A 60-Year-Old Man With Dyspnea, Proximal Muscle Weakness, and Pulmonary Arterial Hypertension.

CASE PRESENTATION: A 60-year-old man with no significant medical history presented to the pulmonology clinic with 2 years of progressive weakness and shortness of breath. Showering and other activities of daily living caused him significant fatigue and dyspnea. He had a 20-pack-year smoking history, but no significant history of alcohol or illicit drug use. He did not take any prescribed or over-the-counter medications for chronic medical conditions and had never been on statin therapy. Vital signs were significant for an oxygen saturation of 91% on 4-L nasal cannula. He required up to 6 L of oxygen during a walk test. Physical examination showed mild inspiratory crackles in the lung bases, loud splitting of the second pulmonic valve (P2) with a right parasternal heave, and 2+ pitting edema in the lower extremities. There was muscle weakness, pain, and wasting of the proximal upper and lower extremities, particularly in his legs. He denied any joint pain, and there was no evidence of rash or dysphagia.

A 58-Year-Old Man With Acute Encephalopathy, Fever, and Multi-Organ Dysfunction.

CASE PRESENTATION: A 58-year-old man with a medical history of type 2 diabetes mellitus and COPD presented with fever, chills, nausea, vomiting, left upper quadrant abdominal pain, and altered mental status for the past week. His mental status rapidly deteriorated and work of breathing increased, which required intubation and mechanical ventilation. The patient's wife reported recent exposure to tick bites after finding several ticks while changing the sheets in their bedroom.

Clinically Significant Lab Errors due to Vitamin B7 (Biotin) Supplementation: A Case Report Following a Recent FDA Warning.

A 67-year-old female with a past medical history of multiple endocrine issues presented for follow-up subsequent to abnormal routine blood testing results. These included low thyroid stimulating hormone (TSH), low parathyroid hormone (PTH), and mildly elevated calcium levels. The presence of hypercalcemia and accompanying low PTH raised the concern for malignancy, while the depressed TSH indicated hyperthyroidism. Review of the patient's medications revealed daily supplementation with 5 mg of vitamin B7 (biotin). The biotin was discontinued after suspecting the supplement was interfering with the patient's lab values. The labs were repeated one month later. The results showed normalized TSH, PTH, and calcium levels. The increasingly wide-spread use of biotin supplementation and the use of biotin as a component in many of the most common clinical assays has led to a trend of lab errors due to biotin interference. While some physicians are aware of the possibility of skewed results, steps need to be taken to prevent misdiagnosis. This includes ensuring that information about this issue is more widely disseminated, accurately accounting for a patient's supplement use, reconciling proper clinical correlation with lab results, and promptly reporting when biotin is determined to be the cause of otherwise unexplained lab errors.

Methicillin-resistant Staphylococcus Aureus Colitis Secondary to Complicated Acute Diverticulitis: A Rare Case Report.

A 33-year-old obese female with a recent diagnosis of acute diverticulitis (AD) was admitted to the hospital for severe abdominal pain, intractable nausea and vomiting, and diarrhea two days following oral antibiotic treatment for AD. Stool cultures collected upon her readmission were negative for Clostridium difficile (C. difficile) antigen and toxins A and B, but were notable for methicillin-resistant Staphylococcus aureus (MRSA). She was started on intravenous (IV) piperacillin/tazobactam, IV vancomycin, and an oral liquid vancomycin solution, which resulted in rapid resolution of her symptoms. Unfortunately, her symptoms recurred two weeks later and she eventually underwent laparoscopic low anterior resection (LAR) of her colon for continued diverticulitis. This resulted in complete and continued resolution of her symptoms.

DPP-4 inhibitor (sitagliptin)-induced seronegative rheumatoid arthritis.

Sitagliptin is a dipeptidyl peptidase-4 inhibitor commonly used in the treatment of type 2 diabetes mellitus for glycaemic control. Concerns have arisen regarding adverse events caused by this drug, particularly concerning arthralgias. Here, we report on a 56-year-old man being treated with sitagliptin who developed inflammatory arthritis after taking the drug for 6 months. The patient presented with pain, swelling and erythema in multiple joints and was eventually diagnosed with seronegative rheumatoid arthritis (RA) under the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria. His symptoms continued for several months after stopping sitagliptin and eventually went into remission after a tapered course of steroids, hydroxychloroquine and methotrexate. Furthermore, the patient is HLA-DRB3 positive, a genetic marker that is still being investigated for its role in the pathogenesis of RA and that may have been a predisposing factor in the development of this patient's inflammatory arthropathy.

Early Repolarization vs. Acute Pericarditis Morphology: A Case Report of Electrocardiographic Mimicry.

A 27-year-old male presented to the outpatient clinic with a two-week history of daily episodes of palpitations, chest pain, and shortness of breath. He also complained of fatigue and nausea that continued after he recovered from an upper respiratory infection (URI) one month prior. Of note, he described the chest pain as increasing in intensity when sitting or standing upright. Auscultation revealed regular rate and rhythm with no audible rubs or murmurs. An electrocardiogram (ECG) was performed and showed diffuse ST-segment elevations that the machine interpreted as pericarditis. Based on the patient's symptoms and ECG findings, he was sent for an evaluation by cardiology. After he failed a trial of non-steroidal anti-inflammatory drugs (NSAIDs), the patient was started on colchicine and his symptoms ultimately resolved within a few weeks. Review of his records showed an ECG performed in the emergency department (ED) a year prior demonstrated morphology consistent with early repolarization (ER). The ECG morphology of ER, acute pericarditis (AP), and even acute myocardial infarction (AMI) can often be similar and difficult to differentiate. In this patient, confusing ER with AP may have led to unnecessary evaluation and treatment by a specialist.

Membrane vesicles in sea water: heterogeneous DNA content and implications for viral abundance estimates.

Diverse microbes release membrane-bound extracellular vesicles from their outer surfaces into the surrounding environment. Vesicles are found in numerous habitats including the oceans, where they likely have a variety of functional roles in microbial ecosystems. Extracellular vesicles are known to contain a range of biomolecules including DNA, but the frequency with which DNA is packaged in vesicles is unknown. Here, we examine the quantity and distribution of DNA associated with vesicles released from five different bacteria. The average quantity of double-stranded DNA and size distribution of DNA fragments released within vesicles varies among different taxa. Although some vesicles contain sufficient DNA to be visible following staining with the SYBR fluorescent DNA dyes typically used to enumerate viruses, this represents only a small proportion (<0.01-1%) of vesicles. Thus DNA is packaged heterogeneously within vesicle populations, and it appears that vesicles are likely to be a minor component of SYBR-visible particles in natural sea water compared with viruses. Consistent with this hypothesis, chloroform treatment of coastal and offshore seawater samples reveals that vesicles increase epifluorescence-based particle (viral) counts by less than an order of magnitude and their impact is variable in space and time.

Diffusion of clean indoor air ordinances in the southwestern United States.

The authors investigate the process through which clean indoor air ordinances were considered in 10 communities in the southwestern United States and key factors that influenced diffusion and adoption. Clean indoor air ordinances, which ban smoking in public places, were adopted in approximately 1,409 U.S. communities from 1986 to April 2004. The authors gathered data from 10 communities in New Mexico and Texas by means of face-to-face interview, e-mail, and telephone interviews and by analyzing archival materials. Important influences on the adoption or rejection of clean indoor air ordinances were (a) personal experiences of policy champions, (b) local framing of the ordinance as a public health issue versus as an economic/ business or an individual rights issue, and (c) interpersonal networks connecting a community to previously adopting communities. The policies that were adopted ranged in comprehensiveness, with each community of study reinventing model policies obtained from other communities.

A framework for research utilization applied to seven case studies.

BACKGROUND: It is widely acknowledged that prevention research often is not fully or adequately used in health practice and/or policies. This study sought to answer two main questions: (1) Are there characteristics of research utilization in communities that suggest stages in a process? (2) What factors, including barriers and facilitators, are associated with the use of prevention research in community-based programs, policies, and practices? METHODS: Researchers used a multiple case study design to retrospectively describe the research-utilization process. A conceptual framework modified from Rogers's diffusion of innovations model and Green's theory of participation were used. Data were gathered from archival sources and interviews with key people related to any one of seven community-based practices, programs, or policies. Fifty-two semistructured interviews were conducted with program or project staff members, funding agency project managers, community administrators and leaders, community project liaisons, innovation champions, and other members of the research user system. RESULTS: Participation in the process of research utilization was described by using characteristics of collaborative efforts among stakeholders. Program champions or agents linking research resources to the community moved the research-utilization process forward. Practices, programs, or policies characterized by greater community participation generally resulted in more advanced stages of research utilization. CONCLUSIONS: Investigating the interactions among and contributions of linking agents and resource and user systems can illuminate the potential paths of prevention research utilization in community settings. Because community participation is a critical factor in research utilization, prevention researchers must take into account the context and needs of communities throughout the research process.

Small-area variations in conviction rates for DWI: the significance of contextual variables in a Southwestern state.

Average annual conviction rates (1990-2000) of people arrested for driving under the influence of alcohol in each of New Mexico's 33 counties are described. Conviction rates vary from 58 to 95%. Rates are correlated with political conservatism, being higher where a higher proportion of voters voted for the republican presidential candidates, and with measures of crowding in the courts. Conviction rates are higher in rural than urban areas and are correlated with a low prevalence of alcohol-related problems in the population. The variance in conviction rates is higher in rural than urban areas, and higher where measures of court crowding are low. The results suggest that political culture and the efficiency of court functioning are each independently associated with conviction rates for DWI and may also be associated in a reciprocal fashion with both low DWI arrest rates and alcohol-involved crash rates.

Variations in jail sentences and the probability of re-arrest for driving while intoxicated.

OBJECTIVE: The probability of re-arrest for driving while intoxicated (DWI) is compared for four different groups of individuals classified by whether the individual was convicted and, if so, the type of sentence received. METHOD: Subsequent re-arrests for DWI were examined for all individuals whose index arrest for DWI had occurred between 1994 and 2001 in a county in New Mexico. The groups included (1) those convicted as a result of the index arrest and sentenced to a 28-day jail/treatment program (N (#)=(#) 2,703); (2) all those not convicted as a result of the index arrest (N = 709); (3) those who were convicted but not sentenced to jail (N = 1,047); and (4) those convicted and sentenced to jail (N = 1,290). RESULTS: Adjusting for covariates of BAC, number of prior arrests, ethnicity, age, and sex, the probability of not being re-arrested was greatest among those sentenced to the jail/treatment program (Group 1), next highest in the two groups convicted but not sentenced to jail/treatment (Groups 3 and 4), and lowest in the group that was not convicted (Group 2). Length of jail sentence among people convicted but not sentenced to the jail/treatment program was unrelated to the probability of re-arrest. CONCLUSION: Conviction for DWI, regardless of the sentence, appears to reduce the probability of re-arrest, and being sentenced to a multi-modal treatment/incarceration program further reduces the probability of re-arrest. However, the other types of sentences do not appear to differ in their impact on probability of re-arrest.

A prospective and retrospective look at the diffusion model.

In this article we discuss how the diffusion model originally was created, some of the most important ways in which it has evolved over the past 30 years, and its future prospects.

Effectiveness of customized Victim Impact Panels on first-time DWI offender inmates.

This study investigates the effectiveness of a customized Victim Impact Panel (VIP) on reducing 'driving while impaired' recidivism, alcohol consumption and drinking and driving behavior. The study was conducted at a 28-day Detention/Treatment Program in a largely rural county in northwestern New Mexico. Study participants were randomly assigned to attend or not attend a VIP while participating in the program for court-defined first-time driving while intoxicated (DWI) offenders. There were no significant differences between the two groups on alcohol consumption, drinking and driving behavior, or recidivism within 2 years. These findings support the findings of other studies that VIPs do not produce a differential benefit with regards to recidivism of those convicted as a first-time DWI offenders.

Rearrest rates after incarceration for DWI: a comparative study in a southwestern US county.

OBJECTIVES: This study was undertaken to assess a 28-day detention and treatment program's effect, in a multiethnic county with high rates of alcohol-related arrests and crashes, on first-time offenders sentenced for driving while impaired (DWI). METHODS: We used comparison of baseline characteristics, survival curves of subsequent arrest, and Cox proportional hazards regression to examine probability of rearrest of those sentenced and those not sentenced to the program. RESULTS: Probability of not being rearrested was significantly higher for the treatment group after adjustment for covariates. At 5 years, probability of not being rearrested for the treatment vs the nontreatment group was 76.6% vs 59.9%. CONCLUSIONS: Results suggest that this county's program has significantly affected rearrest rates for Native Americans, Hispanics, and non-Hispanic Whites.

Diffusion of preventive innovations.

The present paper draws on the diffusion of innovations model to derive a series of strategies for speeding up the spread and implementation of new ideas in preventing addiction. Preventive innovations usually require an action at one point in time in order to avoid an unwanted future condition. Hence, preventive innovations diffuse rather slowly, in part due to delayed rewards from adoption. Here we suggest five strategies, based on diffusion theory, for speeding up the diffusion of preventive innovations.

Patient oriented activities in Dutch community pharmacy: diffusion of innovations.

OBJECTIVES: To explore the implementation of patient oriented activities, the perception of an innovation aimed at implementation of patient education and the preconditions for implementation of this innovation among Dutch pharmacists. METHOD: A survey, based on Roger's theory of diffusion of innovations, was carried out among a random sample (n = 300) of Dutch managing pharmacists. MAIN OUTCOME MEASURES: Reported activities regarding patient education, medication surveillance and drug therapy meetings, as well as perception of the innovation and its perceived compatibility with pharmacy practice. RESULTS: The response rate was 49.3%. Hundred (84.7%) respondents reported to provide extra written and verbal information with first prescription medication. Medication surveillance (100% check by computer, and check of the lists by the pharmacist) was reported by 43 (36.4%), and complete participation in drug therapy meetings was reported by 57 (48.3%) respondents. Observability (or results to others) of the new strategy was perceived as important by 90 (77.6%), compatibility (perceived consistency with existing values, past experiences and needs of potential adopters) by 87 (76.4%) and trialability (degree to which an innovation may be experimented with) by 81 (69.8%) respondents. Relative advantages (perception of the innovation as being better) and complexity (relatively difficult to understand and use) of the innovation were perceived as important by less respondents. The preconditions that were met by most pharmacists were 'financial resources' (n = 70; 59.8%), 'enough workspace' (n = 61; 53.1%) and 'enough time' (n = 58; 50%). Fifty-eight (49.2%) respondents intend to adopt the innovation, but this intention would be higher when more time and money and technicians are available, as well as less situations that are experienced as barriers (rush hours, lack of support, illness of employees). CONCLUSION: Based on the definitions used, we conclude that the implementation of medication surveillance and drug therapy meetings is relatively low compared to patient education. The development of an implementation tool is justified, but should deal with the experienced preconditions, barriers and needs of pharmacists. Combined, comprehensive pharmacy interventions promise to be a good way to change pharmacy practice.

Mass media estimates of a disaster's severity : The 1989 Loma Prieta earthquake

One of the most important aspects of a disaster reported by the mass media is its severity, usually by the number of deaths, injuries, and the amount of property damage. This article analyses the accuracy with which the news media reported the 1989 Loma Prieta earthquake in Northern California, USA.(AU)