Oral antimicrobial therapy for cellulitis versus outpatient parenteral antimicrobial therapy: a single-centre audit of cellulitis outcomes.

BACKGROUND: Cellulitis is a common acute skin and soft tissue infection that causes substantial morbidity and healthcare costs. AIMS: To audit the impact on cellulitis management, regimen tolerability and outcomes of switching from outpatient parenteral antimicrobial therapy (OPAT) using intravenous (i.v.) cefazolin once daily plus probenecid to oral beta-lactam therapy (OBLT) using oral flucloxacillin plus probenecid. METHODS: We undertook a retrospective audit on cellulitis management, regimen tolerability and outcomes at the Dunedin Public Hospital Emergency Department (ED) before and after a change of the local outpatient cellulitis treatment pathway from OPAT using i.v. cefazolin once daily plus probenecid to OBLT using oral flucloxacillin plus probenecid. RESULTS: OPAT was used in 97/123 (78.9%) patients with cellulitis before compared to 1/70 (1.4%) after the pathway change (odds ratio (OR), 0.04, P < 0.01). OBLT was used in 26/123 (21.1%) patients with cellulitis before and 69/70 (98.6%) after (OR, 218.8, P < 0.01). Antimicrobial change due to intolerance occurred in 4/123 (3.2%) patients with cellulitis before and 4/70 (5.7%) after (OR, 1.8, P, not significant (NS)) the pathway change. Inpatient admission within 28 days occurred in 15/123 (12.2%) cellulitis patients before and 9/70 (12.9%) after (OR, 1.1, P, NS) the pathway change. CONCLUSIONS: Implementation of a change in outpatient cellulitis treatment pathway resulted in a significant change in prescribing practice. Our findings suggest that OBLT was both tolerable and had similar outcomes to OPAT.

An automated rat grimace scale for the assessment of pain.

Pain is a complex neuro-psychosocial experience that is internal and private, making it difficult to assess in both humans and animals. In pain research, animal models are prominently used, with rats among the most commonly studied. The rat grimace scale (RGS) measures four facial action units to quantify the pain behaviors of rats. However, manual recording of RGS scores is a time-consuming process that requires training. While computer vision models have been developed and utilized for various grimace scales, there are currently no models for RGS. To address this gap, this study worked to develop an automated RGS system which can detect facial action units in rat images and predict RGS scores. The automated system achieved an action unit detection precision and recall of 97%. Furthermore, the action unit RGS classifiers achieved a weighted accuracy of 81-93%. The system's performance was evaluated using a blast traumatic brain injury study, where it was compared to trained human graders. The results showed an intraclass correlation coefficient of 0.82 for the total RGS score, indicating that the system was comparable to human graders. The automated tool could enhance pain research by providing a standardized and efficient method for the assessment of RGS.

Disseminated Erysipelothrix rhusiopathiae with Secondary Prosthetic Hip Joint Infection: A Case of Successful Identification and Management in a Regional Hospital.

CASE: This article reports a case of a 72-year-old man with bilateral total hip joint replacements who suffered cuts to his hands while butchering a wild boar. He presented to the emergency department with fevers and unilateral hip pain. Erysipelothrix rhusiopathiae (E. rhusiopathiae) was isolated on hip aspirate and blood cultures. E. rhusiopathiae is a well-recognized zoonotic infection in humans, particularly in at-risk hosts, most commonly infecting swine. Infection is spread by ingestion or through skin abrasion. CONCLUSION: This illustrates an example of successful operative and perioperative management of prosthetic joint infection secondary to E. rhusiopathiae, particularly microbiological identification, within a multispecialty team of physicians and surgeons.

Leprosy rash precipitated by immunotherapy for suspected inflammatory neuropathy.

Leprosy is a chronic granulomatous infection caused by Mycobacterium leprae complex, causing skin and nerve lesions with potential for permanent disability. Leprosy can be overlooked in Western settings, as it is more prevalent in low-income and middle-income countries. We describe a 38-year-old woman with a 4-year history of progressive numbness of the left hand incorrectly diagnosed as multifocal acquired demyelinating sensory and motor neuropathy on the basis of clinical and neurophysiological findings. Treatment with empirical weekly corticosteroid followed by intravenous immunoglobulin resulted in the sudden development of a widespread rash; we then diagnosed borderline lepromatous leprosy on skin biopsy. We postulate that the immune treatments induced a temporary state of immune tolerance followed by a rebound of a T cell-mediated immune response resulting in a type 1 immunological response.

Traumatic chest wall pyomyositis presenting with mediastinitis.

Pyomyositis is an acute bacterial infection of the skeletal muscle that is commonly associated with localized abscess formation. It is estimated that pyomyositis accounts for up to 4% of all hospital admissions throughout Asia, tropical Africa, Oceania and the Caribbean Islands. However, there has been an increasing emergence of pyomyositis in temperate climates and high-income countries. Staphylococcus aureus is the most common organism implicated. Management requires a high index of clinical suspicion, prompt diagnosis and early management to prevent sequalae that can be fatal if left untreated. We describe an interesting case of pyomyositis in an otherwise fit and immunocompetent individual causing mediastinitis; a rare sequalae of the disease. Percutaneous drainage of his left pectoral abscess and a prolonged course of antibiotics provided complete clinical and radiological resolution of the disease despite mediastinal extension. Here we discuss aetiology, associations, pathophysiology and epidemiology of pyomyositis with associated sequalae of the disease.

Changes to management of a non-pandemic illness during the COVID-19 pandemic: case study of invasive management of acute coronary syndrome.

The coronavirus 2019 (COVID-19) pandemic requires significant changes to standard operating procedures for non-COVID-19 related illnesses. Balancing the benefit from standard evidence-based treatments with the risks posed by COVID-19 to patients, healthcare workers and to the population at large is difficult due to incomplete and rapidly changing information. In this article, we use management of acute coronary syndromes as a case study to show how these competing risks and benefits can be resolved, albeit incompletely. While the risks due to COVID-19 in patients with acute coronary syndromes is unclear, the benefits of standard management are well established in this condition. As an aid to decision making, we recommend systematic estimation of the risks and benefits for management of any condition where there is likely to be an increase in non-COVID-19 related mortality and morbidity due to changes in routine care.

Mycobacterium bovis infection of total hip arthroplasty after intravesicular Bacillus Calmette-Guérin.

Intravesicular application of Bacillus Calmette-Guérin (BCG), a live attenuated strain of Mycobacterium bovis, is effective in the treatment of bladder cancer. However, systemic dissemination and subsequent infection of implants have been reported. We present a case of M. bovis infection of a total hip arthroplasty 5 years after BCG instillation for bladder cancer. He was treated with debridement, antibiotics, irrigation, and prosthesis retention with appropriate antituberculous therapy. At 4 years after surgery and 3 years after cessation of treatment, he has had no recurrence of infection with a good functional outcome. This case highlights the need to consider Mycobacteria infection in patients who have received intravesicular BCG. Debridement and retention of well-fixed implants can be successful in combination with appropriate antituberculous therapy.

Reliability of HEARTSMAP as a Tool for Evaluating Psychosocial Assessment Documentation Practices in Emergency Departments for Pediatric Mental Health Complaints.

OBJECTIVES: The goal of this study was to assess the reliability of HEARTSMAP as a standardized tool for evaluating the quality of psychosocial assessment documentation of pediatric mental health (MH) presentations to the emergency department (ED). In addition, we report on current documentation practices. METHODS: We conducted a retrospective cross-sectional study of pediatric (up to age 17) MH-related visits to four EDs between April 1, 2013, and March 31, 2014. The primary outcome was the inter-rater agreement when evaluating the completeness of pediatric emergency psychosocial assessments using the HEARTSMAP tool. The secondary outcome was to describe the adequacy of documentation of emergency pediatric MH assessments, using HEARTSMAP as a guide for a complete assessment. RESULTS: A total of 400 medical records (100 from each site) were reviewed. We observed near-perfect inter-rater agreement (κ = 0.99-1.00) regarding the presence of documentation and good-to-perfect agreement (κ = 0.71-1.00) regarding whether sufficient information was documented to score a severity level for every component of an emergency psychosocial assessment. Inter-rater agreement regarding whether referrals or resources were documented for identified needs was observed to be good to very good (κ = 0.62-0.98). Current psychosocial documentation practices were found to be inconsistent with significant variability in the presence of documentation pertaining to HEARTSMAP sections between medical centers and initial clinician assessor and whether specialized MH services were involved prior to discharge. CONCLUSIONS: The HEARTSMAP tool can be reliably used to assess pediatric psychosocial assessment documentation across a diverse range of EDs. Current documentation practices are variable and often inadequate, and the HEARTSMAP tool can aid in quality improvement initiatives to standardize and optimize care for the growing burden of pediatric mental illness.

The Assessment and Sustainable Management of Sickle Cell Disease in the Indigenous Tharu Population of Nepal.

Sickle cell disease is an inherited hemoglobinopathy associated with significant morbidity and mortality. Reports suggest a high sickle cell disease burden among the indigenous Tharu population of Nepal, who for centuries have inhabited regions where malaria is endemic. Unfortunately, health care resources are limited and often inaccessible for Tharu individuals suffering from sickle cell disease. We conducted a large-scale screening effort to estimate the prevalence of Hb S (HBB: c.20A>T) among the Tharu population and delivered community-based education sessions to increase sickle cell disease awareness. A total of 2899 Tharu individuals aged 6 months to 40 years in the rural district of Dang in Western Nepal were screened using a sickling test, of whom, 271 [9.3%; 95% confidence interval (95% CI): 8.3-10.4%] screened positive for Hb S. Those who screened positive were offered diagnostic gel electrophoresis testing. Of the 133 individuals who underwent diagnostic testing, 75.9% (n = 101) were confirmed to be Hb AS heterozygotes, 4.5% (n = 6) were confirmed to be Hb SS homozygotes and 19.5% (n = 26) were false positives. These findings support a large burden of sickle cell disease among the Tharu population and highlight the importance of appropriate resource allocation and management. With a positive predictive value of 80.0% (95% CI: 73.0-87.0%), the sickling test in conjunction with raising local sickle cell disease awareness may be a simple and sustainable way to promote access to health resources.

VEGF can protect against blood brain barrier dysfunction, dendritic spine loss and spatial memory impairment in an experimental model of diabetes.

Clinical and experimental studies have shown a clear link between diabetes, vascular dysfunction and cognitive impairment. However, the molecular underpinnings of this association remain unclear. Since vascular endothelial growth factor (VEGF) signaling is important for maintaining vascular integrity and function, we hypothesized that vascular and cognitive impairment in the diabetic brain could be related to a deficiency in VEGF signaling. Here we show that chronic hyperglycemia (~8weeks) in a mouse model of type 1 diabetes leads to a selective reduction in the expression of VEGF and its cognate receptor (VEGF-R2) in the hippocampus. Correlating with this, diabetic mice showed selective deficits in spatial memory in the Morris water maze, increased vessel area, width and permeability in the dentate gyrus/CA1 region of the hippocampus and reduced spine densities in CA1 neurons. Chronic low dose infusion of VEGF in diabetic mice was sufficient to restore VEGF signaling, protect them from memory deficits, as well as vascular and synaptic abnormalities in the hippocampus. These findings suggest that a hippocampal specific reduction in VEGF signaling and resultant vascular/neuronal defects may underlie early manifestations of cognitive impairment commonly associated with diabetes. Furthermore, restoring VEGF signaling may be a useful strategy for preserving hippocampal-related brain circuitry in degenerative vascular diseases.

Risk factors of shock in severe falciparum malaria.

The objective of this study was to determine the risk factors for the development of shock in adult patients admitted with severe falciparum malaria. As an unmatched case-control study, the records of patients who were admitted to the Bangkok Hospital for Tropical Diseases, Thailand, between the years 2000-2010, were reviewed. One hundred patients with severe falciparum malaria and shock, and another 100 patients with severe malaria but without shock were studied. Demographics, presenting symptoms, physical observations, and laboratory data of these patients were analyzed. Five risk factors for the development of shock were identified: female gender (OR 6.16; 95% CI 3.17-11.97), red cell distribution width (RDW) >15% (adjusted OR 2.90; 95% CI 1.11-7.57), anorexia (adjusted OR 2.76; 95% CI 1.03-7.39), hypoalbuminemia (adjusted OR 2.19; 95% CI 1.10-4.34), and BUN-creatinine ratio >20 (adjusted OR 2.38; 95% CI 1.22-4.64). Diarrhea was found to be a protective factor (adjusted OR 0.33; 95% CI 0.14-0.78). Metabolic acidosis was only weakly correlated to mean arterial blood pressure on admission (r(s) = 0.23). Female gender was the strongest risk factor for the development of shock. We concluded that female gender, RDW >15%, anorexia, hypoalbuminemia, and BUN-creatinine ratio >20 were risk factors of shock development in severe falciparum malaria.

Sudden onset proptosis secondary to cavernous sinus thrombosis from underlying mandibular dental infection.

The present report concerns a patient who presented with a 4-day history of left-sided facial pain arising from a pre-existing dental infection and progressive shortness of breath. The patient had a previous diagnosis of rheumatoid arthritis and was being treated with methotrexate. The rapid development of a right eye proptosis necessitated urgent decompression with a lateral canthotomy and cantholysis. Imaging revealed a left facial abscess, cavernous sinus thrombosis (CST), bilateral internal jugular thrombosis and multiple lung abscesses. Blood cultures yielded Streptococcus constellatus, a member of the Peptostreptococcus family. The patient was admitted to the intensive care unit (ICU) with respiratory failure and septic shock. She was treated with intravenous meropenem and clindamycin, and anticoagulated. Despite early intervention, the patient developed a middle cerebral artery infarct. Over a 3-week period she was gradually weaned from vasopressor and ventilatory support.