Correlation between early clinical response after catheter removal and diagnosis of catheter-related bloodstream infection

We conducted a retrospective post hoc analysis of prospectively collected data of cancer patients with central venous catheters (CVCs) who developed bacteremia with positive quantitative blood cultures (QBCs) drawn simultaneously through peripheral vein and CVC and which grew the same microorganisms from both blood cultures. We investigated whether clinical response of bacteremia, within 24, 48, or 72 h post-CVC removal, could be diagnostic of catheter-related bloodstream infection (CRBSI) when compared with microbiologic methods. Clinical response to antimicrobial therapy within 24 h of CVC removal in a patient with bacteremia was found to be highly suggestive of CRBSI, a finding that correlated well with semiquantitative catheter cultures and differential QBCs. However, response to antimicrobial therapy at >or=48 h after CVC removal was less likely to be diagnostic of CRBSI and could reflect a response to antimicrobial therapy irrespective of the source of the bloodstream infections.     

ST-Elevation Myocardial Infarction in the Presence of Biventricular Paced Rhythm

Background

In the diagnosis of acute myocardial infarction (AMI), the presence of baseline left bundle branch block or a permanent pacemaker rhythm poses a challenge.

Objective

We present a case report highlighting this challenge, along with a review of pertinent literature.

Case Report

A 70-year-old female with known severe idiopathic dilated cardiomyopathy and moderate coronary artery disease who was status post−biventricular pacemaker/implantable cardioverter defibrillator insertion was brought to our institution via Emergency Medical Services with recurrent firing of her implantable cardioverter defibrillator and syncope. After stabilization in the Emergency Department and treatment with intravenous amiodarone, the patient admitted to having ongoing chest pains. The electrocardiogram revealed evidence of biventricular pacing with superimposed ST-segment elevations in the anterolateral leads indicative of myocardial injury. She underwent prompt angiography, thrombectomy, and bare-metal stent insertion to a totally occluded proximal left anterior descending coronary artery, with resolution of her chest pain and improvement in the ST-segment changes.

Conclusions

Despite proposed criteria that aid in the recognition of AMI with underlying left bundle branch block and paced rhythm; the advent of new pacing modalities and the potential variability of pacing sites impose additional diagnostic challenges requiring higher level of suspicion and better physician awareness.     

A biomechanical study comparing cortical onlay allograft struts and plates in the treatment of periprosthetic femoral fractures

BACKGROUND: Periprosthetic femoral fractures with well-fixed femoral components can be difficult to manage and internal fixation is usually necessary. This study was designed to determine the effect of cable plate, strut allograft and combined plate and strut allograft fixations of periprosthetic femoral fractures. METHODS: A transverse fracture at the level of the tip of the femoral stem was simulated in six cadaveric femurs. The fracture was fixed with a plate-strut graft construct with and without proximal screws, a plate only construct with and without proximal screws and with both anterior and lateral struts grafts of 12 cm or 20 cm in length. The intact femur and the six constructs were tested using anteroposterior and axial loads to simulate the forces at the hip during gait. The interfragmentary motions were measured with an optoelectronic camera system. FINDINGS: The highest median interfragmentary translations were observed with the plate only construct without proximal screws. No significant differences in median translations were found between the combined plate-strut and the strut-graft alone constructs. Median interfragmentary rotations were largest with the plate only construct and lowest with the plate-strut constructs. INTERPRETATION: The best fracture fixation was achieved with the combined plate and strut graft constructs particularly in combination with the two unicortical screws above the fracture. The plate only constructs may not provide sufficient fixation stability in rotation for the simulated transverse fracture. The within-construct interfragmentary motions were not significantly different except for the plate only constructs. This suggests that the fixation construct type is the determining factor of interfragmentary motion.     

The G-231A polymorphism in the endothelin-A receptor gene is associated with lower aortic pressure in patients with dilated cardiomyopathy

BACKGROUND: The endothelin system (ES) plays an important role in blood pressure (BP) regulation and also in the pathophysiology of idiopathic dilated cardiomyopathy (DCM). Recently, we demonstrated that a genetic polymorphism in the endothelin A (ET(A)) receptor gene was associated with survival in DCM patients. The aim of this study was to determine whether polymorphisms in the ET(A) receptor gene might be associated with the severity of DCM. METHODS: One hundred twenty-four consecutively recruited unrelated patients with DCM, who underwent a detailed phenotyping protocol, were genotyped for the ET(A) receptor G-231A polymorphism using a hybridization technique with allele-specific oligonucleotides. RESULTS: The exon 1 G-231A polymorphism of the ET(A) receptor gene, upstream of the translation start site, was significantly associated with directly measured intra-aortic pressure in that -231A allele carriers had significantly lower systolic (P = .0043), as well as mean (P = .0016) and diastolic (P = .0041) aortic pressure compared to noncarriers. The association of ET(A) G-231A with aortic pressure was independent from other factors such as prior medication, left ventricular end-diastolic diameter, age, gender, and New York Heart Association (NYHA) functional classification. However, no such association was seen for cuff BP and survival rates were not significantly different between -231A allele carriers and -231G homozygotes (log rank test, P = .66). No significant association with any other parameter investigated in the present study could be observed, even when men and women were analyzed separately. CONCLUSIONS: Our results suggest an association of genetic variation in the ET(A) receptor gene with aortic pressure in patients with DCM.     

Transjugular intrahepatic porto-systemic shunt and variceal embolisation in the management of bleeding stomal varices

Background and aims Bleeding from stomal varices is uncommon. Local measures to control the bleeding offer short-lived control. Our experience with transjugular intrahepatic porto-systemic shunt (TIPS) and variceal embolisation is presented and appraised.Patient and methods Three patients presented with bleeding from stomal varices (Child–Pugh class B, n=2 and class C, n=1) in association with primary sclerosing cholangitis, autoimmune hepatitis and alcoholic liver disease. Local treatment measures including suture ligation, sclerotherapy and re-siting of the stoma achieved short-lived control. TIPS were inserted in all 3 patients, with embolisation of the stomal varices in 2.Results/findings The radiological interventions were uncomplicated and resulted in cessation of the bleeding in all patients. One of the patients has had no further bleeding at 12 months follow-up post-TIPS insertion. The other two patients re-bled at 5 and 6 months post-TIPS insertion and were successfully managed by insertion of a second TIPS in one patient and by balloon dilatation of the TIPS in another. The former patient has had no re-bleeding at a further 8 months follow-up, while the latter had re-bleeding at 12 months post-TIPS insertion and underwent liver transplantation.Interpretation/conclusion Transjugular intrahepatic porto-systemic shunt with variceal embolisation offers an effective, minimally invasive management option in patients with bleeding stomal varices, and may be used as the primary mode of intervention in conjunction with medical therapy, and as the definitive therapy in patients unfit for surgery. TIPS and variceal embolisation do not preclude subsequent liver transplantation, and may be used during the acute situation as a bridge to transplantation.     

Prevalence and impact of cardiovascular risk factors among patients presenting with acute coronary syndrome in the middle East

The authors explored the prevalence and impact of the cardiovascular risk factors (CVRFs) in patients presenting with acute coronary syndrome (ACS). During a five‐month period in 2007, six adjacent Middle Eastern countries participated in the Gulf Registry of acute coronary events. CVRFs were identified on admission. Patients' characteristics and in‐hospital outcomes were analyzed across the types of ACS. Among 6704 consecutive patients with ACS, 61% had non–ST elevation ACS (NSTEACS) and 39% had ST–elevation myocardial infarction (STEMI). Female sex, old age, diabetes mellitus, hypertension, dyslipidemia, and obesity were more prevalent in NSTEACS patients. STEMI patients were more likely to be smokers and less likely to be taking aspirin prior to the index admission. Chronic renal failure (CRF) and diabetes mellitus were independent predictors of in‐hospital heart failure in NSTEACS, while CRF and hypertension were predictors of STEMI. Female sex and CRF were independent predictors of mortality in STEMI (odds ratio, 2.0; 95% confidence interval, 1.19–3.13 and odds ratio, 5.0; 95% confidence interval, 3.47–7.73, respectively). Assessment of the prevalence of CVRF in the acute coronary presentation is of important prognostic value for in‐hospital morbidity and mortality. CVRF and its impact may differ according to ACS type, age, and sex. Coronary heart disease (CHD) is the leading cause of mortality and morbidity worldwide. To achieve a significant reduction in the prevalence of CHD, it is essential to adopt effective preventive strategies with adequate awareness of the epidemiology of cardiovascular risk factors (CVRFs). 1 CVRFs include traditional and nontraditional factors. However, the US Preventive Services Task Force concluded that the evidence is insufficient to assess the balance of benefits and harms of using nontraditional risk factors. 2 , 3 The World Health Organization has recognized obesity, hypertension, hypercholesterolemia, and smoking among the top10 traditional risk factors for premature death and morbidity. 4 Since these risk factors are usually evident before developing CHD, knowledge of their prevalence in a given population allows the prediction of the likely burden of CHD. 3 The American Heart Association has recognized many risk factors; some can be modified, treated, or controlled and some can not. 5 The more risk factors present, the greater the likelihood of developing CHD. Currently, most reports for prevention of CHD are mainly derived from European centers and suggest that risk factors for CHD are varying from country to country. 6 However, data from the Arab Middle East that evaluate the prevalence and impact of these risk factors in acute coronary events are scarce. 4 , 7 , 8 We explore the prevalence of CVRFs in patients with acute coronary syndrome (ACS) who are living in the Arab Middle East and the impact of these factors on in‐hospital heart failure (HF) and mortality. Copyright © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Percutaneous aspiration and drainage with adjuvant medical therapy for treatment of hepatic hydatid cysts

AIM:To determine the efficacy and success of percutaneous aspiration irrigation and reaspiration(PAIR) in the management of hepatic hydatidosis.METHODS:Twenty-six patients with 32 hepatic hydatid cysts had PAIR.Twenty-two patients received at least 2 wk of drug therapy before the procedure was carried out to reduce the risk of recurrence from spillage during the procedure.The procedure was performed under local anesthesia with a 19-gauge 20 cm long needle,the cyst was punctured,cystic content(approximately ...     

Digestive manifestations of parathyroid disorders

The parathyroid glands are the main regulator of plasma calcium and have a direct influence on the digestive tract.Parathyroid disturbances often result in unknown long-standing symptoms.The main manifestation of hypoparathyroidism is steatorrhea due to a deficit in exocrine pancreas secretion.The association with celiac sprue may contribute to malabsorption.Hyperparathyroidism causes smooth-muscle atony,with upper and lower gastrointestinal symptoms such as nausea,heartburn and constipation.Hyperparathyroi...     

Heterogeneity in Phenotype of Usher-Congenital Hyperinsulinism Syndrome: Hearing loss,retinitis pigmentosa,and hyperinsulinemic hypoglycemia ranging from severe to mild with conversion to diabetes

OBJECTIVE

To evaluate the phenotype of 15 children with congenital hyperinsulinism (CHI) and profound hearing loss, known as Homozygous 11p15-p14 Deletion syndrome (MIM #606528).

RESEARCH DESIGN AND METHODS

Prospective clinical follow-up and genetic analysis by direct sequencing, multiplex ligation-dependent probe amplification, and microsatellite markers.

RESULTS

Genetic testing identified the previous described homozygous deletion in 11p15, USH1C:c.(90+592)_ABCC8:c.(2694–528)del. Fourteen patients had severe CHI demanding near-total pancreatectomy. In one patient with mild, transient neonatal hypoglycemia and nonautoimmune diabetes at age 11 years, no additional mutations were found in HNF1A, HNF4A, GCK, INS, and INSR. Retinitis pigmentosa was found in two patients aged 9 and 13 years. No patients had enteropathy or renal tubular defects. Neuromotor development ranged from normal to severe delay with epilepsy.

CONCLUSIONS

The phenotype of Homozygous 11p15-p14 Deletion syndrome, or Usher-CHI syndrome, includes any severity of neonatal-onset CHI and severe, sensorineural hearing loss. Retinitis pigmentosa and nonautoimmune diabetes may occur in adolescence.Congenital hyperinsulinism (CHI, MIM #256450) is a heterogeneous disease with hyperinsulinemic hypoglycemia, most frequently caused by mutations in ABCC8 (1,2). Usher syndrome 1C (USH1C, MIM #296904) is caused by mutations in USH1C (3), a gene situated next to ABCC8 on chromosome 11p15.1. A very rare, homozygous contiguous gene deletion, including USHIC and ABCC8, has been described in three patients, characterized by severe CHI, deafness, vestibular hypofunction, severe enteropathy, and renal tubular dysfunction (MIM #606528) (4,5).We report on 15 new patients from eight consanguineous families with the same homozygous deletion, but with clinical heterogeneity and with manifestations from β-cells, inner ear, and retina only.