Disseminated Saksenaea infection in an immunocompromised host associated with a good clinical outcome: a case report and review of the literature.

BACKGROUND: Saksenaea species (spp.) are uncommon causes of mucormycosis but are emerging pathogens mostly associated with trauma and soil contamination often in immunocompetent hosts. Due to lack of sporulation in the laboratory, diagnosis and susceptibility testing is difficult so optimal treatment regimens are unknown. CASE PRESENTATION: A 67 year-old man from the Northern Territory in Australia, with a history of eosinophilic granulomatosis with polyangiitis, developed disseminated Saksenaea infection after initially presenting with symptoms consistent with bacterial pyelonephritis. Despite a delay in diagnosis; with aggressive surgical management and dual therapy with amphotericin B and posaconazole, he survived. CONCLUSIONS: We describe an unusual case of disseminated infection with a favourable outcome to date.

Effect of celecoxib on anticonvulsant activity of carbamazepine against maximal electroshock-induced convulsions in mice.

This study investigates the effect of celecoxib alone and in combination with carbamazepine (CBZ) on maximal electroshock-induced convulsions in mice. Celecoxib (30, 45, 60, 75 and 90 mg/kg) and CBZ (2, 4, 6 and 8 mg/kg) were each given alone in increasing doses, and CBZ was given in combination with a single dose of celecoxib (30 mg/kg) 40 min prior to electroshock-induced convulsions. The percentage protection and duration of hind limb extension were determined using an electroconvulsiometer. The ED50 value (dose at which there is protection in 50% of animals) of CBZ alone and in combination with celecoxib was determined. When administered alone, CBZ showed an increase in percentage protection at increasing doses, with 100% protection occurring at a dose of 8 mg/kg. However, treatment with celecoxib alone demonstrated maximum protection of 50% occurring at the 60 mg/kg dose. Moreover, celecoxib given at 30 mg/kg did not show any protection. Nevertheless, coadministration of celecoxib (30 mg/kg) enhanced the effect of the subprotective dose of CBZ and was more effective than CBZ given alone. Combined treatment with celecoxib enhanced the potency of CBZ and significantly reduced its ED50 value. This study suggests that celecoxib has an anticonvulsant effect of its own and it also potentiates the anticonvulsant efficacy of CBZ against maximal electroshock-induced convulsions in mice.

Rapid-sequence intubation at an emergency medicine residency: success rate and adverse events during a two-year period.

OBJECTIVES: Rapid-sequence intubation (RSI) is an active airway intervention used frequently in emergency medicine (EM). The authors hypothesized that RSI can be performed safely in the setting of an EM training program at a tertiary care center. METHODS: Observational study of RSI at an urban ED/Level 1 trauma center with annual census of 100,000 patients. Consecutive patients who underwent RSI during a two-year period were studied. Data included age, gender, type of patient (medical/trauma), indication for intubation, number of intubation attempts (laryngoscope passes), training level of operator, and major immediate adverse events (clinical deterioration within 10 minutes of RSI). RESULTS: RSI was used in 417 of 596 (70%) critically ill patients requiring emergent intubation. The patient demographic distribution was the following: adults 89.7%, male 58%, and trauma 44%. Primary indications for intubation among RSI patients were as follows: mechanical ventilation 57.4%, airway protection 41.3%, and cardiac arrest 1.3%. Distribution of intubations by level of EM training was PGY1, 5%; PGY2, 52%; PGY3, 40%; and attendings, 3%. Intubations were successfully completed within two attempts in 97% of the patients. Major immediate adverse events were encountered in six patients (1.4%) (hypotention=2, hypoxemia=1, dysrhythmia=3). There was no death attributable to RSI. The rate of intubations requiring two or fewer attempts and without major immediate adverse events was 96%. Three patients required cricothyrotomy. CONCLUSION: In the setting of an EM residency at a tertiary care ED, RSI can be performed successfully with few major immediate adverse events.

Tracheostomies.

Emergency physicians should be able to quickly evaluate and initiate therapy for tracheostomy tube obstruction, tracheal hemorrhage, interstitial air leading to pneumothorax, and infections throughout the lower respiratory tract. Familiarity with tracheal tubes and their function is a prerequisite to dealing with immediate distress in these patients. Emergency maneuvers including proper suctioning, cannula removal, cannula insertion, balloon hyperinflation, and endoscopy will ensure that tracheostomy patients avoid complications. The many other disorders of the tubes, trachea, esophagus, and soft tissues need to be kept in mind when evaluating tracheostomy patients when symptoms or signs are unusual or strange. Although associated with many complications, patent tracheostomies allow many patients to bypass difficult pathology and access life through an adequate airway.

Bacterial contamination of ambulance oxygen humidifier water reservoirs: a potential source of pulmonary infection.

The risk and benefit of oxygen humidification during ambulance transport is unknown. We cultured the water in plastic multiple-use bottles of humidifiers on 30 randomly selected area ambulances during November 1985. There were 22 positive cultures. Potentially pathogenic bacteria (four Pseudomonas maltophilia, three Pseudomonas aeruginosa, one Klebsiella pneumoniae, and one Staphylococcus epidermidis) were found in nine samples. Assuming that the water in ambulance humidifiers should have been sterile, the findings are statistically significant (P less than .01). Because there is no evidence that humidification is of benefit for nonintubated patients receiving oxygen at flow rates of 4 L/min or less when environmental humidity is adequate, we suggest that such patients should receive oxygen without humidification during ambulance transport. All other patients requiring oxygen during ambulance transport should continue to receive humidified oxygen. If a multiple-use humidifier reservoir is to be used, a written policy for its use must be developed and there must be appropriate documentation of compliance with the policy. An alternative is to replace the multiple-use humidifier reservoir with single-use sterile disposable devices, which cost approximately $2.00 per unit.

Treatment of paroxysmal supraventricular tachycardia in the emergency department by clinical decision analysis.

Vagal maneuvers terminate new onset, catheter-induced paroxysmal supraventricular tachycardia (PSVT) in up to 92% of patients. The risk and benefit of vagal maneuvers for treating PSVT in the emergency department (ED) is inadequately defined. The purpose of this study was to determine the efficacy of nonpharmacological vagal interventions in converting spontaneous episodes of PSVT in adult patients and to derive a treatment plan for such patients based on clinical decision analysis. Seventeen adult patients who presented to the ED because of PSVT were treated with carotid sinus massage, Valsalva maneuver, and head-down tilt (alone and in combination). Only three patients converted out of PSVT with vagal intervention. The remainder received verapamil, which converted 12 of the 14 patients (86%) who received the drug (one required digoxin, one required synchronized cardioversion). Vagal maneuvers are safe in young, otherwise healthy patients but problems have been documented in the literature in older patients, who have a higher likelihood of coronary and/or cerebrovascular disease. Clinical decision analysis indicates that young patients should be treated initially with vagal maneuvers but that older patients (above approximately 65 years of age) should be treated initially with verapamil.