Multiple Weekly Dalbavancin Dosing for the Treatment of Native Vertebral Osteomyelitis Caused by Methicillin-Resistant Staphylococcus Aureus: A Case Report.

BACKGROUND Native vertebral osteomyelitis (NVO) is a common form of hematogenous osteomyelitis, with Staphylococcus aureus (S. aureus) being the most commonly isolated organism. Dalbavancin is approved by the US Food and Drug Administration (FDA) for the treatment of acute bacterial skin and skin structure infections (ABSSSI) and has a sufficiently promising pharmacokinetic and pharmacodynamic profile to be considered for the treatment of vertebral osteomyelitis. We describe here what is probably the first reported case of using multiple weekly dalbavancin to treat a complicated methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and vertebral osteomyelitis. CASE REPORT A 58-year-old man with a long history of recurrent MRSA bacteremia, who failed multiple courses of vancomycin and daptomycin, presented with recurrent MRSA bacteremia complicated by diskitis and osteomyelitis of the lumbar vertebrae. The patient was treated with dalbavancin 1000 mg intravenously weekly for two weeks followed by 500 mg weekly for six additional weeks. He improved clinically, his back pain resolved, and C-reactive protein (CRP) decreased to normal. Three months after the last dose of dalbavancin therapy, he underwent angiography for peripheral artery diseases, after which he developed a fever, mild leukocytosis, an elevated CRP, and the repeat blood cultures were positive for MRSA. No apparent adverse events were observed during dalbavancin therapy. CONCLUSIONS In this case, multiple weekly dalbavancin infusions appeared to be safe in the treatment of vertebral osteomyelitis caused by MRSA, but did not seem to prevent infection recurrence. However, reinfection with a new strain from the angiography catheter insertion is highly likely. Clinical studies are needed to further assess the safety and effectiveness of multiple weekly dalbavancin dosing in the management of vertebral osteomyelitis.

The challenge of inclusive design in the US context.

The paper considers the evolution of thinking and practice of inclusive design in the United States since 1993, the year of the first special edition of Applied Ergonomics on inclusive design. It frames the examination initially in terms of the US social mores that substantially influence behavior and attitudes from a defining individualism to legal mandates for accessibility to the nation's ingrained obsession with youth and delusional attitudes about aging. The authors explore the disparate patterns across the design disciplines and identify promising linkages and patterns that may be harbingers of a more expansive embrace of inclusive design in the years ahead.

Acute medical admissions for older people from residential care facilities: are they appropriate?

AIM: Acute medical admissions are increasing and potentially avoidable admissions (PAA) from residential care facilities (RCF) have been blamed. Estimates for the proportion of PAA from RCFs vary enormously in the literature. This study aimed to prospectively determine the level of PAA to a New Zealand hospital. METHODS: Two cohorts of consecutive acute medical admissions of older (65 years and older) people from RCFs were reviewed (one retrospective and one prospective). Discharge domicile and survival at 6 months were determined for all patients. PAAs were determined by the treating general physician/geriatrician in the prospective cohort. RESULTS: Admissions from RCF are a very heterogeneous group with a wide range of diagnoses, levels of dependency and outcomes. Most admissions (88%) from lower level care (LLC) were appropriate and most returned to their usual RCF on discharge. Patients from higher level care (HLC) patients had poorer outcomes (5/8 died in the acute hospital and only 1/8 alive at 6 months). Twenty percent of all RCF admissions were potentially avoidable and could have been managed in a different setting CONCLUSIONS: Most admissions from RCF were appropriate. However for a minority of admissions, other models of care within RCFs and community care are needed to provide alternative options of care. These may reduce some acute hospital admissions.

How well is cognitive function documented by medical staff in the over-65 age group at the time of acute medical admission?

AIMS: Cognitive function in the elderly has a significant impact on prognosis and functional ability during an acute illness requiring hospital admission. METHODS: This prospective review was designed to measure how well cognitive function in the elderly was documented by medical staff at admission to hospital. Over a 2-week period, 257 patient admissions were reviewed. RESULTS: Of these, only 153 (59%) had their cognitive function documented on admission and only 14% had their premorbid cognitive function documented. Delirium was only diagnosed in 8 patients (3%) with at least 10 others having descriptions of delirious states without the formal diagnosis. CONCLUSION: In keeping with other studies, this audit shows that the documentation of cognitive function by medical staff is poor.

Effect of aspirin and warfarin on early survival after intracerebral haemorrhage.

BACKGROUND: To determine whether taking aspirin or warfarin at the time of an intracerebral haemorrhage (ICH) has an independent effect on early survival. METHODS: All people with ICH presenting in Christchurch, New Zealand over a three-year period were identified. Independent predictors of mortality at 7, 14 and 28 days were calculated using binary logistic regression. RESULTS: Two hundred and fifty three cases were identified. Unadjusted 28-day mortality was 43% overall, but 53 % for warfarin associated ICH and 43% for patients taking aspirin. Haemorrhage volume, haemorrhage location, intraventricular spread and the use of warfarin were all independently and significantly associated with mortality at all three time intervals (7, 14 and 28 days). The effect of warfarin was apparent despite similar volumes of bleed in each group. Aspirin was not associated with increased early mortality. Increasing age was also an independent predictor associated with death at 28 days. INTERPRETATION: Use of warfarin (but not aspirin) immediately prior to ICH was independently associated with increased mortality, after controlling for comorbidities. Thus therapeutic efforts to rapidly reverse the warfarin induced coagulopathy may be justified to lower mortality.

Improving care to stroke patients: adding an acute stroke unit helps.

BACKGROUND: Stroke units save lives, reduce dependency, and increase the chance of returning home. A 15-bed Acute Stroke Unit (ASU) was opened on the acute hospital campus to complement an established Stroke Rehabilitation Unit (SRU) on a distant campus. The aim of this study was to address whether patient care was improved with the establishment of the ASU. METHODS: Retrospective case-note review of a sample of patients admitted with an acute stroke to Christchurch Hospital. A before and after design was utilised to audit the processes of care (PoC) using the Royal College of Physicians (London) stroke audit tool. RESULTS: 648 patients were admitted to the Acute Stroke Unit in the first year. The retrospective audit included 119 and 72 patients in the "before" and "after" cohorts respectively. The "after" cohort had more severe strokes (greater incontinence at one week, [p=0.03], and worse level of consciousness [p=0.008]). Length of stay, domicile on discharge, and mortality outcomes were similar for the two cohorts. Processes of care improved in the "after" cohort in 27 of the 43 domains audited. CONCLUSION: Adding an ASU to complement an existing SRU can give major improvements in PoC across many different facets of stroke care. We believe this is one step closer to both the ideals of an overall coordinated stroke service and better overall care for patients with stroke.

Clinical, pathologic, and immunologic features of human T-lymphotropic virus type I- associated infective dermatitis in children

Objectives: To define the clinical and laboratory features associated with infective dermatitis (ID) and confirm its association with human T-lymphotropic virus type 1 (HTLV-I). Design: A case series of patients with ID were compared with patients with atopic dermatitis (AD) which is an important disease in the differential diagnosis of ID. Setting: Patients were recruited from dermatology and pediatric clinics at the University Hospital of the West Indies and the Bustamante Children's Hospital, Kingston, Jamaica. Main Outcome Measures: Clinical and laboratory features of patients with AD were compared with those of patients with ID. Patients: Consecutive patients older than 1« years diagnosed as having ID (n=50) and AD (n=35) were enrolled based on clinical findings. Results: The mean age of patients with ID and AD were 6.9 and 7.8 years, respectively. Histologically, both disease were predominantly chronic dermatitis... Conclusion: Infective dermatitis is a distinct clinical entity associated with HTLV-I, which plays a role in the pathogenesis and immune perturbations observed.(AU)

Tropical spastic paraparesis ocurring in HLTV-1 associated infective dermatitis: report of two cases

An association between HTLV-1 infection and infective dermatitis(ID), a relapsing eczematous condition of Jamaican children, was reported in 1990. These patients are at a risk of developing other known HTLV-1 related diseases. We have observed the development of HTLV-1 associated myelopathy/tropical spastic paraparesis im two patients, ages 14 and 35 years, who were diagnosed with ID at ages 2 and 10 years, respectively. Infective dermatitis of children serves as an early marker of HTLV-1 infection and may predict later development of either the malignant outcome, adult T-cell leukaemia/lymphoma or the neurologic manifestation HAM/TSP among adult carriers of HTLV-1 infection(AU)

Tropical spastic paraparesis ocurring in HLTV-1 associated infective dermatitis: report of two cases

An association between HTLV-1 infection and infective dermatitis(ID), a relapsing eczematous condition of Jamaican children, was reported in 1990. These patients are at a risk of developing other known HTLV-1 related diseases. We have observed the development of HTLV-1 associated myelopathy/tropical spastic paraparesis im two patients, ages 14 and 35 years, who were diagnosed with ID at ages 2 and 10 years, respectively. Infective dermatitis of children serves as an early marker of HTLV-1 infection and may predict later development of either the malignant outcome, adult T-cell leukaemia/lymphoma or the neurologic manifestation HAM/TSP among adult carriers of HTLV-1 infection

Immunological abnormalities in HTLV-1 infected Jamaican children (abstract)

This paper reports on the immunological findings of a case control study of 50 infective dermatitis (ID) patients and 36 atopic eczema (AE) patients undertaken between December 1990 and August 1991. It also reports on a comparison of these results with those of age and sex matched normal controls, and age and sex matched HTLV-I infected asymptomatic children. Investigations of their immune systems showed that both ID and AE patients had normal responses to delayed hypersensitivity skin tests, and normal compliment levels. However there was a marked increase in the activity of both T and B lymphocyte systems, with all immunoglobulin levels being significantly increased in ID patients versus others. The CD4:CD8 ratio was increased, with an increase in the CD4 counts. Monoclonal antibody tests showed increased T cell activation. The results confirm immune dysfunction though the precise mechanism of the immunodysregulation remains to be determined. (AU)

The evolving natural history of infective dermatitis in Jamaica - abstract

Infective dermatitis (ID) of Jamaican children, described in 1966, has recently been shown to be associated with human T-lymphotropic virus type 1 (HTLV-1) infection. This retrospective study of patients with infective dermatitis attending the dermatology clinic since 1970 was undertaken to determine trends in the natural history of the disorder and to define any link with other established HTLV-I associated disorders such as adult T-cell leukaemia/lymphoma (ATL) and tropical spastic paraparesis (TSP). Eighty-one patients have been followed. The results indicate that scabies was the commonest associated disorder seen in 15 patients (18 percent), with crusted scabies in 2 of these patients. Corneal opacities were seen in 8 patients (10 percent). Tropical spastic paraparesis was seen in 3 patients;lymphocytic interstitial pneumonitis was seen in 2 patients both of whom were persistently negative for human immunodeficiency virus (HIV) antibodies. Chronic glomerulonephritis was seen in 2 patients which led to chronic renal failure and death in one of these. Three patients with infective dermaitis died, one of definite ATL and two of ATL-like syndromes. These results indicate that at least a proportion of patients with infective dermatitis are at risk of developing other HTLV-I associated disorders, as well as other disorders of the immune system. These patients therefore require careful long-term follow-up (AU)

Immunological studies in infective dermatitis flow cytometric analysis of lymphocyte subpopulations in 41 cases - abstract

Infective dermatitis (ID) is a newly described HTLV-I associated with chronic dermatitis that is characterized by super infection of the skin with non-virulent pathogens. In order to investigate the possible mechanisms for this associated immune dysfunction we examined, by flow cytometry, lymphocyte subpopulations in a study group of 41 patients with infective dermatitis and compared the results with an age and sex matched group of patients with atopic eczema (AE) not associated with HTLV-I. Our results show an increase in total T-cells (CD3/Leu 4 +)2 T-helper inducer cells (CD4/Leu 3+), Activated T-cells (Leu RLA - DR+) and a subpopulation of cytotoxic T-cells (CD57: CD8/Leu 7+: Leu 2+) in the study group over the controls. The results support previous observations that T-cell aberrations in asymptomatic HTLV-I seropositive individuals, patients with Tropical Spastic Paraparesis (TSP) and adult T-cell leukaemia (ATL). It would appear that HTLV-I-induced immunodeficiency may be the result of phenotypic qualitative defects in T-lymphocyte subpopulations although absolute counts may be elevated (AU)

Infective dermatitis of Jamaican children 1966-1991 - abstract

Infective dermatitis of Jamaican children, first described by Sweet in 1966, is a chronic eczema associated with persistent infection of the skin or anterior nares with either staphylococcus aureus or B haemolytic streptococcus, or both. In 1990, we reported a pilot study of 14 children with infective dermatitis (ID) and 11 with atopic eczema (AE) as controls, which showed that all the ID patients were positive for antibodies to the human T-lymhotrophic virus (HTLV-1). We postulated then that there was an association between HTLV-1 infection and infective dermatitis, and suggested that this organism might be causing ID through an immune mechanism. This paper reports on findings of a case control study of 50 ID patients and 36 AE patients undertaken between December, 1990 and August, 1991, which confirms the association between HTLV-I and infective dermatitis. All 50 patients with ID were positive for HTLV-I and antibodies, while the AC controls were all negative. In addition, when compared to the atopic controls, the ID patients had lower haemoglobins, higher white cell counts, and higher ESRs. They also had lower serum albumins and serum irons. Investigations of their immune systems showed that both groups had normal responses to delayed hypersensitivity skin tests, and normal complement levels. However, there was a marked increase in the activity of both T and B-lymphocyte systems, with all immunoglobulin levels being significantly increased in ID patients. The CD4: CD 8 ratio was increased, with an increase in the CD4 counts. Monoclonal antibody tests showed increased T-cell activation. The results confirm the association between HTLV-1 infection and infective dermatitis and confirm immune dysfunction. The precise mechanism of the immunodysregulation, however, remains to be determined (AU)

Beta-2-microglobin levels in HTLV-I infection - abstract

The human T-lymphotropic virus (HTLV-I) is endemic to the Caribbean and its importance as a possible cause of disease is increasing. Initial reports were of the association of HTLV-1 infection with adult T-cell lymphoma/leukaemia (ATL). Since then, tropical spastic paraparesis (TSP), infective dermatitis, polymyositis and more recently, crusted scabies have been reported to occur in individuals sero-positive for the virus. á2-microglobulin is a small peptide which forms the light chain of the HLA antigen that is present on the surface of nucleated cells. It has been shown to be an index to tumour burden in patients with lymphoma and to provide valuable information on the prognosis and response to therapy in patients infected with HIV. Here we reported on the serum á2-microglobulin levels in patients with lymphoma, TSP, infective dermatitis, children of HTLV-1-positive mothers and the relationship between HTLV-1 infection and á2-microglobulin levels. (AU)

The association of crusted scabies with T-lymphotropic virus type I and adult T-cell leukaemia/lymphoma - abstract

Crusted scabies is a hyperinfestation with the mite Sarcoptes scabei var Hominis and is characterized by hyperkeratotic plaques and crusting, especially over bony prominences. The disease is often found in association with immunosuppression, down's syndrome, mental retardation and in patients with diminished sensation. Recently a significant association with human T-lymphotropic virus type I (HTLV-I) and adult T-cell leukaemia/lymphoma (ATL) has been reported. Over a 30-month period, 18 patients with crusted scabies were admitted to the dermatology ward, University Hospital of the West Indies, Mona. Of these patients, 13 (72 percent) were found to be HTLV-I seropositive and 4 of this group on further investigation were found to have ATL. The remainder of patients had other HTLV-I associated disease (tropical spastic paraparesis, infective dermattis with lymphocytic interstitial pneumonitis and psoriasiform eczema), immunosuppression due to a carcinoma and malnutrition associated with a cerebrovascular accident, lupus erythematosus on corticosteroid, and in 4 patients no underlying cause was found. Because of this strong association of crusted scabies with HTLV-I seropositivity and HTLV-I associated diseases in our environment, the determination of HTLV-I serostatus and investigation for possible ATL are mandatory in patients with this unusual form of scabies. (AU)

Infective dermatitis of Jamaican children: a marker for HTLV-I infection

In Jamaican children infective dermatitis is chronic eczema associated with refractory nonvirulent Staphylococcus aureus or beta haemolytic streptococcus infection of the skin and nasal vestibule. 14 children between the ages of 2 and 17 years with typical infective dermatitis, attending the dermatology clinic at the University Hospital of the West Indies in Jamaica, were tested for antibody to human T-Lymphotropic virus type 1 (HTLV-1). All were seropositive, whereas 11 children of similar age with atopic eczema were all negative. In 2 of 2 cases of infective dermatitis, the biological mother was HTLV-1 seropositive. None of the 14 patients showed signs of adult T-cell leukaemia/lymphoma, though experience with previous cases of infective dermatitis indicates the possibility of such progression. (AU)