Yale D. Podnos

Eradication of multi-drug resistant Acinetobacter from an intensive care unit.

BACKGROUND Acinetobacter baumannii is a gram-negative coccobacillus that causes outbreaks of nosocomial infections in ICUs. Due to resistance to multiple antibiotics, management of clusters of A. baumannii is useful as a model in eradication of multi-drug resistant infections. We outline the evolution of an A. baumannii outbreak, focusing on methods of transmission and multidisciplinary measures aimed at eliminating it from the ICU. METHODS Patients in an urban, tertiary care medical center from November 1996 to December 1997 having positive cultures for multi-drug resistant A. baumannii are included in this study. A. baumannii was isolated on blood agar and MacConkey cultures and identified by Vitek panel. Disk diffusion including amikacin, imipenem, polymyxin B, and sulbactam were used to determine resistance. RESULTS An outbreak of 52 patients (27 infected, 25 colonized) with 68 positive sites began with the transfer of a colonized >50% total body surface area burn patient from an outside hospital. Within 3 days, the index patient was in the burn ICU, coronary care unit, and medical ICU. Soon, clusters of patients with A. baumannii infections sensitive only to polymyxin B were seen in those units and, ultimately, the surgical ICU. On typing, 2 strains were found, PFGE B and C. Given the level of antibiotic resistance, patients with colonization or infection were cohorted and placed on contact isolation. Strict antiseptic measures, such as hand-washing, barrier isolation, equipment and room cleaning, sterilization of ventilator equipment, and dedication of medical equipment to each patient were instituted. Still, positive environmental cultures were found in ventilator water traps, sinks, and bedrails. Sporadic cases continued for a total of 13 months, with 10 deaths resulting from the infections. CONCLUSION A. baumannii is a mildly virulent organism that becomes resistant to antimicrobials. Because of multiple antibiotic resistance, strict contact isolation cohorting and antiseptic technique are the primary modes of containment. This outbreak serves as a model of eradication of multi-drug resistant organisms from ICUs. These measures will become of greater importance as nosocomial organisms develop increasing resistance to antimicrobials.

Is intraoperative cholangiography during laparoscopic cholecystectomy cost effective

BACKGROUND Common bile duct injuries occur in 0.2% to 0.8% of laparoscopic cholecystectomies (LC). Intraoperative cholangiograms (IOCG) are a useful means of detecting common bile duct injuries in the operating room. METHODS Data were retrospectively reviewed for patients referred for management of common duct injuries from 1996 to 2000. Cost data were obtained from hospital records. Legal settlements were obtained from published sources. RESULTS Twenty-one patients (0.133%) were found to have bile duct injuries and incurred median hospital stays of 11.5 days at an average cost of

Prevention of chronic rejection by pravastatin in a rat kidney transplant model.

587,491. The average cost of those requiring reoperation was

Reducing the noneducational and nonclinical workload of the surgical resident; defining the role of the health technician.

669,134. The 21 cases in our sample had total charges of

Cerebral Phaeohyphomycosis Caused by Ramichloridium obovoideum (Ramichloridium mackenziei)

10,819,767. Performing IOCG during each LC in Orange County would have cost

Carcinoid Tumors of the Common Bile Duct: Report of Two Cases

10,669,725. If extrapolated to state and nationwide levels, the savings is far greater. CONCLUSIONS IOCG during LC is a cost-effective means of preventing the costs of delayed recognition of bile duct injuries.

Minimal deviation melanoma

Background. Pravastatin when administered with cyclosporine (CsA) has been shown to ameliorate transplant vasculopathy in the clinical setting. Previously we showed that pravastatin prevents chronic rejection in rat cardiac and liver transplant models. Here we determine whether pravastatin prevents chronic rejection in a rat renal allograft model. Methods. Orthotopic renal transplantations were performed using Fisher 344 rats as donors and Lewis rats as recipients. Recipients were treated with low-dose CsA for 10 days to prevent acute rejection. Recipients were divided into three groups: CsA, CsA + pravastatin, and syngeneic. Renal function was assessed by serum creatinine level at day 130. Allografts were evaluated by histology and immunohistochemistry. Serum levels of alloantibodies were measured by flow cytometry. Intragraft cytokine mRNA expression was determined by semiquantitative reverse transcriptase-polymerase chain reaction. Intragraft levels of the antiapoptotic Bag-1 gene were measured by Western blot. Results. Unlike allografts from the pravastatin group, control allografts demonstrated glomerulosclerosis, vascular obliteration, tubular atrophy, and interstitial fibrosis. Serum creatinine levels and graft infiltration of T cells and macrophages in the pravastatin-treated animals were significantly lower. Intragraft cytokines showed a T helper 2 polarization and decreased transforming growth factor-&bgr; in the pravastatin group. Intragraft expression of Bag-1 was increased in the pravastatin group. Conclusion. This study demonstrates the ability of pravastatin to inhibit chronic rejection in rat renal allografts. Pravastatin’s pleiotropic effects of reducing intragraft inflammatory cytokines, inhibiting immune cell infiltration, and causing up-regulation of the antiapoptotic gene Bag-1 suggest that its ability to prevent transplant chronic rejection may be multifactorial.

Complications After Laparoscopic Gastric Bypass: A Review of 3464 Cases

PURPOSE Recent controversy over excessive resident work hours has prompted surgical educators and program directors to search for more efficient methods to limit the nonclinical and noneducational workload of surgical residents. Health technicians were employed at a large Veterans Administration Medical Center to allow residents more time for direct patient care in the clinics and wards and in educational activities. METHODS In a two-week period, daily data cards were collected from each intern and health technician identifying total hours spent in work, operations, clinics, and conferences. Each intern recorded the number and type of tasks performed and those tasks assigned to the health technician. The number and type of task performed were tabulated and averaged for each health technician and physician. RESULTS Each intern (n = 3) and health technician (n = 8) completed 100% of the required data forms. In a control survey, each intern worked a mean of 16.9 hours per weekday and 5.0 hours per weekend day. With the addition of the health technicians, interns worked 12.9 hours per weekday and 6.8 hours per weekend day (when the health technicians were not present). Following the addition of the health technicians, resident time in the operating room increased from 3.3 hours per week to 9.8 hours per week. Each health technician aided the intern by performing an average of 20.25 tasks per day. CONCLUSIONS This study shows that health technicians can be effective in reducing the overall hours and workload of surgical residents and increasing time spent in the operating room. Consideration should be given to including the health technician as integral members of the health care team in the teaching hospital.

The implication of lymph node metastasis on survival in patients with well-differentiated thyroid cancer

OBJECTIVE AND IMPORTANCE Only a few cerebral infections with the dark-walled mold Ramichloridium obovoideum (Ramichloridium mackenziei) have been reported in the literature. Central nervous system infections caused by this fungus have poor prognoses; the optimal medical and surgical treatments have not yet been established. We report a case of cerebral R. obovoideum infection for which a combination of medical and surgical treatments failed. CLINICAL PRESENTATION A 58-year-old Kuwaiti woman, with a history of chronic renal failure requiring hemodialysis, presented with a 3-day history of left frontal headache, blurry vision, dizziness, and right-sided clumsiness. Computed tomography demonstrated multiple, ring-enhancing, cerebral lesions (the largest of which measured 2-3 cm) in the deep left parieto-occipital region. INTERVENTION A computed tomography-guided needle biopsy of the parieto-occipital lesion yielded 10 ml of dark caseous fluid. Stains demonstrated long, branching, septate hyphae. Fungal cultures grew R. obovoideum. The patient was treated with a combination of amphotericin B and itraconazole. The condition of the patient continued to deteriorate, and stereotactic aspiration of the largest lesion was performed. Despite this approach, the lesion progressed and the patient died. CONCLUSION R. obovoideum is being increasingly recognized as a cause of cerebral abscesses in patients residing in the Middle East. Prognoses are poor, and responses to antifungal therapy are generally short-lived. Until more effective therapies are found, the greatest chance for adequate treatment involves early recognition, prompt treatment with antifungal agents, and attempts at complete resection.

Effect of the 80-Hour Workweek on Resident Burnout

We report two cases of carcinoid tumors of the common bile duct. The first patient was a 65-year-old woman in whom a carcinoid tumor of the distal bile duct was incidentally found during an open cholecystectomy for cholecystitis. The second patient was a 27-year-old man in whom a distal common bile duct carcinoid was incidentally found during orthotopic liver transplantation for sclerosing cholangitis and multiple biliary strictures. There are few reports of carcinoid tumors of the extrahepatic ducts, and a brief review of the relevant literature is discussed following these case reports.