Lumbar puncture for suspected meningitis after intensive care unit admission is likely to change management.

Hosp Pract (Minneap). 2011 Feb;39(1):141-5

Authors: Khasawneh FA, Smalligan RD, Mohamad TN, Moughrabieh MK, Soubani AO

Purpose: The aim of this study was to determine the outcome of lumbar punctures (LPs) in critically ill medical patients and how likely the results were to change case management. Materials and Methods: A retrospective review was conducted on the medical records of all 168 patients who underwent LP during their medical intensive care unit (MICU) admission at a university hospital during a 4.5-year period beginning in January 2000. Results: Lumbar puncture was performed a mean of 2.8 days after MICU admission. The most common symptoms that prompted LP were changes in mental status and fever. Seventy-four percent of patients were on antibiotics at the time of LP, and 98% of patients had a computed tomography scan of the head performed before the procedure. Lumbar puncture confirmed meningitis in 47 (30%) patients and provided a specific bacteriologic diagnosis in 5 (3%) patients. The results of the procedure led to a change in management in 50 (30%) patients. The presence of meningeal signs and use of antibiotics at the time of the procedure were the factors that predicted change in management. Conclusion: Although the likelihood that LP will yield a specific bacteriologic diagnosis in critically ill patients is low, the procedure frequently provides important information that can lead to a change in case management, most commonly de-escalation of antibiotic therapy.

PMID: 21441769 [PubMed - in process]

Mitral regurgitation: current trends in diagnosis and management.

Hosp Pract (Minneap). 2011 Feb;39(1):181-92

Authors: Ghoreishi M, Dawood M, Stauffer CE, Gammie JS

Mitral regurgitation is the most prevalent heart valve disorder in the United States. Individuals with mitral regurgitation may be asymptomatic or may present with dyspnea, orthopnea, fatigue, and/or heart rhythm disturbances. Long-standing mitral regurgitation causes chronic left ventricular volume overload, which leads to left ventricular dilation and contractile dysfunction. Without treatment, mitral regurgitation results in biventricular failure and death. Echocardiography is the preferred diagnostic test to assess the presence and severity of mitral regurgitation. Mitral valve surgery, the only effective treatment for patients with severe mitral regurgitation, is recommended early in the course of the disease to prevent the development of heart failure. Early recognition of mitral regurgitation and timely referral for mitral valve surgery significantly improve symptoms and long-term survival.

PMID: 21441774 [PubMed - in process]

Osteomyelitis: an update for hospitalists.

Hosp Pract (Minneap). 2011 Feb;39(1):153-60

Authors: Howell WR, Goulston C

Osteomyelitis is a common and challenging condition for hospitalists to manage. The 3 main types of osteomyelitis that are commonly seen in the hospital setting are 1) contiguous spread from decubitus or diabetic ulcers, 2) hematogenous spread, such as in vertebral or long bone metaphyses, and 3) infections associated with a prosthetic joint. In patients with diabetes, osteomyelitis is the underlying cause of about 20% of foot infections, and greatly increases the chance that the patient will eventually need an amputation and be subject to perioperative risks. Osteomyelitis from hematogenous spread is increasing. The prevalence of vertebral osteomyelitis is also increasing, particularly in intravenous drug users and patients treated with immune-modulating agents. Prosthetic joint infections are perhaps the most challenging type to treat, and require hospitalists, orthopedic surgeons, and infectious disease specialists to work closely together to plan for effective treatment. Due to increasing antibiotic resistance, the microorganisms involved are also proving more difficult to treat. Emerging resistance to the commonly used antibiotics is resulting in changes in treatment choices. Community-acquired methicillin-resistant Staphylococcus aureus is commonly seen, and there is increasing concern about emerging vancomycin resistance. Treatment of osteomyelitis is still based largely on expert opinion rather than evidence from controlled studies.

PMID: 21441771 [PubMed - in process]