Rare atypical presentation of a polymicrobial gastropericardial fistula

We present the unique case of a gastropericardial fistula with a rare, delayed presentation in a man in his 70s. Relevant surgeries include Watchman Left Atrial Appendage Closure device placement 1 year prior to arrival and gastric bypass surgery 20 years prior to arrival. The patient presented to the emergency department with weakness, diarrhoea and left knee pain. He was admitted for cellulitis of the left lower extremity, prosthetic septic arthritis of the left knee and group G streptococcus bacteraemia. His hospital course was complicated by acute chest pain and dyspnoea. Imaging revealed pneumopericardium. Oesophagogastroduodenoscopy visualisation confirmed the diagnosis of gastropericardial fistula. The patient could not be transferred to a tertiary centre for definitive management because of the effect of the COVID-19 pandemic on tertiary hospital volumes. After pericardial drainage and administration of antimicrobials without improvement, the patient was discharged to hospice care at his request and died 1 day after discharge.

Comparison of Isogenic Strains Shows No Evidence of Altered Nosocomial Transmission-Competency of Rough, GPL-Negative Mycobacterium abscessus Strains

Mycobacterium abscessus is an emerging pathogen causing severe pulmonary infections. While environmental in origin, in the clinical setting M. abscessus often changes to a Rough phenotype associated with severe non-remitting infections. Clinical isolates baring mutations in glycopeptidolipid-synthesis genes, leading to the Rough phenotype, were suggested to have increase bacterial virulence while possibly showing reduced transmissibility on fomites. We set to determine whether an isolated glycopeptidolipid (GPL) defect affects transmissibility. We used transposon technology to create a fully isogenic Rough (GPL-defective) (Tn_4099c) and compare it to the isogenic parent strain (ATCC 19977). Survival on fomites was determined by spotting, drying, and retrieving the isolates at designated time points. This was repeated as a competition experiment using a mixture of differentially fluorescent M. abscessus 19977 (Smooth) and the Tn_4099c mutant (Rough). Survival ability in chlorhexidine solution (Septal Scrub Teva) was performed using a disinfectant killing-assay for mycobacteria. Despite significant bacterial killing in all assays, we found no survival advantage to either GPL-defected Rough or GPL-reserved Smooth morphotype-both on fomites and in chlorhexidine. Our findings suggest that while transmission fitness may be altered due to some within-host evolutionary changes, decreased transmissibility of clinical strains cannot be attributed to the GPL-synthesis defect alone. Further studies are needed to determine the effect of other mutations on the transmission potential of M. abscessus in the clinical setting. IMPORTANCE Mycobacterium abscessus is an emerging pathogen causing severe pulmonary infections. In the clinical setting, M. abscsssus undergoes molecular and genetic changes associated with increased virulence. Specifically, bacterial defects in glycopeptidolipid (GPL) synthesis, creating the "Rough" colony phenotype, have been associated with increased virulence, yet were also presumably observed to have decreased survival on fomites, leading to reduced transmissibility. We set to determine whether GPL-synthesis defects are indeed responsible for reduced transmissibility of clinical isolates. We compared fully isogenic GPL-disrupted versus GPL-preserved strains, and demonstrated no survival advantage for either strain on fomites. Additionally, neither isolate had a survival advantage in chlorhexidine, a widely used disinfectant in health care settings. Our findings suggest that reduced transmissibility of clinical isolates, should it be found, cannot be attributed to GPL-synthesis mutations. While clinical isolates may show changes in transmission potential, more studies are needed to investigate the mechanisms leading to these phenotypic changes.

Chronic Carpometacarpal Dislocation of the Thumb: A Case Report and Review of the Literature

CASE

We report a case of a chronic, irreducible carpometacarpal (CMC) dislocation of the thumb, which was managed with a trapeziometacarpal arthrodesis.

CONCLUSION

This case demonstrates that arthrodesis is a suitable salvage procedure for chronic, irreducible CMC dislocations of the thumb.

Investigations regarding the wet decontamination of fluorescent lamp waste using iodine in potassium iodide solutions

With the rising popularity of fluorescent lighting, simple and efficient methods for the decontamination of discarded lamps are needed. Due to their mercury content end-of-life fluorescent lamps are classified as hazardous waste, requiring special treatment for disposal. A simple wet-based decontamination process is required, especially for streams where thermal desorption, a commonly used but energy demanding method, cannot be applied. In this study the potential of a wet-based process using iodine in potassium iodide solution was studied for the recovery of mercury from fluorescent lamp waste. The influence of the leaching agent's concentration and solid/liquid ratio on the decontamination efficiency was investigated. The leaching behaviour of mercury was studied over time, as well as its recovery from the obtained leachates by means of anion exchange, reduction, and solvent extraction. Dissolution of more than 90% of the contained mercury was achieved using 0.025/0.05 M I2/KI solution at 21 °C for two hours. The efficiency of the process increased with an increase in leachant concentration. 97.3 ± 0.6% of the mercury contained was dissolved at 21 °C, in two hours, using a 0.25/0.5M I2/KI solution and a solid to liquid ratio of 10% w/v. Iodine and mercury can be efficiently removed from the leachates using Dowex 1X8 anion exchange resin or reducing agents such as sodium hydrosulphite, allowing the disposal of the obtained solution as non-hazardous industrial wastewater. The extractant CyMe4BTBP showed good removal of mercury, with an extraction efficiency of 97.5 ± 0.7% being achieved in a single stage. Better removal of mercury was achieved in a single stage using the extractants Cyanex 302 and Cyanex 923 in kerosene, respectively.

Treatment of an open medial tibiotalar dislocation with no associated fracture

Tibiotalar dislocations without associated fractures are very uncommon in adults, and only a few studies have been published regarding this injury. More than 50% of these dislocations will be posteromedial, with a high incidence of open injuries, and 25% are pure posterior dislocations. In the present report, we discuss our experience and management of a medial tibiotalar dislocation with no associated fracture. In the present case, the patient was brought to the operating room on presentation to our facility and underwent irrigation and debridement with primary closure of his wound. He was immobilized postoperatively. The patient tolerated the operation well and did not sustain any postoperative complications. He was able to regain function of the injured extremity until he was lost to follow-up. Regarding treatment, the surgery should be speedy, gentle to the soft tissue, and with as little implanted material as possible. Although we do not advocate that our management and treatment of this injury become the standard, the present case provides a good example of some of the challenges often encountered when treating these injuries.

Radon capture with silver exchanged zeolites

To enable laboratory work with larger amounts of 226Ra and its decay products, e.g., 222Rn and its daughters, these need to be captured in order to avoid unnecessary alpha contamination of the laboratory work space and ventilation systems.

In this study, radon gas was pumped through a column filled with the silver exchanged zeolite called “silver exchanged molecular sieves 13X” (Ag84Na2[(AlO2)86(SiO2)106]·xH2O). After exposure to radon, the radioactivity of the zeolite was measured repeatedly using high resolution gamma spectrometry. It was shown that radon was captured and retained in the silver exchanged zeolite. The zeolites´ ability to retain radon was decreased by formation of metallic silver, caused by ionizing radiation. However, the zeolite was regenerated by heating and its radon capture ability was restored. The daughters of radon are not in gas phase and will hence stay on the column.

Self-organizing hierarchies in sensor and communication networks

We consider a hierarchical multicellular sensing and communication network, embedded in an ageless aerospace vehicle that is expected to detect and react to multiple impacts and damage over a wide range of impact energies. In particular, we investigate self-organization of impact boundaries enclosing critically damaged areas, and impact networks connecting remote cells that have detected noncritical impacts. Each level of the hierarchy is shown to have distinct higher-order emergent properties, desirable in self-monitoring and self-repairing vehicles. In addition, cells and communication messages are shown to need memory (hysteresis) in order to retain desirable emergent behavior within and between various hierarchical levels. Spatiotemporal robustness of self-organizing hierarchies is quantitatively measured with graph-theoretic and information-theoretic techniques, such as the Shannon entropy. This allows us to clearly identify phase transitions separating chaotic dynamics from ordered and robust patterns.

Neotrofin increases heme oxygenase-1 selectively in neurons

There is evidence that heme oxygenase plays a role in cellular defense against reactive oxygen species and thereby has neuroprotective effects. We examined the interaction of Neotrofin, a cognitive-enhancing and neuroprotective drug, with the heme oxygenase system. In adult rats, both a single administration or seven daily injections of Neotrofin at 10, 30 or 100 mg/kg intraperitoneally increased HO-1 immunoreactivity in neurons of the hippocampal formation and its connections including CA1-4, fornix, septal nuclei, hippocampal commissure, septohippocampal nucleus, fimbria, anteroventral thalamic nucleus, frontal and parietal cortex. Prominent HO-1 staining of neuronal cells in the proximity of blood vessels and circumventricular organs was also observed. Increasing doses of Neotrofin resulted in an increase in the number of neuronal populations expressing HO-1 with 100 mg/kg evoking a widespread neuronal cell response in brain. Quantification by ELISA confirmed that intraperitoneal administration of 100 mg/kg Neotrofin caused a significant increase in HO-1 protein expression in the hippocampus. The increase was evident by 6 h post-injection, peaked at 24 h with a 4-fold increase, and persisted for at least 48 h. Similarly, oral administration of 100 mg/kg Neotrofin produced a 5-fold increase in HO-1 protein 24 h post-administration. The effect of Neotrofin on HO-1 appears to be at the transcriptional level, as suggested by an increase in HO-1 mRNA levels. Neotrofin treatment was also associated with a significant increase in HO-2 mRNA levels in whole brain homogenate. These data may explain the neuroprotective effects of Neotrofin in models of excitotoxic neuronal injury.

Hepatitis B-related polyarteritis nodosa complicated by pulmonary hemorrhage

A 34-year-old man presented with fever, weight loss, paresthesia, abdominal pain, and hypertension. He had hepatitis B antigenemia, with negative antineutrophil cytoplasmic antibody, antinuclear antibody, and antiglomerular basement membrane serology results. Renal arteriography showed multiple intrarenal microaneurysms. In spite of therapy with antiviral agents (lamivudine, famciclovir), prednisone, cyclophosphamide, and plasmapheresis, renal function deteriorated. He later developed rapidly progressive dyspnea and hemoptysis. Diffuse alveolar hemorrhage was confirmed by bronchoscopy. He died of respiratory failure. The cause of pulmonary hemorrhage in this case of polyarteritis nodosa is unclear, but may include underlying capillaritis, cocaine-induced pulmonary hemorrhage, or recurrent attacks of malignant hypertension.

Consequences of not recognizing delirium superimposed on dementia in hospitalized elderly individuals

OBJECTIVE

The purpose of this study was to describe the recognition and management of delirium in hospitalized patients with and without dementia.

DESIGN

A descriptive, exploratory design was used with a convenience sample of 20 hospitalized older patients who were observed indepth using qualitative interviews and observations of 13 family members and 11 staff members.

SETTING

This research was conducted on the medical-surgical units of a 550-bed, nonprofit, state-supported teaching hospital in the southeastern United States. The facility provides primary and tertiary care with five intensive care units and eight medical-surgical units.

PARTICIPANTS

This study did not exclude individuals with dementia or pre-existing delirium. Subjects were not excluded on the basis of race or gender. Twenty patients in the sample underwent observation and mental and functional status testing. Thirteen family members and 11 staff members were interviewed and observed.

MEASUREMENTS

In Phase 1 of the study, patients had daily mental status testing performed by the investigator. In Phase 2, family members and staff members were interviewed about the confusion event. For each patient, demographics and information regarding their health status and current diagnosis and treatment were obtained. The Mini-Mental State Examination (MMSE) and the Confusion Assessment Method were completed on each subject within 36 hours of being admitted to the hospital. The Cornell Depression Scale and Katz Activities of Daily Living scale were completed within 48 hours of admission.

RESULTS

The prevalence of delirium in this study was 60%. The incidence, or new onset of delirium, was 30%. The presence of delirium was associated with new onset incontinence, lower baseline MMSE scores, depression, weight loss, and comorbidity. Of the eight individuals with delirium superimposed on dementia, 63% (n = 5) were re-admitted to the hospital within 30 days, compared to none of the individuals with delirium in the absence of dementia. Delirium superimposed on dementia also was less likely to be recognized by nurses and physicians.

CONCLUSIONS

Delirium in individuals with dementia should be assessed and treated routinely because the failure to recognize delirium superimposed on dementia promptly has significant negative personal, social and financial consequences.

Induction of alpha1-tubulin gene expression during development and regeneration of the fish central nervous system

The alpha1- and alpha2-tubulin encoding genes were cloned from a goldfish genomic DNA library. alpha1- and alpha2-tubulin RNA expression was examined in developing and adult retinas. These studies demonstrated increased alpha1-tubulin RNA in presumptive ganglion cells that grow axons early in retinal development and in adult retinal ganglion cells whose optic axons had been damaged. The alpha2-tubulin RNA was undetectable in developing retina and constitutively expressed in adult retinal ganglion cells regardless of optic nerve crush. To determine if these changes in alpha1-tubulin RNA reflected changes in alpha1-tubulin promoter activity, we introduced into zebrafish embryos and adult goldfish retinal explants expression vectors harboring the alpha1-tubulin gene's promoter. These studies showed that the alpha1-tubulin promoter confers a developmentally regulated, neuron-restricted pattern of reporter gene expression in vivo and its activity is increased in adult retinal neurons induced to regenerate their axons. Promoter deletions defined regions of alpha1-tubulin DNA necessary for this pattern of expression. These results suggest that DNA sequences necessary for alpha1-tubulin gene induction during central nervous system development and regeneration are contained within the alpha1-tubulin gene's 5'-flanking DNA and that this promoter will be useful for identifying these elements and their DNA binding proteins.

Extracorporeal whole body hyperthermia treatment of HIV patients, a feasibility study

The literature supports that the retrovirus, Human Immunodeficiency Virus (HIV), which is thought to cause Acquired Immunodeficiency Syndrome (AIDS), is heat sensitive at temperatures which can be achieved in man. Invasive or non-invasive induction of whole body hyperthermia (WBH) has been used to treat an array of illnesses, primarily in the field of oncology, until recently. Non-invasive methods have proven to be less toxic than invasive means. However, new technology and refined patient management have shown a dramatic decrease in the side effects with extracorporeal whole body hyperthermia (EWBH). The Food and Drug Administration granted a prospective trial for six HIV positive/AIDS patients to undergo a single treatment of EWBH, with patients randomized to a core temperature of either 41 or 42 degrees C. All patients had failed antiretrovirals and experienced at least one episode of an opportunistic infection. Organetics, Ltd., PS-1 extracorporeal, centrifugal pump device was used to induce EWBH. Results of this feasibility study demonstrated the ability of this equipment and technique to induce EWBH with acceptable toxicity. It was not possible to assess efficacy in this small study.

Are men taking over the nursing profession?

Although men are a minority in the nursing profession, many men obtain senior positions and hence their motivation for becoming registered nurses is often questioned. International nursing literature is used to clarify why men may want to become nurses and to suggest possible reasons for the gender inequities in senior nursing appointments.

Satisfaction of nurse managers in long-term care

Nurse managers control quality and cost of the principal service provided by long-term care agencies. Job satisfaction was higher for long-term care nurse managers in metropolitan than in rural or suburban agencies. Findings suggest that continuing education may increase task satisfaction, as well as job knowledge of diploma-prepared nurse managers.

Detecting delirium among hospitalized older patients

BACKGROUND

Delirium occurs commonly among older hospitalized patients and is frequently not recognized. In an effort to identify tools useful to clinicians in the diagnosis of delirium, test characteristics of four screening instruments were compared.

METHODS

Patients 65 years of age or older who were admitted to one of four medical and surgical wards of a university teaching hospital were followed up prospectively. Potential subjects were excluded if unavailable for interviews or discharged within 48 hours of admission, or if judged too impaired to participate in the daily interviews. Research assistants administered four instruments used to detect delirium: Digit Span Test, Vigilance 'A' Test, Clinical Assessment of Confusion, and Confusion Assessment Method. Abnormal scores on these tests or suspicion of acute confusion prompted a referral to the clinician-investigators who then assessed the patient daily for delirium based on the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria.

RESULTS

Delirium occurred in 64 (14.8%) of 432 subjects. The positive likelihood ratios for all of the instruments were significantly more than 1. The instruments remained useful when applied to selected subgroups: subjects in whom acute mental status changes were documented, subjects on surgical services, and subjects with impaired cognitive status on admission. Combinations of any two instruments did not perform substantially better than the instrument with the best test characteristics: the Clinical Assessment of Confusion. All instruments were more useful at confirming delirium than in excluding it.

CONCLUSION

The four instruments studied, which are suitable for use at the bedside, can aid the clinician in identifying patients likely to be suffering from delirium.

Delirium in hospitalized older persons: outcomes and predictors

OBJECTIVE

The purpose of this study was fourfold; to determine the rate of delirium among hospitalized older persons, to contrast the clinical outcomes of patients with and without delirium, to identify clinical predictors of delirium, and to validate the predictive model in an independent sample of patients.

DESIGN

Two prospective cohort studies

SETTING

Medical and surgical wards of 2 university teaching hospitals.

PATIENTS

In the derivation cohort, 432 patients were enrolled from the University of Chicago Hospitals. Patients 65 years of age or older admitted to 1 of 4 wards were eligible. Subjects were excluded if they were discharged within 48 hours of admission, unavailable to the research assistants during the first 2 days of hospitalization, or judged too impaired to participate in the daily interviews. In the test cohort, 323 patients 70 years of age or older admitted to Yale-New Haven Hospital were studied.

MEASUREMENTS

Subjects were screened for delirium daily and referred to experienced clinician investigators if acute mental status changes were observed. The clinician investigators assessed the patient for delirium based on DSM-III-R criteria. Duration of hospitalization was adjusted for diagnosis-related groups (DRG) and mortality rates were determined at discharge and 90 days after discharge. Sociodemographic characteristics, cognitive and functional status, comorbidity, depression, and alcoholism were examined as predictors of delirium.

MAIN RESULTS

The rate of delirium in the derivation cohort was 15%; subjects with delirium had longer hospital stays and an increased risk of in-hospital death. Cognitive impairment, burden of comorbidity, depression, and alcoholism were found to be independent predictors of delirium. The ability of the model to stratify patients as low, moderate, or high risk for developing delirium was validated in the test cohort in which the rate of delirium was 26%.

CONCLUSIONS

This study confirms the high rate of delirium among hospitalized older persons and the associated adverse outcomes of prolonged hospital stays and increased risk of death. Patients can be stratified according to their risk for developing delirium using relatively few clinical characteristics which should be assessed, on all hospitalized older persons.

Intermittent back pain after central venous catheter placement

We report a case of inadvertent azygos placement of a central venous catheter. The patient experienced ill-defined back pain associated with total parenteral nutrition infusion. The catheter malposition remained unrecognized and resulted in extensive diagnostic work-up. Symptoms resolved after the catheter was withdrawn.

Banach-Tarski paradox using pieces with the property of Baire

In 1924 Banach and Tarski, using ideas of Hausdorff, proved that there is a partition of the unit sphere S2 into sets A1,...,Ak,B1,..., Bl and a collection of isometries [sigma1,..., sigmak, rho1,..., rhol] so that [sigma1A1,..., sigmakAk] and [rho1B1,..., rholBl] both are partitions of S2. The sets in these partitions are constructed by using the axiom of choice and cannot all be Lebesgue measurable. In this note we solve a problem of Marczewski from 1930 by showing that there is a partition of S2 into sets A1,..., Ak, B1,..., Bl with a different strong regularity property, the Property of Baire. We also prove a version of the Banach-Tarski paradox that involves only open sets and does not use the axiom of choice.

Strategy for detection and differentiation of Coxiella burnetii strains using the polymerase chain reaction

A method for the rapid detection of Coxiella burnetii and differentiation between strains that cause endocarditis and those that cause acute Q fever is based on the observation that the different strains contain unique plasmid sequences. This method employs the polymerase chain reaction (PCR) and requires knowledge of specific DNA sequences in the region (target) of DNA to be amplified. To detect and differentiate between C. burnetii isolates, two sets of primers are required. The first set was derived from a fragment of plasmid QpH1 which has been detected in all C. burnetii isolates. A second PCR reaction was conducted using primers specific for DNA sequences that are shared only by QpRS plasmid-containing strains of C. burnetii. The first reaction detects the presence of C. burnetii. The second PCR is necessary to determine whether the isolate contains DNA sequences associated with strains causing chronic disease. These procedures detect as few as one to ten organisms.

Sonographic characterization of carotid plaque: detection of hemorrhage

By careful evaluation of the sonographic characteristics of carotid plaques, two patterns can be identified: a homogeneous pattern containing uniform echoes corresponding to dense fibrous tissue and a heterogeneous pattern containing mixed echoes and anechoic areas that represent intraplaque hemorrhage pathologically. A prospective study was conducted of 50 patients to determine the accuracy of identifying these different forms of plaque. The patients' carotid arteries were examined by a high-resolution duplex scanner before carotid endarterectomy. The plaques were evaluated carefully by vascular surgeons and pathologists for the presence of intraplaque hemorrhage. In this study, the accuracy of identifying the presence or absence of intraplaque hemorrhage with sonography was 90% (48 of 54); sensitivity, 94% (17 of 18); and specificity, 88% (27 of 31). High-resolution sonography appears to be an accurate means of identifying intraplaque hemorrhage and may ultimately be useful in identifying patients at risk for embolic disease.