Faculty Bibliography

BACKGROUND: Failures of communication during the transfer of patient care errors. METHODS: We created a new format for written sign-out material, based on aviation industry practice and cognitive psychology theory, designed to improve interns' and senior medical students' communication during transfers of patient care responsibility. We carried out a randomized, blinded, crossover trial, comparing a new, narrative, written sign-out report to a usual written sign-out. Thirty-two interns and fourth-year medical students rated their confidence across various clinical tasks and answered clinical questions regarding hypothetical patients presented to them in written, new, narrative sign-out compared with the customary format. RESULTS: There was no statistical difference in confidence when interns and senior medical students received usual versus narrative sign-outs. CONCLUSIONS: Although a limited measure suggested some improvement in competence, the narrative format did not improve participants' self-rated confidence during patient-care transfer.

We have reported results from the formative stage of a community health worker intervention designed to improve diabetes management among Bangladeshi patients in New York City. Trained community health workers conducted focus groups (n = 47) and surveys (n = 169) with Bangladeshi individuals recruited from community locations. Results indicated that participants faced numerous barriers to care, had high rates of limited English proficiency, and had low levels of knowledge about diabetes. Most participants expressed interest in participating in a community health worker intervention.

We describe a novel Tn4401 variant (Tn4401d) in epidemic Klebsiella pneumoniae clone ST258, from which a partial bla(KPC) fragment has been excised along with ISKpn7 and a partial tnpA fragment. Nested-PCR experiments confirmed that this region can be removed from distinct Tn4401 isoforms in both K. pneumoniae and Escherichia coli. This study highlights that the region surrounding bla(KPC) is undergoing recombination and that Tn4401 itself is heterogeneous and highly plastic.

A total of 299 nares and 194 blood isolates of methicillin-resistant Staphylococcus aureus (MRSA), each recovered from a unique patient, were collected from 23 U.S. hospitals from May 2009 to March 2010. All isolates underwent spa and staphylococcal cassette chromosome mec element (SCCmec) typing and antimicrobial susceptibility testing; a subset of 84 isolates was typed by pulsed-field gel electrophoresis (PFGE) using SmaI. Seventy-six spa types were observed among the isolates. Overall, for nasal isolates, spa type t002-SCCmec type II (USA100) was the most common strain type (37% of isolates), while among blood isolates, spa type t008-SCCmec type IV (USA300) was the most common (39%). However, the proportion of all USA100 and USA300 isolates varied by United States census region. Nasal isolates were more resistant to tobramycin and clindamycin than blood isolates (55.9% and 48.8% of isolates versus 36.6% and 39.7%, respectively; for both, P < 0.05). The USA300 isolates were largely resistant to fluoroquinolones. High-level mupirocin resistance was low among all spa types (<5%). SCCmec types III and VIII, which are rare in the United States, were observed along with several unusual PFGE types, including CMRSA9, EMRSA15, and the PFGE profile associated with sequence type 239 (ST239) isolates. Typing data from this convenience sample suggest that in U.S. hospitalized patients, USA100 isolates of multiple spa types, while still common in the nares, have been replaced by USA300 isolates as the predominant MRSA strain type in positive blood cultures.

Staphylococcus aureus infections are a significant cause of morbidity and mortality in health care settings. S. aureus clinical isolates vary in the function of the accessory gene regulator (agr), which governs the expression of virulence determinants, including surface and exoproteins, while agr activity has been correlated with patient outcome and treatment efficiency. Here we describe a duplex real-time nucleic acid sequence-based amplification (NASBA) detection and quantification platform for rapid determination of agr functionality in clinical isolates. Using the effector of agr response, RNAIII, as the assay target, and expression of the gyrase gene (gyrB) as a normalizer, we were able to accurately discriminate agr functionality in a single reaction. Time to positivity (TTP) ratios between gyrB and RNAIII showed very good correlation with the ratios of RNAIII versus gyrB RNA standard inputs and were therefore used as a simple readout to evaluate agr functionality. We validated the assay by characterizing 106 clinical S. aureus isolates, including strains with genetically characterized agr mutations. All isolates with dysfunctional agr activity exhibited a TTP ratio (TTP(gyrB)/TTP(RNAIII)) lower than 1.10, whereas agr-positive isolates had a TTP ratio higher than this value. The results showed that the assay was capable of determining target RNA ratios over 8 logs (10(-3) to 10(4)) with high sensitivity and specificity, suggesting the duplex NASBA assay may be useful for rapid determination of agr phenotypes and virulence potential in S. aureus clinical isolates.

Case Presentation: A 65-year-old female with metastatic breast cancer, glioblastoma multiforme, bilateral pulmonary emboli diagnosed 4 days prior to admission started on enoxaparin, presented with syncope. On the day of admission the patient collapsed on the street suddenly without any prodrome. She reported abdominal pain for the prior 2-3 days, no other new symptoms, and no change in her baseline fatigue. On presentation to the emergency department (Figure presented) she was afebrile with a blood pressure of 105/72, and a heart rate of 92. Her physical exam was notable for conjunctival pallor and a firm, very tender 6 centimeter mass right of the midline slightly inferior to the umbilicus. Fothergill's sign was present. Her hemoglobin was 5.7 gm/dl (it was 12 gm/dl 4 days prior to admission). On CT scan of the abdomen and pelvis a large rectus sheath hematoma (RSH) was found that extended into the preperitoneal space inferiorly, as well as into the pelvis. The patient was transfused, enoxaparin was stopped and she had a retrievable inferior vena cava (IVC) filter placed. Upon further questioning, the patient reported that she had been injecting herself with enoxaparin intramuscularly rather than subcutaneously. Discussion: RSH is an uncommon cause of abdominal pain and is usually not associated with hemodynamically significant hemorhage. It is caused by rupture of the epigastric arteries or trauma to smaller vessels in the rectus muscle often due to vigorous contraction of the abdominal wall muscles from coughing, retching or straining from constipation. In this case, repeated direct intramuscular trauma from needles as well as the effect of the enoxaparin caused the hematoma. Mortality is reported at 4% for RSH but increases to 25% when anticoagulation plays a role. The patient presented with Fothergill's sign which is a painful abdominal mass that does not cross the midline and remains palpable with rectus muscle contraction thus differentiating it from an intra-abdominal mass. In light of her short term contraindication to receiving anticoagulation, an IVC filter was placed (supported by ACC/AHA guidelines issued in April 2011). The indications for placement of IVC filters are not robustly supported by evidence with only one prospective randomized study and a large populationbased retrospective analysis serving as the basis for recommendations. Because the RSH was caused by incorrect injection of enoxaparin, I recommended attempting to reinitiate anticoagulation in a monitored setting and if tolerated, removal of the retrievable IVC filter. The patient remained hemodynamically stable with an unfluctuating hemoglobin level and was transferred to the hospital where she was receiving her oncological treatment. Conclusions: RSH is often associated with the use of anticoagulation and on occasion can cause significant hemorrhage. IVC filters have a role in protecting patients with known proximal deep venous thrombosis or pulmonary embolism who have a contraindication against the use of anticoagulation

In the United States, the decision of whether to withdraw or continue to provide artificial nutrition and hydration (ANH) for patients in a permanent vegetative state (PVS) is placed largely in the hands of surrogate decision-makers, such as spouses and immediate family members. This practice would seem to be consistent with a strong national emphasis on autonomy and patient-centered healthcare. When there is ambiguity as to the patient's advanced wishes, the presumption has been that decisions should weigh in favor of maintaining life, and therefore, that it is the withdrawal rather than the continuation of ANH that requires particular justification. I will argue that this default position should be reversed. Instead, I will argue that the burden of justification lies with those who would continue artificial nutrition and hydration (ANH), and in the absence of knowledge as to the patient's advanced wishes, it is better to discontinue ANH. In particular, I will argue that among patients in PVS, there is not a compelling interest in being kept alive; that in general, we commit a worse violation of autonomy by continuing ANH when the patient's wishes are unknown; and that more likely than not, the maintenance of ANH as a bridge to a theoretical future time of recovery goes against the best interests of the patient.

Qnexa combines two drugs associated with weight loss: the appetite-suppressant phentermine and the anti-seizure drug topiramate, which appears to alter hunger hormones, decrease appetite, and adjust glucose and insulin concentrations.

BACKGROUND: Detection of lipoarabinomannan (LAM), a Mycobacterium tuberculosis (Mtb) cell wall antigen, is a potentially attractive diagnostic. However, the LAM-ELISA assay has demonstrated variable sensitivity in diagnosing TB in diverse clinical populations. We therefore explored pathogen and host factors potentially impacting LAM detection. METHODS: LAM-ELISA assay testing, sputum smear and culture status, HIV status, CD4 cell count, proteinuria and TB outcomes were prospectively determined in adults diagnosed with TB and commencing TB treatment at a South African township TB clinic. Sputum TB isolates were characterised by IS61110-based restriction fragment length polymorphism (RFLP) and urines were tested for mycobacteriuria by Xpert(R) MTB/RIF assay. RESULTS: 32/199 (16.1%) of patients tested LAM-ELISA positive. Median optical density and proportion testing LAM positive remained unchanged during 2 weeks of treatment and then declined over 24 weeks. LAM was associated with positive sputum smear and culture status, HIV infection and low CD4 cell counts but not proteinuria, RFLP strain or TB treatment outcome. The sensitivity of LAM for TB in HIV-infected patients with CD4 counts of >/= 200, 100-199, 50-99, and < 50 cells/mul, was 15.2%, 32%, 42.9%, and 69.2% respectively. Mycobacteriuria was found in 15/32 (46.9%) of LAM positive patients and in none of the LAM negative controls. CONCLUSIONS: Urinary LAM was related to host immune factors, was unrelated to Mtb strain and declined steadily after an initial 2 weeks of TB treatment. The strong association of urine LAM with mycobacteriuria is a new finding, indicating frequent TB involvement of the renal tract in advanced HIV infection.