Targeted postoperative care improves discharge outcome after hip or knee arthroplasty

OBJECTIVE: To determine whether targeted postoperative care, based on preoperative risk assessment, can increase the number of patients who are discharged home directly from acute care after elective hip or knee arthroplasty. DESIGN: Quasiexperimental with historical control. SETTING: A public university teaching hospital. PARTICIPANTS: One hundred patients who had an elective hip or knee arthroplasty. INTERVENTIONS: Between January and July 2001, 50 patients had their risk of discharge to extended inpatient rehabilitation assessed preoperatively with a newly developed Risk Assessment and Prediction Tool (RAPT). Postoperative management was targeted on the basis of the identified level of risk. Results were compared with those of a similar group of 50 patients treated between January and July 2000. MAIN OUTCOME MEASURES: Discharge destination, length of stay (LOS), and readmission rates. RESULTS: The percentage of patients discharged directly home increased significantly, from 34% during 2000 to 64% in 2001 (P=.002), with no increase in readmission rates in the 12 months postdischarge. In addition, the mean acute hospital LOS decreased by 1.1 days to 7.5 days in 2001 (P=.02). CONCLUSIONS: Use of the RAPT and targeted postoperative care resulted in more patients being discharged directly home after hip or knee arthroplasty while hospital LOS further decreased.     

Non-operative management of diverticular perforation in a patient with suspected Ehlers–Danlos syndrome

INTRODUCTION

No consensus exists regarding definitive management of colonic perforation in Ehlers–Danlos syndrome (EDS), with various authors advocating different operative techniques. Spontaneous colonic perforation is a recognised complication of vascular-type EDS (type IV), with many reported cases in the literature. No such cases have been reported concerning classical-type EDS (type I/II).

PRESENTATION OF CASE

A 55-year-old male with a family history of EDS presented with acute lower abdominal pain and signs of localised peritonitis. Following resuscitation, computerised tomography identified perforation of a sigmoid diverticulum with localised intraperitoneal air. Considering the potential complications associated with laparotomy in a patient with EDS, a trial of conservative management was undertaken including image-guided drainage of a mesenteric abscess. Intensive care monitoring, nutritional support and intravenous antibiotics also facilitated successful non-operative management. Following discharge, molecular studies confirmed COL5A1 mutation, and a diagnosis of classical Ehlers–Danlos syndrome was established.

DISCUSSION

This is the first reported case of successful conservative management of colonic diverticular perforation in a patient with classical Ehlers–Danlos syndrome.

CONCLUSION

EDS is highly significant in the surgical context, with the causative genetic factors serving to further complicate the course of surgical intervention. In the absence of consensus regarding best surgical management, due consideration should be given to non-operative management of benign colonic perforation.     

The role of laparoscopy in children with groin problems

The use of laparoscopic surgery has grown dramatically in recent years in most all types of surgery. Historically, the early use of laparoscopic surgery was for pelvic and groin problems. In this article we review the current technique, indications, benefits and complications of laparoscopy in diagnosis and management of various groin problems in children including undescended testes (non-palpable and palpable) and inguinal hernia.     

Retrospective chart review of severe infusion reactions with rituximab,cetuximab, and bevacizumab in community oncology practices: assessment of clinical consequences

GOALS OF WORK: Monoclonal antibody (MoAb) treatments can result in severe infusion reactions. Managing infusion reactions in the outpatient setting introduces clinical and resource challenges for patients and providers, but there is little information regarding prevention, management, or outcomes of severe infusion reactions. This study represents one of the first attempts to describe the clinical consequences of severe infusion reactions associated with MoAb treatment. MATERIALS AND METHODS: Clinic staff identified adults treated with rituximab, cetuximab, or bevacizumab who experienced a grade 3 or higher (severe) infusion reaction. Chart reviews from 19 oncology practice sites across the USA captured patient demographics, infusion reaction management procedures, and clinical outcomes. MAIN RESULTS: With an average age of 62 years, the sample comprised of 76 patients who experienced a severe infusion reaction while receiving rituximab (n = 47), cetuximab (n = 24), and bevacizumab (n = 5). The most common pretreatment medications were acetaminophen and antihistamine in the rituximab group and corticosteroids (42%) in the cetuximab group. All cetuximab and the majority of rituximab severe infusion reactions occurred during the first cycle of therapy. Postinfusion reaction management typically included corticosteroids, oxygen, and intravenous fluids. Overall, 22% were hospitalized for a mean of 4 days (range = 2.0 to 6.0 days). Permanent discontinuation of MoAb therapy occurred after the majority of cetuximab (79 to 100%) related severe infusion reactions. CONCLUSIONS: Severe infusion reactions are intensive events that present a serious challenge to patients and oncology practices. Efforts to prevent or reduce such reactions could be of great benefit.     

Harm Facilitation

Sexual Abuse: A Journal of Research and Treatment -     

In vitro antimicrobial activity of cefoperazone-sulbactam combinations against 554 clinical isolates including a review and beta-lactamase studies

Cefoperazone was tested against 554 clinical isolates alone and with sulbactam in three combinations. The addition of sulbactam in low concentrations (less than or equal to 4 micrograms/ml) improved the spectrum of cefoperazone principally against gram-negative bacilli such as Acinetobacter species, some Pseudomonas species, and beta-lactamase-positive Enterobacteriaceae. Nearly all of the spectrum increase was achieved at a sulbactam level of less than or equal to 2 micrograms/ml. Sulbactam was found to be an effective antimicrobial agent against Acinetobacter species (MIC50, 1.0 microgram/ml), Pseudomonas acidovorans (MIC50, 2.0 micrograms/ml), Neisseria gonorrhoeae (MIC50, less than or equal to 0.5 microgram/ml), and N. meningitidis (MIC50, less than or equal to 0.5 microgram/ml). Sulbactam had a higher affinity and binding constant for the plasmid-mediated beta-lactamases such as TEM-1 and TEM-2 compared to cefoperazone (greater than or equal to 10-fold difference). This finding was important as cefoperazone can be hydrolyzed at a moderate rate by the highly efficient TEM enzymes (less than 2% of clinical Escherichia coli isolates). Sulbactam increased the susceptibility (less than or equal to 16 micrograms/ml) of 220 isolates of Enterobacteriaceae to cefoperazone from 88.6 to 96.3% when 4.0 micrograms/ml of sulbactam was added. The cefoperazone antimicrobial activity was also increased against the nonenteric bacilli from a 69.5 to a 87.4% total inhibition. MICs among cefoperazone-susceptible gram-negative and gram-positive strains were routinely decreased 2- to 32-fold, as calculated from MIC90 results. Therefore, sulbactam should predictably increase the antimicrobial spectrum and clinical effectiveness of cefoperazone against nosocomial and other pathogens such as the plasmid-containing enteric bacilli, Bacteroides species and Acinetobacter species, and possibly provide the opportunity to reduce dosage schedules for infecting species already susceptible to cefoperazone alone.     

In vitro activity of gemifloxacin against contemporary clinical bacterial isolates from eleven North American medical centers, and assessment of disk diffusion test interpretive criteria

A total of 5499 contemporary clinical bacterial isolates were tested for susceptibility to gemifloxacin and four comparison agents by the broth microdilution method. Gemifloxacin activity against Enterobacteriaceae was generally comparable to that of ciprofloxacin and trovafloxacin, but because the gemifloxacin susceptible MIC breakpoint is lower, the percent susceptible to gemifloxacin was less than that to the other quinolones for some species. All agents were less active against Pseudomonas spp. Gemifloxacin was the most active agent tested against Gram-positive species, though Corynebacterium jeikeium and vancomycin-resistant enterococci were uniformly resistant to all agents tested. With staphylococci, a bimodal distribution of gemifloxacin MICs corresponded with susceptibility or resistance to ciprofloxacin. The significance of ciprofloxacin-resistant staphylococci that have susceptible gemifloxacin MICs is not known at this time. Disk diffusion tests were performed simultaneously with gemifloxacin and trovafloxacin as a control drug. Gemifloxacin MIC-zone diameter scattergrams indicated that interpretive discrepancy rates based on previously proposed criteria when using < or = 0.5 microg/ml as the susceptible MIC breakpoint was within acceptable limits. However, with the currently proposed MIC breakpoint of < or = 0.25 microg/ml, tentative zone diameter breakpoints of > or = 22 mm for susceptible, 19-21 mm for intermediate and < or = 18 mm for resistant are proposed.     

Tentative interpretive standards for disk susceptibility tests with moxalactam (LY127935).

Moxalactam (LY127935; 6059-S) is a new beta-lactam antibiotic. We propose tentative zone standards for agar diffusion susceptibility tests with 30-microgram disks. The final selection of minimal inhibitory concentration breakpoints for definition of resistant and susceptible categories must await clinical experience with this drug. Some of the clinical questions to be answered are defined. A moderately susceptible (intermediate) category is proposed for those strains with minimal inhibitory concentrations of 16 or 32 microgram/ml (zones 15 to 22 mm in diameter). Strains with minimal inhibitory concentrations of greater than or equal to 64 microgram/ml are considered resistant, and those with minimal inhibitory concentrations of less than or equal to 8 microgram/ml are considered susceptible. Tests with 30-microgram disks did not satisfactorily separate strains with minimal inhibitory concentrations of 8 microgram/ml from strains requiring < 2 microgram/ml for inhibition, because the regression line became parabolic at concentrations of 2 microgram/ml and below. However, the disk tests were satisfactory for categorizing isolates into the above-described susceptible, moderately susceptible (intermediate), and resistant categories.     

Biphasic rattlesnake venom-induced thrombocytopenia

Thrombocytopenia is a common occurrence in moderate to severe crotaline envenomation. The exact mechanism by which rattlesnake venom leads to thrombocytopenia is unclear, but aggressive treatment with crotaline-specific antivenom often leads to resolution of this disorder. Crotalinae Polyvalent Immune Fab (CroFab(TM), Protherics Inc., Nashville, TN) (crotaline Fab) is now available for the treatment of symptomatic rattlesnake envenomation. Although recurrence of thrombocytopenia has been reported in patients after envenomation treated with crotaline Fab, cases refractory to this therapy have not been described. We report a case of severe crotaline envenomation that appears to have exhibited two separate episodes of thrombocytopenia, only one of which responded to antivenom. The second, later phase was refractory to both crotaline Fab as well as traditional Antivenin (Crotalinae) Polyvalent (Wyeth-Ayerst Pharmaceuticals, Philadelphia, PA) (ACP). By reviewing the literature regarding venom-induced thrombocytopenia, we attempt to explain this "biphasic" phenomenon and the inability of crotaline Fab to reverse this toxic effect.