This case describes a 48-year-old woman presenting with suspected urosepsis. She reported several days of back pain and 2 days of UTI symptoms including rigors. Initial investigations showed elevated inflammatory markers. She was treated with IV gentamicin and oral trimethoprim but discharged with ongoing rigors. She was later readmitted with persistent rigors and vomiting, and urine and blood cultures grew E. coli. The presence of true rigors indicates a more serious infection requiring inpatient treatment and investigation until the patient has stabilized, rather than early discharge. Initial management could be improved by performing a renal ultrasound and ensuring clear documentation and follow-up plans.
Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss in renal function over a period of time. The three most common causes of CKD are,
-Diabetes mellitus
-Hypertension and
-Glomerulonephritis.
Together, these cause about 75% of all adult cases.
Proper Case Presentation for Dengue Fever, Prevention, Treatment and everything else. Prepared by Dr Zain Khan, Doctor at Liaquat College of Medicine and Dentistry
Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss in renal function over a period of time. The three most common causes of CKD are,
-Diabetes mellitus
-Hypertension and
-Glomerulonephritis.
Together, these cause about 75% of all adult cases.
Proper Case Presentation for Dengue Fever, Prevention, Treatment and everything else. Prepared by Dr Zain Khan, Doctor at Liaquat College of Medicine and Dentistry
DKA is a life-threatening condition that develops when cells in the body are unable to get the glucose they need for energy because deficiency of the insulin.
Without enough insulin, the body begins to break down fat as fuel.
This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.
Leptospirosis is a bacterial disease that affects humans and animals. It is caused by bacteria of the genus Leptospira. In humans, it can cause a wide range of symptoms, some of which may be mistaken for other diseases. Some infected persons, however, may have no symptoms at all.
DKA is a life-threatening condition that develops when cells in the body are unable to get the glucose they need for energy because deficiency of the insulin.
Without enough insulin, the body begins to break down fat as fuel.
This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.
Leptospirosis is a bacterial disease that affects humans and animals. It is caused by bacteria of the genus Leptospira. In humans, it can cause a wide range of symptoms, some of which may be mistaken for other diseases. Some infected persons, however, may have no symptoms at all.
Approach to new fever in ICU and common causes (infectious and non-infectious), including bacteremia, VAP, catheter related infections (CLABSI), CAUTI and drug fever. Brief discussion about new sepsis definitions (2016), qSOFA score and biomarkers (procalcitonin).
Information about Abdominal sepsis and peritonitis final by Dr Dhaval Mangukiya.
Details of Anatomy, intra abdominal infections, physiology, peritonitis, risks for failure of source control, management of critical issues.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Febrile neutropenia - Infections in cancer patientsAli Musavi
This powerpoint provides a summary of infections in neutropenic patients and febrile neutropenia. It contains the definition, etiology, approach, treatments, and recommendations from ESMO and IDSA guidelines.
lecture presented at Al-Mahmoudiya General hospital in the 30th Aug 2023
based upon recent governmental protocols of antibiotic selection, dosage forms conversion by MOH 2023
Peritoneal dialysis is the most common form of renal replacement therapy performed in the home. Peritoneal dialysis is the process of removing excess fluid and metabolic by-products from the body by circulating dialysis solution through the peritoneal cavity using a peritoneal catheter.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
2. History
48 year old woman referred to ED with suspected urosepsis
Arrived 0900 hrs
• R sided back pain for several days, with UTI symptoms last 2 days
• Associated sweats and rigors
• Now feels unwell “like flu”
PH
Well Hypertension Rx Telmisartan
NKA
No history of UTIs
3. Initial examination
• “Not toxic” appearance
• Obs Temp 38.7 HR 110 BP 160/80 RR 14 O2 sat 99%
• Abdomen soft, non tender, and no renal angle tenderness noted
5. Treatment
• IV Gentamicin 240mg
• Trimethoprim commenced orally
Disposition: “D/C”
Obs on discharge:
Temp 37.8 HR 103 BP 122/71 RR 16 O2 sat 97%
6. What do you think of therapy used and disposition in this patient?
7. Antibiotic Guidelines 1 - Introduction
• In patients with acute pyelonephritis, attempts should be made to define or
exclude any underlying anatomical or functional abnormality. In particular,
obstruction of the upper urinary tract should be excluded.
• It is imperative that adequate urine cultures are collected before the
administration of antibiotics. In hospitalised patients, blood cultures should also
be performed. The antibiotic susceptibilities of organisms should be used to guide
therapy. Therapy may need to be prolonged, high-dose, and often parenteral.
• Acute pyelonephritis is common in pregnancy where the special problems
associated with antibiotic use will need to be considered
8. Antibiotic Guidelines 2 – “Mild Pyelonephritis”
Mild cases (low-grade fever, no nausea or vomiting) may be treated by oral therapy alone.
For empirical therapy, while awaiting culture results, use:
amoxycillin+clavulanate 875+125 mg orally, 12-hourly for 10 days
OR
cephalexin 500 mg orally, 6-hourly for 10 days
OR
trimethoprim 300 mg orally, daily for 10 days.
If resistance to all the above drugs is proven or the causative organism is Pseudomonas aeruginosa, use:
norfloxacin 400 mg orally, 12-hourly for 10 days
PBS
Pregnancy
Breastfeeding
OR
ciprofloxacin 500 mg orally, 12-hourly for 10 days.
A follow-up urine culture at least 48 hours after the conclusion of therapy is advised.
9. Antibiotic Guidelines 3 – “Severe Pyelonephritis”
For patients with sepsis or vomiting, give parenteral treatment initially while awaiting culture results. Use:
gentamicin 4 to 6 mg/kg (see Table 2.24) (severe sepsis: 7 mg/kg) IV, for 1 dose, then determine dosing interval for a maximum of
either 1 or 2 further doses based on renal function (see Table 2.25)
PLUS
amoxy/ampicillin 2 g IV, 6-hourly.
In patients hypersensitive to penicillin (see Table 2.2), gentamicin alone will usually suffice.
If gentamicin is contraindicated (see Box 2.7), as a single drug, use:
ceftriaxone 1 g IV, daily
OR
cefotaxime 1 g IV, 8-hourly.
These regimens do not provide adequate cover for P. aeruginosa or enterococci.
10. • Subsequent treatment should be guided by susceptibility results and clinical
response, with early conversion to oral therapy. Other than for short-term
empirical use, gentamicin is no longer recommended except for directed therapy
in specific circumstances (see Dosing and monitoring of aminoglycosides).
• If susceptibility results are not available by 72 hours and empirical IV therapy is still
required, cease the gentamicin-containing regimen and use ceftriaxone or
cefotaxime as above.
• The total duration of therapy is usually 10 to 14 days, but may need to be
extended to 21 days in patients with delayed response.
• A follow-up urine culture at least 48 hours after the conclusion of therapy is
advised.
12. 2 days later
• Review of results – positive urine and blood cultures for E. Coli
Patient recalled for review
Slightly improved with decreased loin pain, but ongoing rigors and vomiting x 6
Exam: still well looking, afebrile, with slightly tender right loin
Repeat investigations: FBE normal, CRP 292
Renal US - normal
Treatment: IV Amoxicillin and Gentamicin
Admit PGMU
13. Course
IV Ampicillin continued for five days IV in total, patient afebrile and mostly
asymptomatic after first 24 hours
Discharged home on a further 10 days of oral Amoxycillin
14. Two questions for you
• What’s a rigor?
• Does a history of rigors have special importance?
15. Definition
• Rigor: derived from Latin for stiffness
• A feeling of coldness / chills accompanied by uncontrollable shaking / shivering
16. Importance
• Traditional medical teaching has associated true rigors (as distinct from simple
shivering) with bacteraemia and serious bacterial infection
• Higher risk for serious sepsis and thus morbidity / mortality
• Shakes may be caused by presence in blood of bacteria, bacterial fragments,
viruses or cytokines / interleukins
18. J Am Geriatric Soc. 1995 Mar;43(3):230-5.
Predicting bacteremia in older patients.
Pfitzenmeyer P, Decrey H, Auckenthaler R, Michel JP.
Source
University Geriatric Hospital, Geneva, Switzerland.
Abstract
OBJECTIVE:
To evaluate potential clinical predictors of bacteremia in hospitalized geriatric patients and to propose an individual risk score as an
alternative to "subjective" clinical judgment for a more efficient approach in early recognition and treatment of bacteremia.
DESIGN:
A 16-month prospective study.
SETTING:
The University Geriatric Hospital of Geneva, Switzerland.
PATIENTS:
Four hundred thirty-eight patients aged 62 years or older in whom 558 episodes of bacteremia were suspected.
MEASUREMENTS:
The unit of evaluation was the blood culture episode, which was defined as a 48-hour period beginning with the drawing of the first blood
for culture. An extensive precoded protocol, including clinical and biological data, was completed by the resident who requested the
blood cultures. For each episode, the resident also provided a subjective assessment of the probability of bacteremia. Odds ratios and
their variances were used to estimate the relative risks of potential predictors of bacteremia. The performance of a predictive clinical
model based on risk score threshold was evaluated by means of a receiver-operating characteristic analysis.
RESULTS:
Of the 558 potentially bacteremic episodes investigated, 46 (8.2%) yielded positive blood cultures. The bacteremia rate was strongly
associated with the type of episode: it reached 15.6% among the community-acquired (CA) episodes (those occurring within 48 hours of
hospital admission) and 6.0% only among the hospital-acquired (HA) episodes (those occurring after the first two days of hospitalization).
Predictors of bacteremia with highest relative risks included: bladder catheter removal, fever (> or = 38.5 degrees C), rigors, shock, total
band count > or = 1500/mm3, and lymphocyte count < or = 1000/mm3. When assessed by episode type, it appeared that bladder
catheter removal and rigors were good predictors of bacteremia in HA episodes only, whereas fever (> or = 38.5 degrees C) had a good
predictive value in CA episodes only. The performance of the clinical model was two times better than the physician's subjective ability to
predict bacteremia when the threshold of the risk score was fixed at two or more predictors per episode.
CONCLUSIONS:
These findings provide means to identify older hospitalized patients at high risk of bacteremia. Although the proposed predictive model
will need further validation and more precise evaluation of the potential benefits, it may nevertheless be of some help in early
recognition and treatment of bacteremia.
19. Eur J Pediatr. 1997 Jun;156(6):457-9.
The clinical significance of rigors in febrile children.
Tal Y, Even L, Kugelman A, Hardoff D, Srugo I, Jaffe M.
Source
Paediatric Department, Bnai Zion Medical Centre, Haifa, Israel.
Abstract
The objective of the study was to evaluate the significance of rigor as a predictor of bacterial infection in hospitalized febrile
infants and children. One hundred febrile children with rigor were studied and compared to 334 febrile matched controls
without rigor. All underwent clinical evaluation and appropriate laboratory investigations. The patients were then divided into
"bacterial" and "non bacterial" infection groups, as defined in the text. It was demonstrated that 66% of the patients with
rigor belonged to the bacterial infection group versus 50% in the non-rigor group (P < 0.005).
There was a significantly greater yield of positive blood cultures in the patients with rigor (P < 0.04), especially those over
the age of 1 year (P < 0.015).
The only laboratory examination of potential value as a predictor of bacterial infection in children with rigor was the band
count. An absolute band count of more than 1500/mm was significantly more frequent in the rigor group (P < 0.003), and
the combination of a rigor and band count of more than 1500 increased the relative risk for a bacterial infection by a factor
of 1.35. These data demonstrate that rigor in hospitalized febrile infants or children significantly increase the likelihood of
bacterial infection.
CONCLUSION: Although the absence of rigors in febrile children does not exclude bacterial aetiology, their presence
significantly increase the probability of an infection requiring appropriate workup and a reader institution of antibiotic
therapy.
20. “Early clinical clues to meningococcaemia”
Allen P Yung and Malcolm I McDonald
MJA 2003 178 (3): 134-137
True rigors
A rigor is a shaking chill that cannot be stopped voluntarily. Onset is sudden, and duration may be
10–20 minutes. It should be distinguished from a sensation of chill or shivers that lasts only for
seconds. Although rigors occur in some viral infections, they should generally be regarded as
indicators of significant sepsis, in conditions such as bacteraemia, pneumonia, abscesses,
endocarditis, cholangitis, and pyelonephritis.
We preach the "rigor rule" to our students: any patient, young or old, presenting with a rigor
should be admitted to hospital for observation and investigation. This rule has not been popular
with some colleagues in emergency departments.
21. Important learning points
A history of true rigors should lead to admission of the patient
(even if initial examination / investigations not concerning)
Initial investigation for Pyelonephritis should routinely include an early Renal US
Empiric therapy is IV Gentamicin and Amoxicillin initially
Documentation should be explicit, and adequately detailed about follow-up when
patients are discharged
Strong support by ID physicians at Cabrini Hospital for a “rigor rule” style approach to
disposition planning