Mark Niven

Increased complaints of fever in the emergency room can identify influenza epidemics

BACKGROUND In developing countries, it may be easier to use the reasons why patients come to the emergency room (ER) instead of sentinel practices to identify influenza epidemics. METHODS We studied the reasons why adult patients present to the ER in order to attempt to predict increased hospital activity as a result of influenza. The daily frequency of presenting symptoms during the 30 days of maximal influenza activity was compared to the other days of the study period (335 days). RESULTS During the influenza period, more patients presented with fever, syncope or near syncope, cough, asthma attack, and paralysis than on the days outside of this period. On 50% of the days, eight or more patients presented with fever, an 8.36 (95% CI=4.6-15.19) higher frequency than during the rest of the year. During the subsequent year, days with excess presentations by patients with a principal complaint of fever predicted increased hospital activity due to influenza with no false-positive periods. CONCLUSIONS We conclude that an increase in the number of patients presenting to the ER complaining of fever can identify increased hospital influenza activity.

The addition of fiber and the use of continuous infusion decrease the incidence of diarrhea in elderly tube-fed patients in medical wards of a general regional hospital: a controlled clinical trial.

Goals To determine if feeds high in fiber continuously administered might minimize diarrhea. Background The addition of soluble fiber to enteral feedings has not consistently decreased diarrhea in controlled clinical trials, and the effect of the use of intermittent or continuous infusions on the rate of diarrhea is similarly controversial. Study We studied 148 of 160 selected elderly well-nourished patients with acute disease prohibiting oral intake in a controlled clinical trial in the setting of an internal medicine departments in a regional hospital who were divided into 4 groups and fed according to combinations of intermittent or continuous systems, with fiber-free or fiber rich formulas. The 5-day rate of diarrhea was defined as 2 liquid stools or 3 or more semisolid or liquid bowel movements during a 24-hour period. Other outcome variables included mortality, hospital days, prolonged hospitalization (over 20 d), fever, and stools positive for Clostridium difficile cytotoxin A/B. Results The increased relative risk of the continuous/fiber-free, intermittent/fiber, and intermittent/fiber-free groups compared with the continuous/fiber group was 2.8 [95% confidence interval (CI)=1.0-8.1], 2.5 (95% CI=0.9-7.1), and 5.0 (95% CI=1.9-13.2), respectively. These findings were independent of age (>80 y), female sex, being treated with antibiotics for respiratory or urinary infections, receiving respiratory support, or being fully conscious. There were no significant differences in the other outcomes. Conclusions We conclude that in elderly well-nourished hospitalized patients with acute diseases prohibiting oral intake, continuous and closed enteral feedings with the addition of fiber is effective in reducing the rate of diarrhea.

The clinical response of West Nile virus neuroinvasive disease to intravenous immunoglobulin therapy

The aim of the study was to determine whether intravenous gamma globulin (IVIG) treatment is effective in patients with West Nile Virus (WNV) neuroinvasive disease. We contacted hospital based infectious disease experts in Israeli hospitals to identify patients with WNV neuroinvasive disease who were treated with IVIG. The main outcome measure was neurological response after treatment. There were 12 patients who received IVIG and four improved within 48 h. Three patients died, 6 had partial recovery, and 3 recovered completely. Eleven of the 12 patients were infected with Israeli genotypes that are highly homologous to Europe/Africa viruses. The rapid response in some patients suggests that IVIG is effective, and might be used to treat patients with WNV neuroinvasive disease with IVIG.

A novel potential therapy for vascular diseases: blood-derived stem/progenitor cells specifically activated by dendritic cells

Vascular diseases are a major cause of morbidity and mortality, particularly in diabetic patients. Stem/progenitor cell treatments with bone marrow‐derived cells show safety and promising outcomes, albeit not without some preprocedural adverse events related to cell collection and mobilization. We describe a novel technology for generating a therapeutic population (BGC101) of enriched endothelial progenitor cells (EPCs) from non‐mobilized blood, using dendritic cells to specifically direct stem/progenitor cell activity in vitro.

Symptomatic Hypocalcemia Precipitated by Small-Volume Blood Transfusion

We present 2 cases in which the transfusion of small volumes of packed RBC was sufficient to precipitate symptomatic hypocalcemia. Subsequent inquiry revealed that both of the patients had preexisting, untreated, and asymptomatic hypocalcemia, 1 following partial thyroidectomy many years earlier and the other with documented hypocalcemia but without a definitive diagnosis.

The Effect of Urinary Bladder Catheterization on Patient Care in an Internal Medicine Department

Introduction:Recommendations for urinary catheterization in newly hospitalized patients are inconsistent and unclear. Methods:The authors studied prospectively consecutive patients who were catheterized in an internal medicine department over a 3-month period, with follow-up for 6 months or until the catheter was removed. Patient records were reviewed to determine if catheterization was definitely not indicated by commonly accepted criteria. After chart review, a category of possibly not indicated was defined as having no demonstrable effect on patient care. Results:There were 17.7% patients (122/691) catheterized during their admission. According to accepted criteria, definite inappropriate catheterization occurred in 18 patients (14.7%). There were an additional 69 patients (56.6%) with unclear clinical benefits, hospitalized because of fever, acute congestive heart failure, a cerebral vascular accident or respiratory insufficiency due to exacerbation of chronic obstructive lung disease. During hospitalization, attempts to remove the catheter failed in 13 patients, 4 of who remained with the catheter permanently, complicated by urosepsis in 1 patient. Conclusion:Over 50% of the patients had acceptable indications for catheterization but no demonstrable benefit from the procedure. In such patients, the uncertain benefits of catheterization should be balanced by potential complications. Additional studies are warranted to determine the effect of acute urinary catheterization on patient care.

Bacillus cereus Peritonitis after Cesarean Section

Because Bacillus cereus rarely causes medical problems in hospitalized patients [1], we write to share our experience with bacterial peritonitis occurring in two patients after otherwise-uncomplicated cesarean sections. A 42-year-old healthy woman was delivered of a healthy baby at 38 weeks by emergency low longitudinal cesarean section with spinal anesthesia, which was performed because of fetal bradycardia. Two days later, she developed a temperature of 39°C with shaking chills. After nine days of fever unresponsive to empiric treatment with ampicillin, gentamicin, and metronidazole, abdominal ultrasonography and computed tomography (CT) showed loculated ascites. Exploratory laparotomy was performed, which revealed diffuse peritonitis with several collections of pus. Peritoneal toilet was performed, and antibiotic therapy was changed to clindamycin and ticarcillin-clavulanic acid. Gram stain of pus from the peritoneal cavity was negative, but culture revealed methicillinsensitive Staphylococcus aureus and Bacillus cereus. Two blood cultures were positive for Bacillus cereus, sensitive to clindamycin and vancomycin. The patient received 10 days of intravenous clindamycin 900 mg q 8 h. Fever resolved after four days, and she was discharged in good condition. Fifty-four days later, a 33-year-old woman had an elective cesarean section because of maternal request. The day after the operation, the patient reported abdominal pain, with a temperature of 37.5°C. After 48 h, her condition had deteriorated markedly, with increasingly severe abdominal pain, shortness of breath, persistent fever, systolic blood pressure of 80 mm Hg, and a pulse of 128 beats/min. An abdominal CT scan showed moderate ascites. Exploratory laparotomy revealed diffuse purulent peritonitis without evidence of perforation. The uterus was normal. Cultures were taken, and peritoneal irrigation was performed. Gram stain of the intra-abdominal pus was negative, as were preoperative blood cultures. Antibiotic therapy was changed to piperacillin-tazobactam, her condition improved over the next 10 h, and she was extubated. However, two days postoperatively, superficial infection of the surgical site was diagnosed with rapidly progressive cellulitis. Cultures of the abdominal fluid grew B. cereus. Her condition improved gradually after therapy was changed to intravenous clindamycin, and she was discharged 14 days postoperatively. In both cases, antibiotic susceptibility was determined by disc diffusion techniques according to the National Clinical Laboratory Standards Institute (CLSI). Both isolates were resistant to amoxicillin-clavulanic acid, ampicillin, and first-, second-, and third-generation cephalosporins. After the second case of this rare infection, we investigated possible sources. In our hospiSURGICAL INFECTIONS Volume 9, Number 1, 2008

Cell Therapy for Vascular Diseases in Israel

In Israel, as elsewhere in the world, people with vascular disease suffer severe complications, including critical limb ischemia, which can result in gangrene and amputation. This chapter describes the step-wise progression in translational medical research as a scientific breakthrough progresses from a laboratory invention to the start of a clinical trial. The novel idea is a method whereby a sub-population of non-mobilized peripheral blood cells can be turned, within a day, into a cellular therapeutic product code-named BGC101, composed of endothelial progenitor cells (EPCs) and Stem/progenitor cell (SPCs). In addition, the benefits of collaboration between an Israeli biotechnology company and an Israeli medical center in overcoming the hurdles of bringing the idea to fruition will be described.

Can in-hospital urinary catheterization rates be reduced with benefits outweighing the risks?

Abstract Urinary catheterization has risks and its use should be limited because it is the main cause of healthcare-associated urinary tract infection. Other risks are the potential for urethral injuries and the possibility that the catheter will be left in permanently. Rates of urinary catheterization in internal medicine departments generally range from 8% to 20%, with higher rates in older adult patients. Various attempts have been made to decrease catheterization rates with variable success. A major problem is that the guidelines and criteria for urinary catheterization are inconsistent and open to variable interpretations. More restrictive criteria based on observable patient benefit can reduce rates of urinary catheterization and may improve patient care.