A randomized trial of loading vancomycin in the emergency department.

BACKGROUND: Optimizing vancomycin dosing may help eradicate bacteria while avoiding resistance. The guidelines recommend loading doses; however, there are no data to demonstrate that this may result in a more rapid achievement of therapeutic troughs. OBJECTIVE: To evaluate the percentage of troughs reaching therapeutic levels at 12, 24, and 36 hours following an initial vancomycin dose of 30 mg/kg compared with 15 mg/kg. METHODS: This prospective, randomized study was performed in a community academic medical center. Patients who were to receive vancomycin in the emergency department were randomized to an initial traditional dose of 15 mg/kg or a 30-mg/kg loading dose followed by 15 mg/kg every 12 hours for 3 doses. Patients weighing >120 kg or with creatinine clearances <50 mL/min were excluded. RESULTS: In total, 99 patients were enrolled; 12 hours after the initial dose of vancomycin, there was a significantly greater proportion of patients reaching target trough levels of 15 mg/L among the patients who received a loading dose as compared with a traditional dose (34% vs 3%, P < 0.01). This trend continued at 24 hours but was not statistically significant. At 36 hours, there was no difference in the percentage of patients reaching target levels between the 2 groups. No statistically significant difference in nephrotoxicity or adverse events among the 2 groups was demonstrated. CONCLUSION: A loading dose of 30 mg/kg of vancomycin achieved a higher percentage of therapeutic levels at 12 hours when compared with the traditional dose of 15 mg/kg, without increased nephrotoxicity or adverse events.

Rhinocerebral Mucor circinelloides infection in immunocompromised patient following yogurt ingestion.

The purpose of this case report is to illustrate the cause of this patient's headache and sinus pain in the setting of a unique environmental exposure: the patient ingested yogurt only days before presentation. This particular brand of yogurt caused controversy in early September 2013 when the manufacturer voluntarily recalled all flavors. The yogurt was found to be contaminated with Mucor circinelloides. The recall was triggered by the FDA, after receiving many complaints from consumers affected by temporary gastrointestinal symptoms such as abdominal cramping, diarrhea, and nausea. This patient was diagnosed with Rhinocerebral mucormycosis through fungal culture of the affected area. He was specifically colonized with Mucor circinelloides, a variant that rarely causes disease in humans. According to a literature review, only eight cases of mucormycosis in adults caused by this strain were documented before 2009.

Malignant acanthosis nigricans in rectal adenocarcinoma.

A case of generalized malignant acanthosis nigricans is reported. The patient was asymptomatic of any gastrointestinal complaints and investigations revealed the presence of adenocarcinoma of the rectum. The association between paraneoplastic acanthosis nigricans and internal malignancy is well established and the most common association is with adenocarcinoma of gastrointestinal origin.

An unusual presentation of invasive squamous cell carcinoma of the upper extremities in a patient with a history of severe electrical burns and chronic thermal and chemical exposure.

This is a case report that depicts an atypical presentation of very aggressive, metachronous invasive squamous cell carcinomas of the upper extremities in a patient with no prior history of precancerous or cancerous skin lesions and no significant solar radiation exposure. Potentially causative factors that played a role in the emergence of this aggressive form of skin cancer in this case study are multifactorial: (1) chronic thermal exposure of 3000 degrees F daily to his hands for an eight to ten-year time period; (2) chronic chemical exposure of DMSO solvent and higher levels of chemical contaminants such and finally; (3) a form of chronic immunosuppression as a result of his severe electrical burns that resulted in widespread second and third burns throughout his body.