Adjunctive Corticosteroid Therapy in the Treatment of Coccidioidal Meningitis.

Coccidioidal meningitis (CM) has high morbidity, and adjunctive measures to improve outcomes are needed. Using an established multicenter retrospective cohort study of CM (N = 221), we found that patients receiving adjunctive corticosteroids had a significant reduction in secondary cerebrovascular events (P = .0049). Those with CM-associated cerebrovascular events (8%) may benefit from short-term corticosteroids.

Routine CSF analysis in coccidioidomycosis is not required.

Although routinely done, there has been no evaluation of the utility of performing routine cerebrospinal fluid (CSF) examination in patients with active coccidioidomycosis and high complement fixation (IgG) antibody titers or other risk factors for disseminated infection. In our review 100% of patients diagnosed with coccidioidal meningitis had at least one sign or symptom consistent with infection of the central nervous system, headache was present in 100% of those with meningitis, while no patients without signs/symptoms of CNS infection were found to have coccidioidal meningitis, irrespective of antibody titers or other risk factors. Thus routine lumbar puncture may be unnecessary for patients with coccidioidomycosis who lack suggestive clinical symptoms.

Central sleep apnea interfering with adequate left ventricular filling in a patient with left ventricular assist device.

Central sleep apnea is common in patients with advanced heart failure. Apneic episodes are associated with hypoxemia, hypercapnia, and neurohumoral activation resulting in a rise in pulmonary vascular resistance. This case report describes a patient with a left ventricular assist device implanted for severe heart failure in whom unrecognized central sleep apnea resulted in under-filling of the left ventricle and a reduction in left ventricular assist device inflow.

Diagnostic approach to deep venous thrombosis and pulmonary embolism in the critical care setting.

Considerable progress has been made during the last 30 years in the prevention, diagnosis, and therapy of venous thromboembolism. This article discusses the epidemiology, pathophysiology, and clinical presentation of the disease as well as the diagnostic uncertainty that exists in the critical care setting. Diagnostic approaches for deep venous thrombosis and pulmonary embolism are considered, including clinical prediction rules, D-dimer, contrast venography, duplex ultrasonography, computed tomographic angiography and venography, magnetic resonance imaging, ventilation­perfusion scanning, chest radiograph, arterial blood gases, electrocardiography, and echocardiography.

Coccidioidomycosis during pregnancy: a review and recommendations for management.

Pregnancy is an established risk factor for the development of severe and disseminated coccidioidomycosis, particularly when infection is acquired during the later stages of gestation. Although recent studies suggest that the incidence of symptomatic coccidioidomycosis during pregnancy is decreasing and that outcome has improved, management is complicated by the observations that azole antifungal agents can be teratogenic when given to some women, particularly at high doses, early in pregnancy. This article summarizes the data on these issues and offers guidance on the management of coccidioidomycosis during pregnancy.

Testicular microlithiasis in association with pseudoxanthoma elasticum.

PURPOSE: To determine the presence of testicular microlithiasis in male subjects with pseudoxanthoma elasticum (PXE). MATERIALS AND METHODS: Institutional review board approval was obtained for the prospective and retrospective components of this HIPAA-compliant study. Informed consent was obtained from all patients or their parents. Testicular ultrasonography (US) was performed in eight men aged 29-56 years and in one 13-year-old boy, all with confirmed PXE. Two radiologists reviewed the US images by consensus for testicular microlithiasis, testicular masses, and additional testicular abnormalities. Testicular microlithiasis was judged to be classic when at least five microliths were seen on a single US image and to be limited when fewer than five microliths were seen on all obtained US images. Urologic physiologic examinations were performed. A history and/or symptoms of testicular disease also were recorded at the time of examination. Similarly, the testicular US images obtained in two additional men, aged 48 and 59 years, and in another 13-year-old boy were retrospectively reviewed. Histopathologic testicular analysis was performed in one autopsy case. RESULTS: Of the 12 participants, 11 (92%) had classic and one (8%) had limited testicular microlithiasis. None of the 12 participants had evidence of testicular malignancy at US or physical examination. Histopathologic analysis at autopsy revealed intratubular microlithiasis without the calcification of elastic fibers in arterial walls that is characteristic of cutaneous PXE. CONCLUSION: Study findings suggested an association between PXE and testicular microlithiasis. It is possible that the testicular microlithiasis in male subjects who have PXE is related to the underlying PXE abnormality.

Can goal-based advance planning guide medical care in the nursing home?

OBJECTIVE: To determine whether a goal-based system of advance planning, which allows patients to choose among five "pathways of care" (longevous, ameliorative/comprehensive, ameliorative/basic, palliative/comfort, or palliative/hospice), enables physicians to select treatment options in specified clinical situations. DESIGN: A pencil and paper test was administered in which clinicians were presented five common clinical scenarios and were asked which of four possible treatment options they would recommend, given a predetermined "pathway of care." SETTING: A 725-bed teaching nursing home and affiliated continuing care retirement community. MEASUREMENTS: The proportion of correct answers was measured for each clinician, for each clinical scenario, and for each pathway. RESULTS: Of the test answers, 78% coincided with the reference answers. The greatest rate of correct answers was found for the ameliorative/comprehensive pathway and the palliative/hospice pathway. CONCLUSION: Establishing pathways of care by asking nursing home residents to prioritize their goals of care may help clinicians narrow the range of appropriate options when facing an acute medical problem. Key Words: Advance planning; goals of care; treatment limitations