Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired pneumonia: a comparison of management practices with National Guideline Recommendations.

PURPOSE: Community-acquired pneumonia (CAP) is the most common infection leading to hospitalization in the USA. The objective of this study was to evaluate management practices for inpatient CAP in relation to Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines to identify opportunities for antibiotic and health care resource stewardship. METHODS: This was a retrospective cohort study of adults hospitalized for CAP at a single institution from 15 April 2008 to 31 May 2009. RESULTS: Of the 209 patients with CAP who presented to Denver Health Medical Center during the study period and were hospitalized, 166 (79 %) and 43 (21 %) were admitted to a medical ward and the intensive care unit (ICU), respectively. Sixty-one (29 %) patients were candidates for outpatient therapy per IDSA/ATS guidance with a CURB-65 score of 0 or 1 and absence of hypoxemia. Sputum cultures were ordered for 110 specimens; however, an evaluable sample was obtained in only 49 (45 %) cases. Median time from antibiotic initiation to specimen collection was 11 [interquartile range (IQR) 6-19] h, and a potential pathogen was identified in only 18 (16 %) cultures. Blood cultures were routinely obtained for both non-ICU (81 %) and ICU (95 %) cases, but 15 of 36 (42 %) positive cultures were false-positive results. The most common antibiotic regimen was ceftriaxone + azithromycin (182, 87 % cases). Discordant with IDSA/ATS recommendations, oral step-down therapy consisted of a new antibiotic class in 120 (66 %), most commonly levofloxacin (101, 55 %). Treatment durations were typically longer than suggested with a median of 10 (IQR 8-12) days. CONCLUSIONS: In this cohort of patients hospitalized for CAP, management was frequently inconsistent with IDSA/ATS guideline recommendations, revealing potential targets to reduce unnecessary antibiotic and healthcare resource utilization.

Evaluation of a residency program's experience with a one-week emergency medicine resident rotation at a medical liability insurance company.

INTRODUCTION: The authors' residency program implemented a one-week rotation at the office of a medical liability insurance company. Residents examined 30 closed malpractice claims cases and sat in on settlement discussions. OBJECTIVE: To review the residents' evaluations of their experiences and to determine whether this was a worthwhile addition to the emergency medicine (EM) residency curriculum. METHODS: This was a five-year retrospective study that reviewed residents' annual evaluations from 1994 to 1999 regarding the medical liability rotation. A five-point scale was used to score specific categories in the rotation and an open-ended section was used to collect general comments. RESULTS: A total of 179 resident evaluations were reviewed. The quality of teaching ranked in the 80th percentile, the clinical caseload ranked in the 85th percentile, and level of responsibility ranked in the 79th percentile for all EM rotations. Specific comments included "All MDs should do this in their training"; "Quite an eye opener"; and "Good exposure to legal aspects of EM." CONCLUSIONS: Overall, EM residents found the one-week rotation to be invaluable and a good learning experience. This rotation ranked above average when compared with all of our other EM residency rotations.

Does participation in the electronic residency application service (ERAS) affect the quality of applications to a residency program?

PURPOSE: To determine whether the quality of applicants to an emergency medicine (EM) residency would improve during a year that the program did not participate in the Electronic Residency Application Service (ERAS). METHODS: Applications to the Denver Health Medical Center Residency in Emergency Medicine (DHMCREM) were retrospectively compared for three consecutive years: 1996-97, during which ERAS was not available to EM programs; 1997-98, during which DHMCREM did not participate in ERAS; and 1998-99, during which DHMCREM participated in ERAS. The quality of applicants was based on their application scores, which were determined using a 20-point equation that rated individual attributes: U.S. Medical Licensing Examination Step 1 score, medical school, research, extracurricular activities, personal statement, letters of recommendation, and dean's letter. T-tests were used to compare application scores and individual attributes among applicants, those invited for an interview, and those who matched to the program. In addition, numbers of applications to the DHMCREM were compared with national trends. RESULTS: A total of 1,318 complete applications were reviewed for the three-year study period. There was a 50% reduction in applications during 1997-98 when DHMCREM did not participate in ERAS, which did not correlate with the national trend in applications to residency programs. However, there was no statistically significant difference in the quality of applicants, interviewees, or matched candidates as defined by the overall application score. In addition, applicants who matched to the program were higher on the rank-order list during the 1997-98 application year than were applicants who matched for the year prior to ERAS and for the year DHMCREM participated in ERAS. CONCLUSIONS: Participation in ERAS increased the number of applicants, but did not correlate with an increase in the quality of applicants.

Avalanche deaths in the United States: a 45-year analysis.

OBJECTIVE: To describe the demographic characteristics and patterns of death of persons killed in snow avalanches over a 45-year study period. METHODS: The national avalanche database was the source of data in this retrospective, descriptive study. RESULTS: A total of 440 victims were killed in 324 fatal avalanches, of which 87.7% were fully buried, 4.7% were partially buried, and 7.6% were not buried. The average age was 27.6 +/- 10.6 years, and 87.3% were men. Victims who died included climbers (25.5%), backcountry skiers (22.7%), out-of-bounds skiers (10.0%), snowmobilers (6.8%), in-bounds skiers (5.2%), residents (4.5%), ski patrollers (3.6%), workers (3.6%), and motorists (3.0%). Over the 45-year study period there appear to be decreases in the deaths of in-bounds skiers, highway workers, and motorists. Increasing fatalities were observed among out-of-bounds skiers, snowmobilers, ski patrollers, and backcountry skiers. Most deaths occurred in Colorado (33.0%), Washington (13.2%), and Alaska (12.0%). CONCLUSIONS: Avalanche fatalities have increased over the last 45 years. Climbers, backcountry skiers, out-of-bounds skiers, and more recently snowmobilers constitute the majority of the victims. The decrease in deaths among groups that benefit from avalanche control programs supports the benefit of avalanche prevention strategies. Further study is needed to assess the impact of avalanche safety education for individuals who travel in remote and uncontrolled terrain.

Entrance and exit gunshot wounds: incorrect terms for the emergency department?

Gunshot wounds (GSWs) pose significant medicolegal and forensic issues. Mistakes have been made regarding identification of gunshot wounds. We present a case of an atypical gunshot wound and review contact, near contact, intermediate, and distant wounds. There is an objective terminology to describe GSWs in the Emergency Department.

Traumatic carotid cavernous sinus fistula following a gunshot wound to the face.

A case of a traumatic carotid cavernous sinus fistula following a gunshot wound to the face is described. Although its occurrence is rare, the diagnosis can be made in the emergency department. The presentation, pathogenesis, and management of carotid cavernous sinus fistula are discussed.

Home care of patients with amyotrophic lateral sclerosis (ALS).

Optimal home care maximizes function and quality of life for patients with ALS. We designed a survey to study home care in the ALS population. Ninety-eight patients with ALS completed our survey. Of these, 24 receive non-hospice home care, nine hospice home care, and seven both hospice and non-hospice home care. Fifty-eight patients receive no outside help. Patients receiving hospice are older than those receiving non-hospice home care (68.9 vs. 57.7 years, P<0.05). Patients with home care assistance have a mean ALS Functional Rating Scale (ALS FRS) score of 13, and those without home care assistance have a mean score of 26 (P<0.0001). Patients receiving non-hospice home care assistance have a median of 16 h/week of care, while those with hospice receive 5.5 h/week (P=0.05). Patients on Medicaid receive more hours of home care than those with any other insurance (median 61 vs. 3.4 h/week with Medicare and 5 h/week with commercial insurance, P=0.008). Primary caregivers spend a median of 11 h/day caring for patients despite having home care assistance. Forty-two and 48% of primary caregivers feel physically and psychologically unwell, respectively. Home care received by patients with ALS often is inadequate and too late to relieve the burden placed on family caregivers.

Perforation of the sigmoid colon by hydrostatic pressure of a public water fountain.

A 39-year-old woman presented to the emergency department complaining of rectal bleeding and abdominal pain 7 h after sitting on a water display fountain. On examination, the abdomen was rigid, and the patient had a prolapsed rectum with rectal bleeding. A chest radiograph demonstrated free air. On emergent exploratory laparotomy, the patient had a perforated sigmoid colon at the rectosigmoid junction with gross abdominal soilage. The patient survived to hospital discharge. This case provides a review of the literature regarding hydrostatic injury to the colon and other self-induced colorectal perforations.

Prolonged myasthenic syndrome after one week of muscle relaxants.

A child developed severe, generalized muscle weakness which persisted for 6 weeks, after receiving muscle relaxants for 1 week while requiring ventilator support. Electrodiagnostic studies indicated a presynaptic disorder of the neuromuscular junction which improved with high-frequency stimulation, similar to findings in Lambert-Eaton syndrome. Muscle specimens exhibited neurogenic targetoid fiber atrophy. Ultrastructure of the neuromuscular junction indicated terminal axon degeneration and atrophy with depletion of the secretory vesicles. Most reported patients with post-ventilator paresis have received steroids and muscle relaxants; muscle weakness commonly has been brief and attributed to steroids. We believe that this reversible myasthenic syndrome probably represents neurotoxicity due to high doses of steroidal nondepolarizing blocking agents; however, available data are insufficient to resolve this controversy.

A modified wire-guided technique for venous cutdown access.

The use of a guidewire to facilitate the placement of an IV cannula through a cutdown is described. This technique was taught to 24 novice operators (medical students and first-year residents). In a randomized, prospective, crossover study, their performance of this technique in an animal model was compared with the use of the classic cutdown technique. The modified technique was performed 22% (two minutes, 13 seconds) more rapidly, on average, than the classic technique (P less than .05). Other potential advantages of this technique are discussed.

The use of inhaled nebulized atropine for the treatment of malathion poisoning.

Malathion is an organophosphate insecticide that is toxic to humans. Deaths are related to respiratory failure. The traditional treatment has included oxygen, ventilatory support, and intravenous administration of atropine. A case is presented in which a patient with moderate to severe malathion poisoning was also treated with inhaled nebulized atropine with apparently favorable results. The rationale for this approach to therapy is discussed.

Diagnosis of porcine and bovine enteric coronavirus infections using cloned cDNA probes.

Molecular clones representing the first 2,000 bases from the 3' end of the porcine transmissible gastroenteritis coronavirus genome and the first 2,160 bases from the 3' end of the bovine enteric coronavirus genome were used in dot blot hybridization assays to detect viral RNA from cell culture and from fecal specimens. In each case, the cloned DNA represents approximately 10% of the genome. The cloned sequence for each virus encompasses the 3' noncoding region, the nucleocapsid protein gene, and a large portion of the matrix protein gene. 32P-labeled cDNA probes prepared from these clones detected as little as 25 pg of RNA from the parental virus but did not detect RNA from the nonparental virus even when amounts of up to 10 ng per dot were used. This specificity reflects the antigenic diversity between these two coronaviruses. The hybridization assay could also detect coronaviruses antigenically closely related to the parental virus but not coronaviruses belonging to an antigenically unrelated subgroup. Dot blot hybridization for transmissible gastroenteritis coronavirus diagnosis was compared with the routine procedures of virus isolation and electron microscopy as a diagnostic test.