Endobronchial actinomycosis after airway stenting.

Actinomycosis is a chronic suppurative infection with filamentous, gram-positive, nonspore forming anaerobic bacteria of the genus Actinomyces. Actinomyces species are commensals of the human oropharynx, gastrointestinal tract, and female genitalia. Involvement of the thorax accounts for 15% to 20% of actinomycosis cases. Thoracic actinomycosis classically presents as an intrapulmonary infection of the alveoli, peribronchial tissue, and/or bronchioles. Endobronchial actinomycosis is a rare condition that has been reported in association with aspiration of a foreign body or broncholithiasis. A critical component in the pathogenesis is disruption of the mucosal barrier, thereby allowing invasion of the microorganisms from aspirated oropharyngeal secretions. Even with a high clinical suspicion, actinomycosis is a diagnostic challenge. The most common symptoms of endobronchial actinomycosis include cough, sputum production, and fever. The disease is often confused with lung cancer, tuberculosis, fungal infections, nocardiosis, and poorly responding pneumonia. The present case highlights the first reported case of endobronchial actinomycosis associated with a covered nitinol endobronchial stent.

Internal medicine residents' time study: paperwork versus patient care.

BACKGROUND: Multiple factors affect residency education, including duty-hour restrictions and documentation requirements for regulatory compliance. We designed a work sampling study to determine the proportion of time residents spend in structured education, direct patient care, indirect patient care that must be completed by a physician, indirect patient care that 5 be delegated to other health care workers, and personal activities while on an inpatient general practice unit. METHODS: The 3-month study in 2009 involved 14 categorical internal medicine residents who volunteered to use personal digital assistants to self-report their location and primary tasks while on an inpatient general practice unit. RESULTS: Residents reported spending most of their time at workstations (43%) and less time in patient rooms (20%). By task, residents spent 39% of time on indirect patient care that must be completed by a physician, 31% on structured education, 17% on direct patient care, 9% on indirect patient care that 5 be delegated to other health care workers, and 4% on personal activities. From these data we estimated that residents spend 34 minutes per patient per day completing indirect patient care tasks compared with 15 minutes per patient per day in direct patient care. CONCLUSIONS: This single-institution time study objectively quantified a current state of how and where internal medicine residents spend their time while on a general practice unit, showing that residents overall spend less time on direct patient care compared with other activities.

Chemical pneumonitis and subsequent reactive airways dysfunction syndrome after a single exposure to a household product: a case report.

INTRODUCTION: Household products are usually safe to use. Adverse events arising from their use are mostly reported in patients with pre-existing atopy or pulmonary problems and usually only after a prolonged exposure to such products. We report the case of a patient with no prior problems who developed significant side effects from a single exposure to a domestic product. CASE PRESENTATION: A 43-year-old Caucasian American man, previously in good health, used a domestic aerosol product called 'Stand N' Seal "Spray-On" Grout Sealer' in an enclosed room in his house. The product contained n-butyl acetate (<5%), propane (10%), isobutane (<5%), C8-C9 petroleum hydrocarbon solvent (80%), a fluoropolymer resin and a solvent. Within a few hours of exposure to the sealant, he developed rapidly progressive shortness of breath and a severe non-productive cough. By the time he reached the emergency room he was severely hypoxic. A diagnosis of chemical pneumonitis was made based on the clinical scenario and the diffuse infiltrates on the computer tomography scan. With supportive therapy, his condition improved and he was discharged from the hospital. However, he continued to have symptoms of intermittent cough and shortness of breath in response to strong odours, fumes, cold air and exertion even after his chest radiograph had normalized. Three months later, bronchial hyper-responsiveness was documented by a methacholine inhalation test and a diagnosis of reactive airways dysfunction syndrome was made. The patient was started on high-dose inhaled steroids and his symptoms improved. The mechanism of toxicity and determination of the exact agent responsible is still under investigation. CONCLUSION: A household product may still prove unsafe to use even after it has gone through vigorous testing and approval processes. Even healthy individuals are susceptible to adverse outcomes after a brief exposure. Extra precautions should be taken when using any chemical product at home.