Mark J. Ault

Infection and diabetes: The case for glucose control☆

This review summarizes data concerning the host resistance to infection in diabetes and the influence of an acute infection upon the endocrinologic-metabolite status of the diabetic patient. While it is well known that acute infections lead to difficulty in controlling blood sugar levels and the infection is the most frequently documented cause of ketoacidosis, controversy persists as to whether or not patients with diabetes mellitus are more susceptible to infection than age- and sex-matched nondiabetic control subjects. Our data obtained from the charts of 241 diabetic patients who were being followed as outpatients show a striking direct correlation between the overall prevalence of infection (p less than 0.001) and the mean plasma glucose levels (representing three or more fasting glucose determinations taken at times when no evidence of infection existed). There is a significant diminution in intracellular bactericidal activity of leukocytes with Staphylococcus aureus and Escherichia coli in subjects with poorly controlled diabetes in comparison with the control group. Serum opsonic activity for both Staph. Aureus and E. coli were significantly lower than in the control subjects. Taken together, the results from published reports as well as our data suggest to us that good control of blood sugar in diabetic patients is a desirable goal in the prevention of certain infections (Candida vaginitis, for example) and to ensure maintenance of normal host defense mechanisms that determine resistance and response to infection.

Do hospital employees benefit from the influenza vaccine?: A placebo-controlled clinical trial

Although current guidelines target hospital employees who contact high-risk patients as a high priority for influenza immunization, there are few data to support or refute this recommendation. Therefore, the authors enrolled 179 hospital employees in a randomized double-blind placebo-controlled clinical trial during the 1985–1986 influenza season. Influenza immunization was performed without serious adverse reactions and there was no increase in absenteeism attributable to the vaccination. Among those who developed clinical influenza, there was a trend toward fewer days of illness in the vaccinated group compared with the placebo group (6.0 vs. 8.0, p=0.07). There were no statistically significant differences between subjects receiving influenza vaccine and those receiving the placebo when comparing incidences of influenza-like illness, severities of illness, and sick absenteeism. Influenza immunization of hospital employees was performed at minimal cost and risk but provided little benefit, most likely because of an unexpected drift of the prevalent influenza strain away from the vaccine type.

Pyomyoma associated with polymicrobial bacteremia and fatal septic shock: case report and review of the literature.

case of fatal septic shock due to pyomyoma (suppurative leiomyoma of the uterus) is reported. This unusual cause of sepsis and polymicrobial bacteremia should be rapidly identified because surgical therapy is essential for cure. Nine additional cases reported since 1945 are reviewed. Pyomyoma develops in association with either recent pregnancy or in postmenopausal patients who frequently have underlying vascular disease. The triad of: 1) bacteremia or sepsis; 2) leiomyoma uteri; and 3) no other apparent source of infection should suggest the diagnosis of pyomyoma.

The use of tissue models for vascular access training. Phase I of the procedural patient safety initiative.

INTRODUCTION: Following the Institute of Medicine report “To Err is Human,” the Agency for Healthcare Research and Quality identified proper central venous catheter (CVC) insertion techniques and wide sterile barriers (WSB) as 2 major quality indicators for patients safety. However, no standard currently exists to teach proper procedural techniques to physicians. AIM: To determine whether our nonhuman tissue model is an effective tool for teaching physicians proper wide sterile barrier technique, ultrasound guidance for CVC placement, and sharps safety. PARTICIPANTS: Educational sessions were organized for physicians at Cedars-Sinai Medical Center. Participants had a hands-on opportunity to practice procedural skills using a nonhuman tissue model, under the direct supervision of experienced proceduralists. PROGRAM EVALUATION: An anonymous survey was distributed to participants both before and after training, measuring their reactions to all aspects of the educational sessions relative to their prior experience level. DISCUSSION: The sessions were rated highly worthwhile, and statistically significant improvements were seen in comfort levels with ultra-sound-guided vascular access and WSB (P<.001). Given the revitalized importance of patient safety and the emphasis on reducing medical errors, further studies on the utility of nonhuman tissue models for procedural training should be enthusiastically pursued.

Rapid Identification of Group A Streptococcus as the Cause of Necrotizing Fasciitis

Group A beta-hemolytic Streptococcus pyogenes (GAS) causes a spectrum of highly aggressive, invasive infections. We report two cases of necrotizing fasciitis in which GAS was identified as the presumptive causative organism with the use of the standard rapid streptococcal diagnostic kit. We believe the rapid test kits may be a useful adjunct in the diagnosis and treatment of this catastrophic illness and may play a role in limiting the spread of infection.

Thoracentesis outcomes: a 12-year experience

Background Despite a lack of evidence in the literature, several assumptions exist about the safety of thoracentesis in clinical guidelines and practice patterns. We aimed to evaluate specific demographic and clinical factors that have been commonly associated with complications such as iatrogenic pneumothorax, re-expansion pulmonary oedema (REPE) and bleeding. Methods We performed a cohort study of inpatients who underwent thoracenteses at Cedars-Sinai Medical Center (CSMC) from August 2001 to October 2013. Data were collected prospectively including information on volume of fluid removed, procedure side, whether the patient was on positive pressure ventilation, number of needle passes and supine positioning. Iatrogenic pneumothorax, REPE and bleeding were tracked for 24 h after the procedure or until a clinical question was reconciled. Demographic and clinical characteristics were obtained through query of electronic medical records. Results CSMC performed 9320 inpatient thoracenteses on 4618 patients during the study period. There were 57 (0.61%) iatrogenic pneumothoraces, 10 (0.01%) incidents of REPE and 17 (0.18%) bleeding episodes. Iatrogenic pneumothorax was significantly associated with removal of >1500 mL fluid (p<0.0001), unilateral procedures (p=0.001) and more than one needle pass through the skin (p=0.001). For every 1 mL of fluid removed there was a 0.18% increased risk of REPE (95% CI 0.09% to 0.26%). There were no significant associations between bleeding and demographic or clinical variables including International Normalised Ratio, partial thromboplastin time and platelet counts. Conclusions Our series of thoracenteses had a very low complication rate. Current clinical guidelines and practice patterns may not reflect evidence-based best practices.

Ultrasonography Performed by Primary Care Residents for Abdominal Aortic Aneurysm Screening

A prospective pilot study was undertaken to assess a protocol to educate primary care residents in how to personally perform ultrasonography for abdominal aortic aneurysm screening. Resident exams were proctored by a primary care physician trained in ultrasonography and were scored on the level of competence in doing the examination. Patients had ultrasound performed by a resident, followed by repeat examination by the vascular lab. Primary care resident abdominal aortic imaging was achieved in 79 of 80 attempts. Four abdominal aortic aneurysms were identified. There were 75 normal examinations; resident ultrasonography results were consistent with the results of the vascular lab. Ten residents achieved an abdominal aortic ultrasound-independent competence level after an average of 3.4 proctored exams. The main outcome of this study is that a primary care resident, with minimal training in ultrasonography imaging, is able to rapidly learn the technique of ultrasonography imaging of the abdominal aorta.

Portable ultrasound: the next generation arrives.

PurposeA new category of handheld devices has recently emerged that are even smaller than current portable models, with their main advantages being increased portability and affordability relative to their counterparts. However, these new devices have not yet been thoroughly evaluated in the clinical setting.MethodsA prospective, non-blinded, three-phase study was designed to evaluate a handheld ultrasound device as compared to a common compact ultrasound machine for the performance of paracenteses and thoracenteses on human patients.ResultsFor the vast majority of straight-forward evaluations, the handheld device was sufficient to safely complete the procedure without further imaging. For difficult cases with smaller fluid collections or anatomic aberrations, further localization with the common compact machine continued to be useful to improve the operator’s confidence in the findings.ConclusionThis novice handheld device represents only one of what appears to be a growing number of new ultra-portable ultrasound devices on the market. These devices represent a new and exciting form of ultrasound technology that may benefit patients and physicians in multiple venues. While they are unlikely to replace standard ultrasound devices for many of the more complex applications, their extreme portability allows for ultrasound imaging in more diverse situations that has previously been practical. Based on our limited experience, the image quality is adequate and the learning curve is reasonable. Future integration of PDA technology could further the utility of these devices and additional study will be important to further define their appropriate niche and clinical utility.

Vascular Ultrasonography: A Novel Method to Reduce Paracentesis Related Major Bleeding

&NA; Paracentesis is a core competency for hospitalists. Using ultrasound for fluid localization is standard practice and involves a low‐frequency probe. Experts recommend a “2‐probe technique,” which incorporates a high‐frequency ultrasound probe in addition to the low‐frequency probe to identify blood vessels within the intended needle path. Evidence is currently lacking to support this 2‐probe technique, so we performed a pre‐ to postintervention study to evaluate its effect on paracentesis‐related bleeding complications. From February 2010 to August 2011, procedures were performed using only lowfrequency probes (preintervention group), while the 2‐probe technique was used from September 2011 to February 2016 (postintervention group). A total of 5777 procedures were performed. Paracentesis‐related minor bleeding was similar between groups. Major bleeding was lower in the postintervention group (3 [0.3%], n = 1000 vs 4 [0.08%], n = 4777; P = .07). This clinically meaningful trend suggests that using the 2‐probe technique might prevent paracentesis‐related major bleeding. Journal of Hospital Medicine 2018;13:30‐33. Published online first October 18, 2017.

Out of Sight Should Not Be Out of Mind What Lurks Just Beneath the Surface of the Cirrhotic Abdominal Wall

Paracentesis is a commonly performed procedure in both inpatient and outpatient settings. Useful for diagnostic and therapeutic purposes, prior studies have documented the inherent safety of this procedure. In proper hands, modern techniques such as the use of safety (Turkel) tipped needles and ultrasound localization have reduced the risk of major complications to less than 1%. Nevertheless, major bleeding remains a dreaded complication of this procedure, especially in patients with liver failure. Our historical experience has been that this complication is unpredictable, likely because of procedural injury to an abdominal wall artery or peritoneal varix. The authors report a case where the risk of vascular injury was mitigated using portable ultrasound and suggest a simple procedure for future risk reduction.