Clinical, Epidemiological, and Etiological Changes in Erythema Nodosum.

BACKGROUND: Erythema nodosum (EN) is the most common type of panniculitis, commonly secondary to infectious diseases. OBJECTIVES: To elucidate the causative factors and the clinical presentation of patients with EN (2004-2014) and to compare their data to those reported in a previous study. METHODS: A retrospective study was conducted of all patients diagnosed with EN who were hospitalized at Soroka University Medical Center (2004-2014). The clinical, demographic, and laboratory characteristics of the patients were compared to those in a cohort of patients diagnosed with EN from 1973-1982. RESULTS: The study comprised 45 patients with a diagnosis of EN. The most common symptoms of patients hospitalized with EN were arthritis or arthralgia (27% of patients). Patients with EN, compared to those reported in 1987, has significantly lower rates of fever (18% vs. 62% P < 0.001), streptococcal infection (16% vs. 44%, P = 0.003), and joint involvement (27% vs. 66%, P < 0.001). In addition, fewer patients had idiopathic causes of EN (9% vs. 32%, P = 0.006). CONCLUSIONS: In the past decades, clinical, epidemiological, and etiological changes have occurred in EN patients. The lowering in rate of fever, streptococcal infection, and joint involvement in patients with EN are probably explained by improvements in socioeconomic conditions. The significantly decreasing rate of idiopathic causes of EN is possibly due to the greater diagnostic accuracy of modern medicine. The results of the present study demonstrate the impact of improvements in socioeconomic conditions and access to healthcare on disease presentation.

Anaphylactic reactions in adult patients in Southern Israel.

BACKGROUND: Southern Israel is inhabited by Jews and Bedouins. Children from these populations differ in the epidemiology of anaphylactic reactions; however, the effects of ethnicity on the epidemiology of anaphylactic reactions in adults in these populations are unknown. METHODS: Retrospective review of medical records of patients with anaphylactic reactions treated in a single institution during 2008-2012. RESULTS: A total of 192 evaluable cases of anaphylaxis were recorded; 155 (80.7%) anaphylactic reactions occurred in Jews and 37/192 (19.3%) occurred in Bedouins. A trend towards an older mean age of occurrence of anaphylaxis was recorded in Jewish patients compared with Bedouin patients: 48.1 years versus 41.2, respectively (P = 0.053). Anaphylaxis was more common in Jewish female patients than males and more common in Bedouin male patients than females. Overall, 93/155 (60.0%) females in Jewish patients were affected compared with 14/37 (37.8%) in the Bedouin population (P = 0.015). More Jewish patients had more anaphylaxis attributed to food compared with Bedouin patients: 31/155 (20%) versus 2/37 (5.4%) (P = 0.034). The mean yearly incidence of anaphylaxis was similar in Bedouin and Jewish patients: 12.1 ± 5.3 versus 17.6 ± 15.3, respectively (P = 0.466). However, a significant trend towards a higher incidence of anaphylactic reactions was recorded throughout the study years only in Jewish patients (r = 0.906, P = 0.034). CONCLUSIONS: Adult Jewish patients have a significantly higher probability of having anaphylactic reactions due to food compared with Bedouin patients, with females being more affected, and the incidence of anaphylactic reaction is increasing only in the Jewish population. The epidemiology of anaphylactic reactions can differ between populations residing in the same geographical area.

The role of icatibant-the B2 bradykinin receptor antagonist-in life-threatening laryngeal angioedema in the ED.

Angioedema is a localized, sudden, transient, and often recurrent swelling of the deeper layers of the skin or mucosa with no epidermal component. It is caused by vasoactive substances that produce a transient increase in endothelial permeability. Angioedema involving the laryngeal components is a life-threatening situation for the patient,and it is a challenge for the emergency medicine physician to rapidly achieve a safety airway. Most cases of laryngeal angioedema are induced by histamine release; but 10% are bradykinin induced, which does not respond to the conventional algorithm of treating allergic induced angioedema. We present a case report of an angiotensin converting enzyme (ACE) inhibitor­induced laryngeal angioedema alleviated only after treatment with the new bradykinin receptor inhibitor medication icatibant which was licensed only for use in hereditary angioedema. We reviewed the literature for the use of icatibant in acquired drug-induced angioedema; and because of the similar pathogenesis between the hereditary angioedema and the ACE inhibitor­induced angioedema,we propose an algorithm for careful use of icatibantin life-threatening angioedema in the emergency department.

Carbapenem-resistant Acinetobacter baumannii: Colonization, Infection and Current Treatment Options.

Carbapenem-resistant Acinetobacter baumannii (CRAB) causes colonization and infection predominantly in hospitalized patients. Distinction between the two is a challenge. When CRAB is isolated from a non-sterile site (soft tissue, respiratory samples, etc.), it probably represents colonization unless clear signs of infection (fever, elevated white blood count, elevated inflammatory markers and abnormal imaging) are present. Treatment is warranted only for true infections. In normally sterile sites (blood, cerebrospinal fluid) the presence of indwelling medical devices (catheters, stents) should be considered when evaluating positive cultures. In the absence of such devices, the isolate represents an infection and should be treated. If an indwelling device is present and there are no signs of active infection, the device should be replaced if possible, and no treatment is required. If there are signs of an active infection the device should be removed or replaced, and treatment should be administered. Current treatments options and clinical data are limited. No agent or combination regimen has been shown to be superior to any other in randomized clinical trials. Ampicillin-sulbactam appears to have the best evidence for initial use. This is probably due to its ability to saturate penicillin-binding proteins 1 and 3 when given in high dose. Tigecycline when used should be given in high dose as well. Polymyxins are a treatment option but are difficult to dose correctly and have significant side effects. Newer treatment options such as eravacycline and cefiderocol have potential; however, currently there are not enough data to support their use as single agents. Combination therapy appears to be the best treatment option and should always include high-dose ampicillin-sulbactam combined with another active agent such as high-dose tigecycline, polymyxins, etc. These infections require a high complexity of skill, and an infectious disease specialist should be involved in the management of these patients.

Reliability of blood tests taken from the peripheral intravenous catheter.

We aimed to compare the reliability of laboratory blood tests using 2 sampling methods, via a peripheral venous catheter (PVC) vs direct venipuncture stab (DVS), we evaluated the effect of time elapsed since PVC insertion, PVC diameter, and administration of saline and/or antibiotic infusion through PVC on the blood test results. A prospective comparative study was conducted between May 2018 and July 2019. Patients aged ≥ 18 years and admitted to our department with a 20G/22G PVC inserted within the last 24 hours were enrolled. Blood samples were collected from each participant in the morning, and a second sample was drawn using PVC. Dependent variables included the percentage of hemolysis, failure rate, complete blood count, biochemical testing parameters, and coagulation functions. A total of 211 patients participated in the study. In total, 237 blood tests were conducted, of which 167 were performed on day 1 and the remaining on day 2, with a second blood sample collected from 26 patients on day 2. Twenty-one participants received 22G PVC, and 23 participants received active infusion. No significant differences were found in failure rates when each subgroup was compared with the primary day 1 group. The intraclass correlation coefficient indicated significant correlations among all the indices in all groups. Both blood sampling methods (PVC and direct venipuncture) can be used interchangeably for routine laboratory tests on days 1 and 2 after PVC insertion using 20G/22G PVC or infused PVC.

Haiti earthquake 2010: a field hospital pediatric perspective.

On January 12 2010, a 7.0-magnitude earthquake struck Haiti. The region had suffered an estimated 316,000 fatalities with approximately 300,000 injured and more than 1 million people who lost their houses. Following the quake, the Israeli Defense Force Medical Corps dispatched a field hospital unit to the capital city, Port au Prince. The hospital had a pediatric division which included pediatric emergency department, pediatric ward and neonatal unit. We elaborate on the various aspects of pediatric treatment that was provided by our hospital. A total of 363 pediatric patients (younger than 18 years) were admitted to our facility during its 10 days of operation. Out of this total, 272 pediatric patients were treated by the pediatric division, 79 (29%) were hospitalized and 57 (21%) required surgery. The pediatric team included seven pediatricians, one pediatric surgeon and six registered nurses. An electronic record and a hard copy file were created for each patient. Fifty-seven percent of the children presented with direct earthquake related injuries. Twelve patients required resuscitation and stabilization and three patients had died. The majority of injuries were orthopedic while infectious diseases accounted for most of the general pediatric diagnoses. In conclusion, operating a field hospital for a population affected by natural disaster is a complex mission. However, pediatric care has its own unique, challenging characteristics.

Early disaster response in Haiti: the Israeli field hospital experience.

The earthquake that struck Haiti in January 2010 caused an estimated 230,000 deaths and injured approximately 250,000 people. The Israel Defense Forces Medical Corps Field Hospital was fully operational on site only 89 hours after the earthquake struck and was capable of providing sophisticated medical care. During the 10 days the hospital was operational, its staff treated 1111 patients, hospitalized 737 patients, and performed 244 operations on 203 patients. The field hospital also served as a referral center for medical teams from other countries that were deployed in the surrounding areas. The key factor that enabled rapid response during the early phase of the disaster from a distance of 6000 miles was a well-prepared and trained medical unit maintained on continuous alert. The prompt deployment of advanced-capability field hospitals is essential in disaster relief, especially in countries with minimal medical infrastructure. The changing medical requirements of people in an earthquake zone dictate that field hospitals be designed to operate with maximum flexibility and versatility regarding triage, staff positioning, treatment priorities, and hospitalization policies. Early coordination with local administrative bodies is indispensable.

Nonhepatic hyperammonemic encephalopathy complications following bariatric surgery: a case report and review of the literature.

BACKGROUND: Hyperammonemic encephalopathy, a rare but fatal condition, is increasingly being reported as a possible complication of bariatric surgery. Here, we present a case of hyperammonemic encephalopathy, focusing on the clinical presentation, diagnostic measures, and our treatment methods, which resulted in a rare favorable outcome, emphasizing the unique role of renal replacement treatment. We also provide a detailed discussion of the mechanism through which hyperammonemia occurs secondarily to bariatric surgery. CASE PRESENTATION: A 44-year-old Moroccan Jew woman with a history of obesity presented in the hospital with urea cycle disorder that manifested after bariatric surgery. A rapid diagnostic process, together with conservative treatment with lactulose, nutritional supplementation, dietary protein restriction, and ammonia scavengers did not result in adequate improvement. Therefore, hemofiltration was performed, which yielded a favorable outcome. CONCLUSIONS: The case findings indicate an association between hyperammonemic encephalopathy and bariatric surgery, and support early treatment with ammonia scavengers, as currently accepted. Nevertheless, if rapid improvement is not seen, it is advisable to consider hemodialysis or hemofiltration as early invasive strategies.

Sex Differences in Infective Endocarditis.

BACKGROUND: The impact of sex on the presentation, etiology, and outcomes of infective endocarditis (IE) has not been adequately studied. The aim of the present research was to analyze the impact of sex on the presentation, etiology, and outcomes of IE. METHODS: We performed a retrospective study of 214 adult patients (131 male and 83 female) with IE. All cases of IE were reviewed by two investigators- both senior physicians in internal medicine. Two groups of patients were compared: male and female patients with IE. The primary outcome was in-hospital mortality. RESULTS: We found significant differences in etiologic factors of IE in male and female patients. Microbiologic etiology differences between male and female groups of patients were in coagulase negative staphylococcus (15.0% in male vs 3.8% in female groups, P = 0.011), and culture negative endocarditis (8.7% in male vs 23.8% in female groups, P = 0.004). We did not find a difference in the primary outcome between the two groups; however, all-cause mortality was significantly higher in the female group as compared to the male group (26 [31.3] vs 22 [16.8], P = 0.018). CONCLUSIONS: We found that sex may have important role in both the microbial profile and the patient's outcome with IE.

QuikClot Combat Gauze use for hemorrhage control in military trauma: January 2009 Israel Defense Force experience in the Gaza Strip--a preliminary report of 14 cases.

BACKGROUND: Standard gauze field dressings and direct pressure occasionally are inadequate for the control of hemorrhage. QuikClot® Combat Gauze™ (QCG) combines surgical gauze with an inorganic material and is approved by the Food and Drug Administration and by the Israeli Standards Institute for external hemorrhage control. The purpose of this article is to report clinical use of this dressing during Operation Cast Lead in the Gaza strip during January 2009. METHODS: QuikClot Combat Gauze and the QCG guidelines were issued to advanced life support (ALS) providers during the preparations for the Operation. All cases of injuries involving hemorrhage were reviewed, as well as interviews with the ALS providers (physicians and paramedics) and injured soldiers. RESULTS: Fourteen uses of QCG were reported and reviewed (out of a total of 56 hemostatic interventions in 35 cases). Dressings were applied to injuries to the head, neck, axilla, buttocks, abdomen, back, and pelvis in 10 cases, and to extremities in four cases. In 13 cases (93%), injuries were caused by blast or gunshot mechanisms. The success rate was reported as 79% (11/14). Failure to control hemorrhage was reported in three cases in three different locations: neck, buttock, and thigh. All failures were attributed to severe soft tissue and vascular injuries. No complications or adverse events were reported. CONCLUSIONS: This report on the clinical field use of the QCG dressing by ALS providers suggests that it is an effective and safe product, and applicable for prehospital treatment of combat casualties. This report further suggests that QCG should be issued to medics as well as ALS providers. Larger clinical investigations are needed to confirm these findings.

Delirium in Internal Medicine Departments in a Tertiary Hospital in Israel: Occurrence, Detection Rates, Risk Factors, and Outcomes.

Background: The aim of the study was to assess the occurrence rate of delirium among elderly hospitalized patients in the medicine wards of a large tertiary hospital, to identify risk factors, and to evaluate the diagnostic rate for delirium among the medical teams. Methods: A 3-month prospective study of patients 65 years of age and above in three medicine wards: in two wards patients were examined by trained study team members using the Confusion Assessment Method (CAM), while the third was a control ward where CAM was not administered. The third ward served to control for the effect of the presence of investigators in the other wards as a potential confounding factor. Based on the results of this assessment patients were defined as suffering from subsyndromal delirium, full delirium (these two groups were later combined into an "any symptoms of delirium" group), and no delirium. The rate of diagnosis by the medical team was obtained from the electronic medical records. Results: The full delirium rate was 5.1%, the rate of subsyndromal delirium was 14.6%, and the rate of any symptoms of delirium was 19.6%. Absence of a partner, pain, anemia, hyponatremia, hypocalcemia, and the use of drugs with an anticholinergic burden were factors for any symptoms of delirium as well as for subsyndromal delirium. Subsyndromal delirium and any symptoms of delirium were associated with a reduced chance of being discharged to home and a higher 3-month mortality rate. A diagnosis of delirium was found in only 19.4% of the patients with any symptoms of delirium in the medical records. Conclusions: Delirium is a common problem among elderly hospitalized patients, but it is diagnosed sub-optimally by the medical team. There is a need for further training of the medical teams and implementation of delirium assessment as part of the ward's routine.

The role of thromboelastometry and recombinant factor VIIa in trauma.

PURPOSE OF REVIEW: Recombinant factor VIIa (rFVIIa) and thromboelastography have acquired increasing importance in patients with severe bleeding and coagulopathy. This article reviews the current opinions regarding their use, with the purpose of clarifying the ambiguities that exist in dealing with trauma patients. RECENT FINDINGS: Recent evidence encourages the early use of rFVIIa and thromboelastography in the severe trauma patient with hemorrhagic shock, as a component of the damage control strategy. rFVIIa may decrease short-term mortality and the rate of required blood components during resuscitation, with no apparent increase in thromboembolic complications. Thromboelastometry enables better and earlier recognition of the coagulopathy accompanying such trauma patients. In patients with traumatic brain injury and coagulopathy, rFVIIa may delay or even halt the need for surgery, with no proven decrease in mortality. In those who needed urgent neurosurgical intervention, rFVIIa may rapidly correct the coagulopathy, enabling earlier and safer surgical intervention. SUMMARY: Thromboelastometry may guide the medical staff when and to whom rFVIIa could be administered. Evidence also encourages the use of rFVIIa in traumatic brain injury. More research is required to prove decreases in mortality using both thromboelastography and rFVIIa in trauma, with a focus on clear end points and goal-directed therapy.

Recurrent diabetic ketoacidosis.

OBJECTIVE: The purpose of this study is to examine risk factors for recurrence of diabetic ketoacidosis and determine interventions to prevent future admissions. MATERIALS AND METHODS: Review article. RESULTS: Recurrent diabetic ketoacidosis is a serious and not uncommon health problem. Diabetic ketoacidosis is associated with severe morbidity and mortality and hospital admissions due to this problem constitute a serious economic burden on the healthcare system. Younger age at diabetic ketoacidosis onset, poor baseline glycemic control and elevated HbA1C, patient comorbidities, depression, alcohol or substance abuse, particularly active cocaine use, have been associated with recurrent diabetic ketoacidosis. In addition, socioeconomic factors (such as ethnic minority status, use of public health insurance and underinsurance), psychosocial, economic, and behavioral factors (including financial constraint, stretching a limited insulin supply, and homelessness) have been all reported to be associated with readmission among diabetic ketoacidosis patients. CONCLUSIONS: Identifying high-risk patients during the first diabetic ketoacidosis admission and performing relevant interventions (repeated instructions of insulin use, social help and involvement of family members in medical treatment, collaboration with the patient's primary care physician in order to establish a close and frequent follow up program) may help prevent future admissions. Further studies need to take place to determine whether early interventions with those factors prevent future admissions.

Comparison of Clinical Characteristics and Prognosis in Patients with Right- and Left-sided Infective Endocarditis.

OBJECTIVE: Right-sided endocarditis (RSE) accounts for 5%-10% of all cases of infective endocarditis (IE) and frequently has different etiological, pathogenetic, and clinical presentations compared with left-sided endocarditis (LSE). The aims of this study were to evaluate the epidemiologic and clinical characteristics and prognosis of RSE patients and to compare them with those of LSE patients. This study's importance relates to the local understanding of RSE and LSE, since Israeli demographics are different compared to the Unites States and Europe with regard to intravenous drug abuse and rheumatic valvular disease prevalence. MATERIAL AND METHODS: A retrospective cohort study of 215 patients with infective endocarditis was performed. The primary outcome was in-hospital mortality. The secondary outcomes were duration of hospitalization, recurrent hospitalization, recurrent infective endocarditis, and one-year mortality. RESULTS: Of the 215 patients in the study, 176 had LSE and 39 had RSE. The RSE patients were younger than the LSE patients (48.1±18.9 years versus 61.8±17.0 years, P<0.001). The most common pathogen in both groups was Staphylococcus aureus, which occurred more in the RSE group (51%) versus the LSE group (19%). In-hospital mortality was lower among patients with RSE (2.6% versus 17%, P<0.037). CONCLUSIONS: Our study demonstrated an increasing percentage of RSE compared to LSE among patients with IE. Pacemaker lead infection has become the leading cause of RSE in intravenous drug users (IVDU), although less common in Southern Israel. The etiological and clinical differences between RSE and LSE are noteworthy. Patients with RSE have a better prognosis than those with LSE.

Drug-induced eosinophilic pneumonia: A review of 196 case reports.

BACKGROUND AND OBJECTIVE: Eosinophilic pneumonia (EP) is an important subset of patients who present with pulmonary infiltrates and eosinophilia (PIE). EP is classified by chronicity and etiology and drug-induced EP is the main cause of secondary EP. The primary goal of this review was to examine all the case reports published since the syndrome was defined in 1990. It remains unclear whether acute or chronic EP (AEP or CEP) represent different diseases, and the secondary goal of this review is to determine if there are factors that may help distinguish these 2 entities. METHODS: PubMed (MEDLINE and Medical Subject Headings) was searched for case reports of drug-induced EP or PIE syndrome published between 1990 and 2017. Case reports were only included if the diagnostic criteria for AEP or CEP were fulfilled. For each case, data were extracted pertaining to age, sex, type of medication associated with the disease, time from the onset of symptoms to diagnosis, eosinophil counts in the blood, eosinophil fractions in bronchoalveolar lavage (BAL) fluid, initial chest radiograph and computed tomography results, use of mechanical ventilation, and use of steroid treatment and recurrence. RESULTS: We found 196 case reports describing drug-induced EP. The leading cause was daptomycin. From our review, we found that AEP is more common in younger patients with no gender preference. Eosinophilia in the blood at the time of diagnosis characterized only the CEP patients (80% in CEP vs. 20% in AEP). Abnormal findings on radiographic imagine was similar in both syndromes. A significant portion of AEP patients (20%) presented with acute respiratory failure requiring mechanical ventilation. Most patients with EP were treated with steroids with a higher rate of relapse observed in patients with CEP. CONCLUSION: AEP is a much more fulminant and severe disease than the gradual onset and slowly progressive nature of CEP. The pathogenesis of AEP and CEP remains unclear. However, there is significant clinical overlap among AEP and CEP that are associated with drug toxicity, suggesting the possibility that AEP and CEP are distinct clinical presentations that share a common pathogenic pathway.

Coagulopathic patients with traumatic intracranial bleeding: defining the role of recombinant factor VIIa.

BACKGROUND: The combination of coagulopathy and intracranial bleeding (ICB) is a well-recognized cause of morbidity and mortality in the neurosurgical patient because of the risk of hematoma expansion. Although recombinant factor VIIa (rFVIIa) has been shown to be useful in intracerebral hemorrhage, its use in other forms of ICB such as subdural hematomas (SDHs) has rarely been described. METHODS: The clinical and laboratory features of a prospectively followed up case-series of 15 patients with traumatic ICB (mainly isolated SDHs) and coagulopathy international normalized ratio (INR) >1.3 treated with rFVIIa in our institution are presented, along with a review of the literature regarding the role of rFVIIa in neurosurgical patients with ICB. RESULTS: All 15 patients suffered a SDH (4 of 15 had a combined ICB) and coagulopathy (mean INR, 2.34 +/- 0.83; thrombocytopenia rate, 20%), which was attributed to anticoagulants in 46.7%. The mean INR decreased to 1.5 +/- 0.14 after standard therapy and 0.92 +/- 0.1 after rFVIIa therapy. There was no evident progression of bleeding in any patient treated with rFVIIa. In three patients, neurosurgery was obviated by rFVIIa therapy, whereas the other 12 patients underwent neurosurgery safely and successfully. None required subsequent surgery for continuing hemorrhage, and no adverse events secondary to FVIIa administration were observed. Based on our experience and the reviewed literature, a proposed algorithm for a stratified approach to rFVIIa administration in traumatic ICB is discussed. CONCLUSIONS: rFVIIa is an inducer of hemostasis, which successfully controlled potentially devastating bleeding in all of 15 coagulopathic neurosurgical patients with ICB. The use of rFVIIa lowered the INR into the operable range in all patients, allowing surgery, and in some cases, obviated the need for surgery. Randomized, placebo-controlled clinical trials are needed to further assess the efficacy and cost-effectiveness of this approach in this setting.

Effectiveness of Inferior Vena Cava Filters without Anticoagulation Therapy for Prophylaxis of Recurrent Pulmonary Embolism.

OBJECTIVE: The optimal treatment of deep vein thrombosis (DVT) is anticoagulation therapy. Inferior vena cava filter (IVC) placement is another option for the prevention of pulmonary embolism (PE) in patients with deep vein thrombosis. This is used mostly in patients with a contraindication to anticoagulant therapy. The purpose of the present study was to compare the two options. METHODS: A retrospective cohort study of two groups of patients with DVT: patients who received an IVC filter and did not receive anticoagulation due to contraindications; and patients with DVT and similar burden of comorbidity treated with anticoagulation without IVC insertion. To adjust for a potential misbalance in baseline characteristics between the two groups, we performed matching for age, gender, and Charlson's index, which is used to compute the burden of comorbid conditions. The primary outcome was an occurrence of a PE. RESULTS: We studied 1,742 patients hospitalized with the diagnosis of DVT in our hospital;93 patients from this population received IVC filters. Charlson's score index was significantly higher in the IVC filter group compared with the anticoagulation group. After matching of the groups of patients according to Charlson's score index there were no significant differences in primary outcomes. CONCLUSION: Inferior vena cava filter without anticoagulation may be an alternative option for prevention of PE in patients with contraindications to anticoagulant therapy.

Headache in the presentation of noncephalic acute illness.

BACKGROUND: Headache is a frequent symptom of many systemic diseases that do not involve cranial structures. In this observational study, we assessed factors associated with headache in the acute presentation of systemic conditions in a nonsurgical emergency department (ED). METHODS: Consecutive patients, admitted to Soroka University Medical Center ED due to noncephalic illness, were prospectively surveyed using a structured questionnaire focused on the prevalence and characteristics of headache symptoms. Medical data were extracted from the patient's charts. RESULTS: Between 1 and 6/2012, 194 patients aged 64.69 ± 19.52 years, were evaluated. Headache was reported by 83 (42.7%) patients and was more common among patients with febrile illness (77.5% vs. 22.5%, P < 0.001). Respiratory illness and level of O2 saturation were not associated with headache. Headache in the presentation of a noncephalic illness was associated with younger age (58 vs. 69, P < 0.001) and with suffering from a primary headache disorder (48.2% vs. 10.8%, P < 0.001). Headache was also associated with higher body temperature and lower platelets count. CONCLUSIONS: Headache is a common symptom in acute noncephalic conditions and was found to be associated with younger age and febrile disease on presentation. Patients who present with primary headache disorders are more prone to have headache during acute illness. Acute obstructive respiratory disease, hypercarbia or hypoxemia were not associated with headache.

Pharmacokinetic dosing of aminoglycosides: a controlled trial.

PURPOSE: To evaluate whether individualized pharmacokinetic dosing of aminoglycosides can reduce nephrotoxicity and improve the outcome of patients with gram-negative sepsis. METHODS: We conducted a prospective controlled trial at a tertiary care university hospital. Eighty-one patients with suspected or documented gram-negative infections were enrolled. All were treated with either gentamicin or amikacin, according to clinical judgement. Patients were allocated to one of two groups based on the last digit (odd/even) of their identification number. In the study group (pharmacokinetic dosing) of 43 patients, plasma aminoglycoside levels were determined 1 hour after initiation of drug infusion and 8 to 16 hours later to estimate the elimination half-life and volume of distribution, from which the subsequent dosage schedule was calculated. Target peak plasma levels were 20 microg/mL for gentamicin and 60 microg/mL for amikacin. Target trough levels were <1 microg/mL for both drugs. The control group (fixed once-daily dosing) consisted of 38 patients who were prescribed single daily doses of gentamicin or amikacin. The primary endpoints were renal toxicity (> or = 25% increase in serum creatinine level or a serum creatinine level > or = 1.4 mg/dL) and 28-day mortality. RESULTS: The two study groups were similar in age, sex, indications for therapy, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and clinical assessment at baseline. Although the pharmacokinetic group received significantly greater doses of aminoglycosides than did the once-daily group, the incidence of nephrotoxicity was significantly lower in the pharmacokinetic group (5% [2/43] vs. 21% [8/38], P = 0.03). There was no statistically significant difference in 28-day mortality (27% [12/43] vs. 22% [8/38], P = 0.3). CONCLUSION: These results suggest that individualized pharmacokinetic dosing of aminoglycosides reduces the incidence of nephrotoxicity and allows the use of greater doses of aminoglycosides.

Helmet noninvasive ventilation for weaning from mechanical ventilation.

We saw a patient who presented with carbon dioxide narcosis and acute respiratory failure due to an exacerbation of chronic obstructive pulmonary disease. We intubated and 12 hours later he had recovered consciousness and could cooperate with noninvasive ventilation, at which point we extubated and used a helmet to provide noninvasive positive-pressure ventilation in assist/control mode, and then during the ventilator-weaning process, pressure support, and finally continuous positive airway pressure. The patient had no complications from the helmet, and he was discharged from intensive care 48 hours after helmet ventilation was initiated. Helmet noninvasive ventilation is a potentially valuable ventilator-weaning method for certain patients.