Bacteremia due to Pasteurella dagmatis acquired from a dog bite, with a review of systemic infections and challenges in laboratory identification.

A case of bacteremia in a 74-year-old man, which was caused by Pasteurella dagmatis and complicated by thrombocytopenia, is presented. Microorganism identification was performed by the provincial reference laboratory using traditional biochemical profiling, completmented with both the sequencing of the 16S ribosomal RNA gene and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry; antibiotic-susceptibility testing was also performed. After treatment with the appropriate antibiotics, the patient fully recovered. Systemic infections attributed to this organism are rarely reported in the literature. Other reported cases of bacteremia due to P dagmatis are reviewed and compared with the present case. The challenges of relying on standard automatic identification are discussed, with alternative methodologies provided.

Les auteurs présentent un cas de bactériémie chez un homme de 74 ans, causé par un Pasteurella dagmatis et compliqué par une thrombocytopénie. Le laboratoire de référence provincial a identifié le microorganisme au moyen du profilage biochimique classique et l'a complété par le séquençage du gène de l'ARN ribosomique 16S et par la spectrométrie de masse à temps de vol par désorption-ionisation laser assistée par matrice. Le laboratoire a également effectué un test de susceptibilité aux antibiotiques. Après un traitement antibiotique pertinent, le patient s'est complètement rétabli. Les publications scientifiques contiennent peu de déclarations d'infections systémiques attribuées à cet organisme. D'autres cas de bactériémie à P dagmatis sont analysés et comparés à la présente situation. Les problèmes liés à l'identification automatique standard sont exposés et d'autres méthodologies sont proposées.

Hepatitis B virus screening before chemotherapy for lymphoma: a cost-effectiveness analysis.

PURPOSE: Hepatitis B virus (HBV) reactivation is a potentially fatal complication of chemotherapy that can be largely prevented with antiviral prophylaxis. It remains unclear whether HBV screening is cost effective. METHODS: A decision model was developed to compare the clinical outcomes, costs, and cost effectiveness of three HBV screening strategies for patients with lymphoma before R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy: screen all patients for hepatitis B surface antigen (HBsAg; Screen-All), screen patients identified as being at high risk for HBV infection (Screen-HR), and screen no one (Screen-None). Patients testing positive were administered antiviral therapy until 6 months after completion of chemotherapy. Those not screened were initiated on antiviral therapy only if HBV hepatitis occurred. Probabilities of HBV and lymphoma outcomes were derived from systematic literature review. A third-party payer perspective was adopted, costs were expressed in 2011 Canadian dollars, and a 1-year time horizon was used. RESULTS: Screen-All was the dominant strategy. It was least costly at $32,589, compared with $32,598 for Screen-HR and $32,657 for Screen-None. It was also associated with the highest 1-year survival rate at 84.99%, compared with 84.96% for Screen-HR and 84.86% for Screen-None. The analysis was sensitive to the prevalence of HBsAg positivity in the low-risk population, with Screen-HR becoming least costly when this value was ≤ 0.20%. CONCLUSION: In patients receiving R-CHOP for lymphoma, screening all patients for HBV reduces the rate of HBV reactivation (10-fold) and is less costly than screening only high-risk patients or screening no patients.

Does familiarity with technology predict successful use of an external loop recorder? The loop recorder technology cognition study (LOCO).

BACKGROUND: The diagnosis of presyncope, syncope, and palpitations is facilitated by successful documentation of the cardiac rhythm during symptoms. We prospectively assessed technological familiarity using a Technology Cognition Questionnaire to determine influence on proper and effective use of an external loop recorder (ELR). METHODS: Patients with palpitations, presyncope, or syncope were assessed for familiarity with technology and provided an ELR for a period of 6 weeks. Proper use of the device was demonstrated to the patient and test transmissions were sent by analog telephone line on a weekly basis. Patients were instructed to activate the device to record cardiac rhythm when symptoms recurred, and to send these recordings via telephone transmission. RESULTS: Ninety-two patients were prospectively enrolled, with mean age 54.9 +/- 20.9 and 42 males (46%). Sixty-five patients (71%) had recurrence of symptoms during the 6-week monitoring period. Among these patients, 40 (62%) were successful in recording and transmitting data such that a diagnosis was made at a median of 8 days (IQR 12.5, range 0-30). Among patients with symptoms during the monitoring period, 36 (55%) had at least one failed recording or transmission. On multivariate analysis, failed symptom recording/transmission was less likely among patients able to program a home video recorder (odds ratio [OR] 0.25 [0.07-0.93]), and more likely among patients who failed a test transmission (OR 3.45 [1.04-11.7]). No variables were independently associated with successful diagnosis. CONCLUSIONS: Familiarity with technology correlates with successful use of the ELR, but does not necessarily correlate with the ability to reach a diagnosis.

Venous thromboembolism in patients undergoing surgery: low rates of prophylaxis and high rates of filter insertion.

Patients who undergo surgery are at a high risk of developing venous thromboembolism (VTE). To further define the demographics, comorbidities, and risk factors of VTE in patients undergoing major surgery, we analyzed 1,375 hospitalized non-orthopedic surgery patients in a prospective registry of 5,451 patients with ultrasound confirmed deep vein thrombosis (DVT) from 183 hospitals in the United States. Extremity edema (67.9%), extremity discomfort (44.9%), and dyspnea (18.9%) were among the most common presenting symptoms among these surgical patients. Compared to medical patients, surgical patients presented with a more occult clinical picture and complained less often of extremity edema (67.9% vs. 73.7%; p = 0.0001), extremity discomfort (44.9% vs. 56.4%; p < 0.0001), or difficulty walking (6.6% vs. 11.2%; p < 0.0001). Immobility within 30 days of DVT diagnosis, prior hospitalization within 30 days of DVT diagnosis, presence of an indwelling central venous catheter, obesity (BMI>30 kg/m2), and previous smoking were the most commonVTE risk factors among surgical patients. Among surgical patients who developed DVT, some form of prophylaxis had been used in only 44%. Once diagnosed with DVT, surgical patients received IVC filters more often than medical patients (20.0% vs. 14.1%; p < 0.0001; adjusted OR = 1.49, 95% CI = 1.17-1.92; p < 0.001). In conclusion, VTE prophylaxis remains underutilized in surgical patients. The IVC filter utilization rate in surgical patients is significantly higher than in medical patients. Future studies should focus on devising mechanisms to improve implementation of prophylaxis and investigate the long-term safety and efficacy of IVC filters in surgical patients.

Tumor necrosis factor-alpha mediates cardiac remodeling and ventricular dysfunction after pressure overload state.

BACKGROUND: Pressure overload is accompanied by cardiac myocyte apoptosis, hypertrophy, and inflammatory/fibrogenic responses that lead to ventricular remodeling and heart failure. Despite incomplete understanding of how this process is regulated, the upregulation of tumor necrosis factor (TNF)-alpha after aortic banding in the myocardium is known. In the present study, we tested our hypothesis that TNF-alpha regulates the cardiac inflammatory response, extracellular matrix homeostasis, and ventricular hypertrophy in response to mechanical overload and contributes to ventricular dysfunction. METHODS AND RESULTS: C57/BL wild-type mice and TNF-knockout (TNF-/-) mice underwent descending aortic banding or sham operation. Compared with sham-operated mice, wild-type mice with aortic banding showed a significant increase in cardiac TNF-alpha levels, which coincided with myocyte apoptosis, inflammatory response, and cardiac hypertrophy in week 2 and a significant elevation in matrix metalloproteinase-9 activity and impaired cardiac function in weeks 2 and 6. Compared with wild-type mice with aortic banding, TNF-/- mice with aortic banding showed attenuated cardiac apoptosis, hypertrophy, inflammatory response, and reparative fibrosis. These mice also showed reduced cardiac matrix metalloproteinase-9 activity and improved cardiac function. CONCLUSIONS: Findings from the present study have suggested that TNF-alpha contributes to adverse left ventricular remodeling during pressure overload through regulation of cardiac repair and remodeling, leading to ventricular dysfunction.