Faculty Bibliography

CONDENSATION/CONCLUSIONS:Krempasky et al's article on the contraceptive needs of transmasculine individuals overstates pregnancy risk in those maintained on testosterone, creating potential barriers to care.

PURPOSE: This study aimed to determine whether daily dosing of gentamicin using ideal body weight in the treatment of chorioamnionitis is effective. MATERIALS AND METHODS: We conducted a prospective observational study and followed all women receiving treatment for chorioamnionitis which included gentamicin daily dosing calculated using 5 mg/kg ideal body weight. Patients were excluded if pathological analysis of placenta did not confirm chorioamnionitis. Our primary outcome was resolution of infection following delivery without the development of maternal endometritis and/or neonatal sepsis. Ninety-five percent confidence intervals for proportions were calculated using exact binomial tests. These patients were retrospectively compared to patients who received treatment for chorioamnionitis which included traditional gentamicin every 8 h. RESULTS: The study included 160 patients. Of the patients receiving daily dosing (n = 80) compared to traditional dosing (n = 80), 96% (95% CI 95.7-97.6%) achieved the primary outcome versus 91% (88.9-93.1%), 2.5% (95% CI 1.2-3.8%) developed endometritis versus 6.3% (4.2-8.4%), 1.3% (95% CI 0.4-2.2%) delivered neonates with sepsis versus 2.5% (1.2-3.8%), and 39% required cesarean delivery (95% CI 46.2-53.8) versus 37% (33.2-40.8%). CONCLUSION: Daily dosing of gentamicin using ideal body weight is effective in successful treatment of chorioamnionitis without development endometritis and/or neonatal sepsis across different ethnicities.

BACKGROUND:Clinical chorioamnionitis complicates approximately 1-4% of pregnancies overall. Although universal agreement does not exist regarding the antibiotic regimen of choice, most studies have evaluated intravenous ampicillin dosed at 2 g every 6 hours plus gentamicin dosed every 8 hours. Only three studies have examined daily gentamicin for the treatment of intrapartum chorioamnionitis and thus is insufficiently investigated. OBJECTIVE:This study seeks to determine whether daily dosing of gentamicin using ideal body weight for the treatment of intrapartum chorioamnionitis is more or equivalently efficacious when compared to traditional 8-hour dosing regimens. MATERIALS AND METHODS/METHODS:test and exact binomial 95% confidence intervals. We calculated the risk ratios of each outcome in the ideal versus traditional dosing groups using modified Poisson regression, both crude and adjusted. Adjusted models were controlled for variables determined to be potential confounders, which included BMI, diabetes mellitus, gestational blood pressure >140/90, group β-Streptococcus status, race, advanced maternal age (>34 y), and parity. RESULTS:The study included 500 patients with 255 patients receiving daily dosing of gentamicin and 245 receiving traditional dosing of gentamicin. Of the patients receiving daily gentamicin compared to traditional dosing, 95.7% (95% CI 94.9-96.6%) achieved the primary outcome versus 92% (95% CI 90.8 - 93.2%), 2.4% (95% CI 1.8-3%) developed endometritis versus 5.6% (4.5-6.7%), 1.6% (95% CI 1.1-2.1%) delivered neonates with sepsis versus 3.3% (CI 2.5-4.1%), and 36.9% required cesarean delivery versus 41.4%. In crude analysis, compared to traditional dosing, IDW daily dosing was associated with a lower risk of postpartum endometritis (RR 0.42, 95% CI 0.16-1.10, p = .032). After adjusting for BMI, diabetes mellitus, gestational blood pressure >140/90, group β-Streptococcus status, race, advanced maternal age (>34 y), and parity, the IDW daily dosing group had a 5% greater chance of successful outcome (RR 1.05, 95% CI 1.00-1.10, p = .046) and a 64% lower risk of endometritis (RR 0.35, 95% CI 0.15-0.83, p = .017). CONCLUSION/CONCLUSIONS:Daily dosing of gentamicin using ideal body weight is associated with a lower risk of postpartum endometritis and high chance of a successful outcome in the treatment of intrapartum chorioamnionitis compared with traditional 8-hour dosing in our ethnically diverse, urban population and thus may be considered a superior option to every 8 hours dosing regimens.

BACKGROUND: The association between physician-directed goals of care discussions (GOCDs) and the use of aggressive interventions in terminally ill patients has not been well characterized in the literature. We examined the associations between the timing of physician-directed GOCDs in terminally ill patients and the use of aggressive interventions, probability of dying in the inpatient setting, and intensive care unit (ICU) utilization. METHODS: This retrospective cohort study included patients admitted to our urban community hospital in 2015 who had a terminal diagnosis on admission and either died on an inpatient unit or were discharged to hospice. The primary independent variable was the number of days from admission to GOCD, expressed as a proportion of the patient's length of stay (LOS). We used robust variance Poisson and zero-inflated negative binomial regression, as appropriate, to estimate the associations between goals of care timing and risk of having an intervention, risk of dying in the inpatient setting, odds of ICU admission, and ICU LOS. RESULTS: A total of 197 cases were included. After adjusting for age, language, gender, insurance, dementia, and decision maker (patient versus surrogate decision maker), later GOCD was significantly associated with greater risk of having an aggressive intervention (risk ratio [RR] = 1.04, 95% confidence interval [CI] = 1.02-1.06), greater risk of death as an inpatient (RR = 1.04, 95% CI = 1.02-1.06), and greater odds of ICU admission (odds ratio = 1.19, 95% CI = 1.02-1.39). CONCLUSION: Later GOCDs were associated with greater risk of aggressive interventions and death as an inpatient and greater odds of ICU admission. Goals of care discussion should be done routinely and early during the hospitalization of terminally ill patients.

A 32-year-old Chinese woman sought care from our family medicine clinic because she had a headache, neck pain, and an intermittent cough that had produced white sputum for 7 days. She described the headache as severe and pressure-like, and said that it had progressively worsened over the previous 3 weeks, coinciding with her first trip outside of China to the United States. The patient indicated that she also had occasional vomiting, dizziness, a low-grade fever, chills, night sweats, and increasing fatigue.

The fixed-dose combination of Efavirenz/Emtricitabine/Tenofovir is a first-line agent for the treatment of HIV; however few cases have reported hepatotoxicity associated with the drug. We report a case of Efavirenz/Emtricitabine/Tenofovir-associated hepatotoxicity presenting mainly with hepatocellular injury characterized by extremely elevated aminotransferase levels, which resolved without acute liver failure or need for liver transplant referral.

Myocarditis is an uncommon manifestation of dengue fever. We describe a case of a 69-year-old Hispanic male who presented to an emergency room in New York City 3 days after returning from a trip to the Dominican Republic complaining of a 1-day history of chest pain and fever. His first electrocardiogram showed a new left bundle branch block, and initial cardiac enzymes included troponin of 5 ng/dL, creatine kinase-MB of 9 ng/mL, and myoglobin of 234 ng/mL. Dengue fever antibodies were found to be elevated: immunoglobulin M (IgM) titer was 2.48 (reference range < 0.9), and immunoglobulin G (IgG) titer was 4.26 (reference range < 0.9). The patient was diagnosed with myocarditis caused by dengue fever. He improved after 1 week with conservative management in a telemetry unit and was discharged home.