated infection or pre-exposure to macrolides. The increasing prevalence of drug resistant NTM infections is an emerging concern for clinicians treating patients with complications related to medical tourism.

Bridging the Gap Between "Do One" and "Teach One": Impact of a Procedural Objective Structured Teaching Encounter on Resident Procedural Teaching Proficiency.

PROBLEM: Minimal formal training exists in teaching invasive bedside procedures during Internal Medicine (IM) residency despite the large role trainees have in instructing junior colleagues. OBJECTIVE AND METHODS: We investigated if using a Procedural Objective Structured Teaching Encounter (PrOSTE) to disseminate a novel method for teaching procedures would improve supervising residents' (n = 7) ability to teach ultrasound-guided peripheral IV's (USGIV) to incoming interns (n = 67) at a single, large academic IM residency. Supervising residents were assigned to receive the PrOSTE training versus standard procedure training, and then, both groups instructed incoming interns. The impact of the PrOSTE was measured by participant surveys, observed changes in teacher behavior, and performance of incoming interns on a USGIV blinded assessment station. MEASUREMENT AND MAIN RESULTS: PrOSTE-trained residents reported high levels of satisfaction with the session and demonstrated increased desirable behaviors when teaching procedures. There was no statistical difference in incoming intern performance when placing USGIVs between intervention and standard groups (81.0% vs 74.8% items correct; difference 6.2; SD = 12.4; p = 0.22). CONCLUSION: The PrOSTE is a feasible, well-received tool for training supervising residents in our novel teaching framework, as demonstrated in this pilot study. Despite not showing a difference in learner performance, qualitative data suggests the impact of the PrOSTE would be even greater in a more controlled teaching environment. Using a PrOSTE to deliver this teaching framework has broad applicability to any IM residency, and the tenets can be used with any bedside invasive procedure with an effective task trainer.

Invasive Ureaplasma Infection in Patients Receiving Rituximab and Other Humoral Immunodeficiencies-A Case Report and Review of the Literature.

Ureaplasma species are small, fastidious bacteria that frequently colonize the lower reproductive tract of asymptomatic hosts. These organisms have been well described to cause chorioamnionitis, neonatal infection, and urethritis, and to a lesser degree surgical site infection and infection in transplant recipients. Outside of these settings, invasive Ureaplasma infections are rare. We describe the case of a young woman receiving rituximab for multiple sclerosis who presented with fever and bilateral renal abscesses due to Ureaplasma spp., which was successfully treated with oral doxycycline. We searched the literature for cases of invasive Ureaplasma infection and found a patient population that predominates with humoral immunodeficiency, either congenital or iatrogenic. Diagnostic and therapeutic interventions are discussed.

Lingual traction to facilitate fiber-optic intubation of difficult airways: a single-anesthesiologist randomized trial.

PURPOSE: Flexible fiber-optic bronchoscope-guided orotracheal intubation is a valuable technique with demonstrated benefits in the management of difficult airways. Despite its popularity with anesthesia providers, the technique is not fail-safe and airway-related complications secondary to failed intubation attempts remain an important problem. We sought to determine the effect of incorporating lingual traction on the success rate of fiber-optic bronchoscope-guided intubation in patients with anticipated difficult airways. METHODS: In this prospective, randomized, cohort study, we enrolled 91 adult patients with anticipated difficult airways scheduled for elective surgery to undergo fiber-optic bronchoscope-guided orotracheal intubation alone or with lingual traction by an individual anesthesiologist after induction of general anesthesia and neuromuscular blockade. A total of 78 patients were randomized: 39 patients to the fiber-optic bronchoscope-guided intubation with lingual traction group and 39 patients to the fiber-optic bronchoscope-guided intubation alone group. The primary endpoint was the rate of successful first attempt intubations. The secondary outcome was sore throat grade on post-operative day 1. RESULTS: Fiber-optic intubation with lingual traction compared to fiber-optic intubation alone resulted in a higher success rate (92.3 vs. 74.4 %, χ (2) = 4.523, p = 0.033) and greater odds for successful first attempt intubation (OR 4.138, 95 % CI 1.041-16.444, p = 0.044). Sore throat severity on post-operative day 1 was not significantly different but trended towards worsening grades with lingual traction. CONCLUSIONS: In this study, lingual traction was shown to be a valuable maneuver for facilitating fiber-optic bronchoscope-guided intubation in the management of patients with anticipated difficult airways.

Angiotensin type 1 receptor antagonist losartan, reduces MPTP-induced degeneration of dopaminergic neurons in substantia nigra.

BACKGROUND: Recent attention has focused on understanding the role of the brain-renin-angiotensin-system (RAS) in stroke and neurodegenerative diseases. Direct evidence of a role for the brain-RAS in Parkinson's disease (PD) comes from studies demonstrating the neuroprotective effect of RAS inhibitors in several neurotoxin based PD models. In this study, we show that an antagonist of the angiotensin II (Ang II) type 1 (AT1) receptor, losartan, protects dopaminergic (DA) neurons against 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) toxicity both in primary ventral mesencephalic (VM) cultures as well as in the substantia nigra pars compacta (SNpc) of C57BL/6 mice (Fig. 1). RESULTS: In the presence of exogenous Ang II, losartan reduced MPP+ (5 muM) induced DA neuronal loss by 72% in vitro. Mice challenged with MPTP showed a 62% reduction in the number of DA neurons in the SNpc and a 71% decrease in tyrosine hydroxylase (TH) immunostaining of the striatum, whereas daily treatment with losartan lessened MPTP-induced loss of DA neurons to 25% and reduced the decrease in striatal TH+ immunostaining to 34% of control. CONCLUSION: Our study demonstrates that the brain-RAS plays an important neuroprotective role in the MPTP model of PD and points to AT1 receptor as a potential novel target for neuroprotection.

Linear furanocoumarin protects rat myocardium against lipidperoxidation and membrane damage during experimental myocardial injury.

The antioxidant activity and the membrane effects of linear furanocoumarin marmesinin isolated from Aegle marmelose was evaluated during experimental myocardial injury. Isoproterenol (150 mg kg(-1) intraperitonially twice at an interval of 24 h) caused increase in the levels of serum marker enzymes via creatinekinase (CK), creatinekinase-MB (CK-MB) isoenzyme, lactatedehydrogenase (LDH) and lactatedehydrogenase isoenzyme (LDH1). It also produced electrocardiographic changes such as increased heart rate, reduced R amplitude and ST elevation. Marmesinin at a dose of 200 mg kg(-1), when administered orally, demonstrated a decrease in serum enzyme levels and restored the electrocardiographic changes towards normalcy. Myocardial injury was accompanied by the disintegration of lipidperoxides and the impairment of natural scavengers. Marmesinin oral treatment for 2 days before and during isoproterenol administration decreased the effect of lipidperoxidation. It was also shown to have a membrane stabilizing action by inhibiting the release of beta-glucuronidase from the subcellular fractions. Thus, linear furanocoumarin marmesinin could have the protective effect against the damage caused by experimental myocardial injury.

A novel plant-derived inhibitor of cAMP-mediated fluid and chloride secretion.

We have identified an agent (SP-303) that shows efficacy against in vivo cholera toxin-induced fluid secretion and in vitro cAMP-mediated Cl- secretion. Administration of cholera toxin to adult mice results in an increase in fluid accumulation (FA) in the small intestine (FA ratio = 0.63 vs. 1.86 in control vs. cholera toxin-treated animals, respectively). This elevation in FA induced by cholera toxin was significantly reduced (FA ratio = 0.70) in animals treated with a 100 mg/kg dose of SP-303 at the same time as the cholera treatment. Moreover, when SP-303 was administered 3 h after cholera toxin, a dose-dependent inhibition of FA levels was observed with a half-maximal inhibitory dose of 10 mg/kg. In Ussing chamber studies of Caco-2 or T84 monolayer preparations, SP-303 had a significant effect on both basal current and forskolin-stimulated Cl- current. SP-303 also induced an increase in resistance that paralleled the observed decrease in current. These data suggest that SP-303 has an inhibitory effect on cAMP-mediated Cl- and fluid secretion. Thus SP-303 may prove to be a useful broad-spectrum antidiarrheal agent.

Enzyme-linked immunosorbent assay for detection of antibody to human herpesvirus 6.

The results obtained with an enzyme-linked immunosorbent assay (ELISA) for detection of human herpesvirus 6 (HHV-6) immunoglobulin G using a single 1:100 dilution of serum correlated well with those found by an indirect fluorescence microscopic assay (IFA) (r = 0.71). Concordant results were found in all 7 paired serum samples obtained from patients with acute primary infections and in 37 of 41 (90.24%) single serum samples. Fourteen serum samples (25%) which yielded nonspecific results by IFA were evaluable by ELISA. In a serologic survey using the ELISA, a disproportionate number of 12-month-old infants had low difference-of-optical-density values, suggesting that maternal antibody might persist beyond a year of age. This finding and the rises in antibody to HHV-6 found in patients with primary cytomegalovirus infections might lead to overestimation of HHV-6 infection rates in young children in seroprevalence studies. Other herpesvirus infections produced lesser effects on anti-HHV-6.

Abnormalities of measles antibody response in human immunodeficiency virus type 1 (HIV-1) infection.

The finding that severe measles occurs in immunized as well as nonimmunized human immunodeficiency virus (HIV)-infected individuals suggests that both immunologic memory and the initial response to measles may be impaired by HIV infection. That the initial response is affected was supported by the finding that post-measles immunization titers of HIV-infected babies were significantly lower (p = 0.01) than those of normal babies. Poor immunologic memory was evidenced in HIV-infected children by lower titers than in normal children (p < 0.001) and by a continuing decline in measles antibody that was not arrested by reimmunization. Impaired memory appeared to be associated with defective avidity maturation. HIV-infected babies and infants or children had a significantly lower avidity index (AI) than age-matched normal children (p < 0.01). HIV-infected adults, who were infected with HIV following infection with measles, did not have AI values significantly different from normal adults (p = 0.18) but had significantly greater values than did HIV-infected babies and children (p < 0.01). Thus, in contrast to infants and children who were infected with HIV before measles immunization, the adult immune response to measles was less affected.

Clinical manifestations of varicella-zoster virus infections in human immunodeficiency virus-infected children.

OBJECTIVE: To study the clinical course of varicella-zoster infection in children infected with human immunodeficiency virus type I. DESIGN AND SETTING: A clinical and laboratory study of human immunodeficiency virus-infected children was undertaken at Cedars-Sinai Medical Center, Los Angeles. PARTICIPANTS: Twenty-seven human immunodeficiency virus-infected children aged 1 to 13 years who were treated between 1987 and 1992. Twenty-one children had acquired the infection through blood transfusion, 18 during the neonatal period and three during their early years of life. Six infants had acquired the infection perinatally. RESULTS: Seventeen children have developed varicella, of whom 10 had an uncomplicated course and seven suffered from chronic, recurrent, or persistent varicella. Uncomplicated or recurrent varicella was a relatively benign illness that did not require antiviral therapy except in one child. In contrast, patients with persistent varicella required antiviral therapy as they were sicker and had a prolonged course. One had pneumonia, and another patient developed hyperkeratotic lesions that were refractory to therapy. They had lower CD4 counts (P < .01) and had a more advanced stage of the human immunodeficiency virus disease than the other children. Three patients who were receiving regular intravenous immunoglobulin developed their initial attack of varicella despite the presence of the varicella-zoster antibody. Four patients, three of whom had uncomplicated varicella, developed zoster involving one or two dermatomes. One patient developed zoster while receiving acyclovir therapy. CONCLUSIONS: Children infected with human immunodeficiency virus type 1 may suffer unusual manifestations of varicella-zoster infection. The incidence of zoster in these children is higher than in the general population and is close to that in patients with leukemia. The effectiveness of antiviral therapy in these patients was difficult to evaluate.