Vancomycin allergy presenting as fever of unknown origin

A 37-year-old woman receiving long-term hemodialysis was admitted to the hospital with a fever of unknown origin (6 weeks of unexplained, persistent, low-grade fever). Although she had received vancomycin hydrochloride 5 days before the onset of fever, the drug was not suspected as the cause because of the duration of fever, the administration of vancomycin on prior occasions without incident, and the lack of allergic stigmata. After hospitalization, vancomycin and gentamicin sulfate were administered empirically. Immediately thereafter, her temperature rose to 40 degrees C, and over the ensuing 24 hours, eosinophilia and a maculopapular rash developed that resolved entirely when antibiotic therapy was stopped and low-dose steroid therapy was instituted. The prolonged hypersensitivity reaction after a single dose of vancomycin is consistent with the greatly extended half-life of this drug in the population with end-stage renal disease and should alert physicians to the possibility of such persistent idiosyncratic reactions in this group.     

Lyme arthritis

Evanescent arthralgias and myalgias are common early symptoms of Lyme disease. Transient, intermittent episodes of monoarticular, oligoarticular, or sometimes migratory polyarticular arthritis, lasting weeks to months, with disease-free intervals, are frequently observed in untreated patients with erythema chronicum migrans. A minority of patients develop chronic joint involvement, most commonly affecting the knee. Antibiotic therapy given during erythema chronicum migrans is often protective with regard to late joint manifestations. In chronic Lyme arthritis, however, the response to antibiotics is variable.     

Laboratory diagnosis of pulmonary embolism: value of increased levels of plasma D-dimer and thrombin--antithrombin III complexes

Plasma D-dimer (DD) and thrombin--antithrombin III complex (TAT) were measured with ELISAs in 99 patients investigated by 102 ventilation--perfusion lung scintigraphy because of suspected pulmonary embolism. High-probability lung scan was associated with increased DD (more than 500 ng/ml) and TAT (more than 4.1 ng/ml) levels (sensitivity of 100 and 70%, respectively). The corresponding figures of specificity were 81 and 42%. In the 56 patients with low-probability or indeterminate probability scans, 31 (55%) had DD concentrations of less than 500 ng/ml. These preliminary data suggest that a plasma DD concentration of less than 500 ng/ml might rule out the diagnosis of pulmonary embolism in suspected patients with an inconclusive lung scanning.     

Coping with cancer: the spouse's perspective

This study explored coping difficulties experienced by wives of patients with a diagnosis of cancer. Concomitantly, the study explored the ways in which nurses intervened to help these wives. This study was designed as an exploratory study. The qualitative analysis made use of data derived from responses to open-ended questions presented to the respondents by the interview method. The study sample consisted of 40 wives who acknowledged experiencing coping difficulties in meeting the demands of everyday living as a result of their husband's diagnosis of cancer. Respondents were selected randomly from seven eligible representative settings located in the Mid-Atlantic region until the desired sample number was reached. Wives, who encountered the unexpected and uncontrollable situation of having a husband with diagnosed cancer, experienced a multitude of coping difficulties. In addition, wives underwent psychological disorganization, disequilibrium, and emotional imbalance. They attempted to cope with the resulting imbalance by using their habitual problem-solving behavior patterns and experienced difficulty when seeking situational supports. This, in turn, added to their stress. Wives also reported that their children had coping difficulties. Wives identified listening, talking, caring, availability of nurses to patients and patients' spouses, sensitivity, empathy, and honesty as essential helpful nursing behaviors. The study underscored the importance of viewing wives of cancer patients as unique systems in need of therapeutic support, and reaffirmed a view of nursing as the art of understanding the unique needs of individuals who are experiencing coping difficulties. This study also underscored the key role of psychiatric liaison nurses in providing supportive therapeutic interventions to the spouses of cancer patients as well as to the nursing staff.     

A patient with right and left atrial membranes: the role of transesophageal echocardiography and magnetic resonance imaging in diagnosis

A patient who had right and left atrial membranes was examined. The diagnosis and the hemodynamic significance of both membranes were detailed by transesophageal echocardiography and were confirmed by magnetic resonance imaging. Transesophageal imaging was found to be superior to routine echocardiography in visualization of these atrial structures.     

Synovial fluid phospholipase A2s and inflammation.

The activation of phospholipase A2 is believed to have an important role in the inflammatory process owing to its induction of eicosanoids, platelet activating factor, and other mediators. Soluble phospholipase A2 has been associated with exudates in different inflammatory conditions. In this review the general physiology and control of this enzyme and, in particular, the most recent findings on human synovial fluid phospholipase A2s are discussed.     

A preliminary report of the short-term effect of carbonated beverage consumption on calcium metabolism in normal women

A variety of nutritional factors influence the bioavailability of calcium and increase a woman's risk of osteoporosis. Eight healthy women completed an 8-week metabolic study designed to investigate the effect of nonalcoholic carbonated beverage consumption on calcium metabolism. Compared with women receiving a control diet, women consuming a diet high in nonalcoholic carbonated beverages demonstrated similar mean serum levels of calcium, ionized calcium, phosphorus, alkaline phosphatase, parathyroid hormone, 1,25-dihydroxyvitamin D3, and osteocalcin. Twenty-four-hour urine volume, creatinine clearance, calcium-creatinine ratio, and phosphorus-creatinine ratio were similar during consumption of the diet high in nonalcoholic carbonated beverages and the control diet. Twenty-four-hour cyclic adenosine monophosphate-creatinine ratio was significantly lower in women consuming the diet high in nonalcoholic carbonated beverage compared with women receiving the control diet (342 +/- 27.4 nmol/mmol vs 409 +/- 22.1 nmol/mmol). Consumption of a diet high in nonalcoholic carbonated beverages on a short-term basis does not appear to affect adversely the serum or urinary markers of calcium metabolism.     

Pulmonary edema in the renal failure patient

A patient with chronic renal failure presenting to the emergency department with acute pulmonary edema has a true life-threatening emergency. Whereas conventional treatment modalities may prove useful, more unusual therapeutic measures may be necessary. A case is presented followed by useful recommendations for the emergency physician faced with such a patient.     

Randomized trial of Codetron for pain control in osteoarthritis of the hip/knee

Patients suffering from pain due to osteoarthritis of the hip and knee participated in a double-blind placebo controlled trial using daily Codetron home care units for 6 weeks over the tibial, saphenous, popliteal and sciatic nerves, and tender points. Seventy-four percent of patients in the real Codetron (Group A) and 28% of the patients in sham Codetron (Group B) improved their pain level more than 25% as measured by visual analogue scale. The difference in pain improvement in the two groups was statistically significant (p less than 0.02 using Fisher's exact probability ratio). Other functional parameters proved to be insensitive to change in this study. This is highly suggestive of beneficial effect of nonhabituating Codetron as a complementary modality in the therapy of chronic pain conditions such as osteoarthritis.