Waste not want not... Ultrasound in AKI

Great editorial here embracing my philosophy.  Ultrasound has a role in patients for whom conservative measures have failed, or in whom there is a significant pre-test probability of obstruction.  A reduction in unneccessary ultrasounds for AKI will free up the ultrasound machine, technologist and radiologist for many other studies which are more clinically urgent.

A rethink to how we manage uncomplicated cellulitis...

See here.

Essentially, in this study of culture negative cellulitis (without abscess), the authors show that Group A streptococcus is responsible for >75% of cases, and based on response to beta-lactams, 95% of cases are probably caused by GAS, GBS, and MSSA meaning that the need for empiric vancomycin in cellulitis is questioned -- even in areas with high MRSA like the USA.

This CID article discusses how physicians often use too broad a spectrum (i.e. gram negative coverage for non-complicated cellulitis) and utilize too many laboratory and imaging resources.

UPDATE FEB 2011:
The IDSA MRSA guidelines incorporate this data saying initial VANCO is not necessary unless septic shock or purulent cellulitis.  VANCO would be added for those not responding (though you should note erysipelas often worsens in the first 24h of therapy, and  non-cellulitis as a cause of red leg is a common reason for non-improvement)

Medication Use in the Elderly

A nice review in JAMA here.  The author touches on what I believe to be a key point -- the use of medications designed to reduce long term mortality in patients with a limited life expectancy.  


"for patients with advanced dementia, poor prognosis, or both, consensus panels do not recommend (and in some cases advocate against) medications such as statins,bisphosphonates, and cholinesterase inhibitors, although these positions are not universally endorsed."  


I must say, in the era of escalating health care costs, partially driven by medication costs -- thinking about the above statement seems to be reasonable from a policy-making point of view.

Mandatory influenza vaccination?

Article on changing policies in the USA here...

If you don't take the temperature, the patient can't have a fever...

This article reminded me of one of the fatman's rules from Shem's novel.  In this study, computer rule generated central line infection rates were significantly higher than those reported by infection control teams --  in the modern era of reporting and pay for performance, one does wonder if, given a case that is grey one may be more inclined to call it black or white.

Blastomycosis

I saw a case of cutaneous blastomycosis in clinic today -- two lesions, one on the face, the other on the buttock in an otherwise healthy male patient.  A nice review is here.

Blastomycosis is a dimorphic (mould at room temperature, yeast at body temperature) fungus which is endemic in certain geographic areas of North America.  Ontario, where I currently live, and in particular northwest Ontario by the Manitoba border is one such geographic hot spot.

The most common sites of infection are:

• Pulmonary (most patients have some pulmonary involvement)
• Presents as acute (including ARDS) or chronic pneumonia, pulmonary nodule, asymptomatic
• Cutaneous (in 40-80% of cases) presenting as verrucous or ulcerative skin lesions (like my patient)
• Osteomyelitis (~25% of extrapulmonary) presenting as painful lesion in bone, which can mimic sarcoma in radiographic appearance.  Occasionally can have concomittant septic arthritis in adjacent bone.
• GU: (10-30%) in men prostate, testicle, epididymis.
• CNS (5-10%), usually chronic meningitis, occasionally space occupying lesions
• Other

Treatment is with amphotericin B for severe disease (or CNS induction) or with azoles (itraconazole or voriconazole) for other forms.  Treatment guidelines from the IDSA are available here.

PE Prognosis -- Click for article

The simplified PESI is useful to select patients at low risk of death from PE who could probably be treated as outpatients (see archives int medicine article linked above).  A score of zero has a negative predictive value of 99% in both derivation and validation cohorts.