Ryan P. Bodkin

Bacterial Clearance and Cytokine Profiles in a Murine Model of Postsurgical Nosocomial Pneumonia

ABSTRACT The development of a nosocomial pneumonia is facilitated by alterations in host innate pulmonary antibacterial defenses following surgical trauma, which can result in decreased pulmonary bacterial clearance and increased morbidity and mortality. In a murine model of postoperative nosocomial infection, surgical stress (laparotomy) decreased Escherichia coli clearance from the lungs of animals that underwent surgery. Consistent with previous studies, (i) pulmonary levels of tumor necrosis factor alpha at 6 h and of interleukin-1β (IL-1β), IL-6, and gamma interferon (IFN-γ) at 24 h post-bacterial infection (PBI) were decreased in animals that underwent laparotomy 24 h prior to E. coli infection (LAP/E. coli) compared to animals that received E. coli only; (ii) KC and macrophage inhibitory protein 2 were elevated at 6 h PBI in LAP/E. coli animals compared to E. coli-only animals; however, at 24 h PBI, levels were higher in the E. coli-only group; (iii) at 24 h PBI, monocyte chemoattractant protein 1 was lower in the LAP/E. coli group compared to the E. coli-only group; (iv) IL-10 levels were unaffected at all time points evaluated; and (v) the total number of neutrophils present in the lungs of LAP/E. coli animals at 6 h PBI was decreased in comparison to that in E. coli-only animals, resulting in decreased bacterial clearance and increased mortality in LAP/E. coli animals by 24 h PBI. Similar changes in cytokine profiles, pulmonary bacterial clearance, and mortality were consistent with reported findings in patients following surgical trauma. This model, therefore, provides a clinically relevant system in which the molecular and cellular mechanisms that lead to the development of nosocomial pneumonia can be further explored.

A case of tetanus infection in an adult with a protective tetanus antibody level.

Tetanus is a bacterial infection caused by Clostridium tetani and most commonly presents as trismus or other muscle spasms. Despite the development of the tetanus toxoid vaccine, tetanus infection has not been eradicated. Additionally, while there are hypothesized protective levels of tetanus antibody, tetanus infection may still occur in properly vaccinated individuals. We report the case of a 31-year-old male that presented to the emergency department (ED) with a 2-day history of neck and jaw pain. He reports puncturing his hand with a rusty nail 10 days prior. His reported vaccination history was that he received his last booster vaccination 13 years prior to presentation. In the ED, tetanus vaccine, tetanus immune globulin, and metronidazole were administered. His symptoms improved over the next 2 days and resolved at day 6. Despite his presentation of tetanus infection and rule out of other causes for his symptoms, his tetanus antibody level was reported at 8.4 U/mL, which is considered to be protective.A tetanus antibody level that is adequate for protective immunity should not preclude a patient from treatment of tetanus infection. This case demonstrates that a thorough history, physical exam, and rule out of other causes should guide treatment when there is concern for a tetanus infection.

Differences in noninvasive thermometer measurements in the adult emergency department

PURPOSE Detection of accurate temperature in the emergency department (ED) is integral for assessment, treatment, and disposition. The primary objective was to compare temperature measurements from noninvasive temperature devices in the adult ED. The secondary objective was to evaluate the discrepancy between febrile and afebrile patients. METHODS This was a prospective observational study of adult patients presenting to the ED. Patients who required a temperature measurement based on standard of care were included. Data collection included oral and temporal artery (TA) temperature measurement taken consecutively. Data were evaluated using the paired Students t test. RESULTS A total of 100 patients were identified. Mean oral temperature was 37.51°C (SD ±1.25), and mean TA temperature was 37.03°C (SD ±0.94). The mean difference was 0.48°C (SD ±0.8), P < .0001. Overall, 49% of patients had a difference in temperature measurements greater than or equal to 0.5°C. There were 47 febrile patients, determined by a measurement greater than 38°C on oral or TA thermometer. The mean temperature difference in these patients was 0.87°C (SD ±0.85) compared with a mean temperature difference of 0.12°C (SD ±0.55) in the afebrile patients, P < .0001. A total of 57% of fevers recorded by the oral thermometer were not recorded by the TA thermometer. CONCLUSIONS There was a statistically significant difference in measured temperatures between oral and TA thermometers and a clinically significant difference in 49% of patients. Febrile patients had a greater discrepancy and variability between noninvasive temperature measurements. Caution should be taken when evaluating temperature measurements with these noninvasive devices.

Effectiveness of glucagon in relieving esophageal foreign body impaction: a multicenter study

PURPOSE Glucagon is thought to decrease lower esophageal sphincter tone and is used as an alternative to invasive endoscopy for esophageal foreign body impaction (EFBI). The purpose of this study was to evaluate efficacy and safety of glucagon and identify characteristics associated with success. METHODS A multicenter, retrospective study of patients receiving glucagon for EFBI at 2 academic emergency departments was conducted between 2006 and 2010. A control group of patients that did not receive glucagon was evaluated. Data collection included demographics, type of foreign body, glucagon dose, resolution of impaction, incidence of vomiting, additional medication, and endoscopy required. Descriptive and univariate analysis was performed as appropriate. RESULTS A total of 133 doses of glucagon were administered in 127 patients. Glucagon-related resolution of EFBI occurred in 18 patients (14.2%) and vomiting in 16 patients (12.6%). No statistical differences between successful and unsuccessful groups were seen with the exception of concomitant medication administration (benzodiazepine or nitroglycerin) being associated with less glucagon success, 33.3% vs 59.6%, respectively (P = .04). Eighty-four percent of patients in the unsuccessful group underwent endoscopy. Comparing those that received glucagon (n = 127) and the control group (n = 29), there was no significant difference in resolution of EFBI, 14.2% vs 10.3%, respectively (P = .586). CONCLUSIONS Glucagon-related resolution occurred in 14.2% of patients and was not significantly different compared with those that did not receive glucagon (10.3%). Concomitant medication administration was associated with lower success. Overall, glucagon had a low success rate, was related to adverse effects, and does not offer advantages for treatment.

Rhabdomyolysis associated with kava ingestion.

We report a case of rhabdomyolysis temporally related to the ingestion of a large amount of kava. Kava is a naturally occurring plant used in the United States and elsewhere in the world for its sedative properties. A previous case report also related rhabdomyolysis to the ingestion of kava. It is not clear whether this is an action of the kava itself, perhaps, due to its action on voltage ion channels or, perhaps, due to an adulterant in the product. Our patient developed peak creatine phosphokinase levels in excess of 30 000 U/L but had no significant renal damage.

Two Cases of Accidental Injection of Epinephrine into a Digit Treated with Subcutaneous Phentolamine Injections

Accidental injection into the digit from an epinephrine autoinjection device can cause discoloration, pain, and paresthesias. Although loss of digit is rare, treatment in the emergency department is commonly aimed at vasodilation of the affected tissue. We report two cases of accidental injection of epinephrine into the digits that were successfully treated with subcutaneous phentolamine injection with no adverse events.

Sexually Transmitted Infection Review for the Acute Care Pharmacist

Purpose: Review selected sexually transmitted infections (STIs) and treatment recommendations for pharmacists and providers practicing in the acute care setting. Summary: In 2015, the Centers for Disease Control and Prevention (CDC) published an updated guideline on the treatment of STIs with an emphasis on prevention and new diagnostic strategies to combat the growing problem of STIs in the United States. Despite this guidance, the incidence of infection has continued to grow. In October 2016, an in-depth analysis reported that 20 million new infections occur annually in the United States. With this growing burden of disease, it is pertinent that health-care providers optimize their treatment strategies to improve upon the management of STIs. Focusing on identification of asymptomatic- and symptomatic-infected persons, treatment, education, effective follow-up, and counseling for patients and sexual partners, emergency medicine pharmacists and providers can help minimize the negative long-term health consequences of STIs. Conclusion In the emergency department setting, clinical pharmacists and providers can play a crucial role in preventing and treating STIs and should continue to expand and keep current their knowledge of this topic.

MRSA nares swab is a more accurate predictor of MRSA wound infection compared with clinical risk factors in emergency department patients with skin and soft tissue infections

Objectives Skin and soft tissue infections (SSTI) caused by methicillin-resistant Staphylococcus aureus (MRSA) are prevalent in the emergency department (ED). We determined whether MRSA nasal carriage better identifies patients with MRSA wound infection than clinical risk factors or emergency medicine (EM) provider’s choice of discharge prescriptions. Methods Adult patients presenting to a large academic medical centre ED in the USA with SSTI between May 2010 and November 2011 were screened. Research assistants administered a questionnaire regarding MRSA risk factors, and MRSA nares swab PCR testing, wound culture results and information on antibiotics prescribed at discharge were collected. Measures of classification accuracy for nares swab, individual risk factors and physician’s prescription for MRSA coverage were compared with gold standard wound culture. Results During the study period, 116 patients with SSTI had both wound cultures and nares swabs for MRSA. S. aureus was isolated in 59.5%, most often MRSA (75.4%). Thirty patients (25.9%) had a positive MRSA nares swab and culture for a sensitivity of 57.7% and specificity of 92.2%. Positive predictive value (PPV) for MRSA nares swab was 85.7% and positive likelihood ratio was 7.4, while negative predictive value was 72.8% and negative likelihood ratio 0.5. None of the individual risk factors nor EM provider’s prescription for MRSA coverage had a PPV or positive likelihood ratio higher than nares swabs. Conclusions MRSA nares swab is a more accurate predictor of MRSA wound infection compared with clinical risk factors or EM provider’s choice of antibiotics. MRSA nares swab may be a useful tool in the ED.

Asymptomatic Hypotension in a Patient with Catheter-related Right Atrial Thrombus

Atrial thrombi can be a complication in patients with indwelling central-line catheters, and failure to diagnose can potentially be lethal. This condition is generally associated with profound hypo-perfused states. Here we present a case of a 77-year-old female who arrived to our emergency department for evaluation of a leg laceration and was incidentally found to have a catheter-related right atrial thrombus using point-of-care ultrasound.

Rock climbers’ management of hand injuries and perceptions on seeking healthcare: A mixed methods analysis

Abstract This study examined rock climbers’ behaviors and perspectives on utilizing healthcare for climbing-related hand injuries. Twenty-eight climbers were interviewed and completed questionnaires on their management of the 88 climbing-related hand injuries in their lifetimes. The most prevalent reasons for not seeking professional healthcare for hand injuries were: trust in own and/or peers’ treatment knowledge (57%), belief that utilizing healthcare is unnecessary because injuries will self-resolve (35%), and belief that healthcare providers do not have appropriate knowledge to treat climbing-related hand injuries (21%). Ten injuries (11%) were evaluated by primary care physicians, hand specialists, and/or physical therapists. Reasons climbers did seek professional healthcare included an injury required a clearly urgent intervention (57%), repeated or worsening injuries (53%), and knowing a trusted provider (21%). This information can be used to better establish healthcare relationships with climbers to prevent and treat these common injuries and avoid long-term disability from improper management.