Good Samaritan Hospital

IMPORTANCE: Hereditary cancer syndromes infer high cancer risks and require intensive cancer surveillance, yet the prevalence and spectrum of these conditions among unselected patients with early-onset colorectal cancer (CRC) is largely undetermined. OBJECTIVE: To determine the frequency and spectrum of cancer susceptibility gene mutations among patients with early-onset CRC. DESIGN, SETTING, AND PARTICIPANTS: Overall, 450 patients diagnosed with colorectal cancer younger than 50 years were prospectively accrued from 51 hospitals into the Ohio Colorectal Cancer Prevention Initiative from January 1, 2013, to June 20, 2016. Mismatch repair (MMR) deficiency was determined by microsatellite instability and/or immunohistochemistry. Germline DNA was tested for mutations in 25 cancer susceptibility genes using next-generation sequencing. MAIN OUTCOMES AND MEASURES: Mutation prevalence and spectrum in patients with early-onset CRC was determined. Clinical characteristics were assessed by mutation status. RESULTS: In total 450 patients younger than 50 years were included in the study, and 75 gene mutations were found in 72 patients (16%). Forty-eight patients (10.7%) had MMR-deficient tumors, and 40 patients (83.3%) had at least 1 gene mutation: 37 had Lynch syndrome (13, MLH1 [including one with constitutional MLH1 methylation]; 16, MSH2; 1, MSH2/monoallelic MUTYH; 2, MSH6; 5, PMS2); 1 patient had the APC c.3920T>A, p.I1307K mutation and a PMS2 variant; 9 patients (18.8%) had double somatic MMR mutations (including 2 with germline biallelic MUTYH mutations); and 1 patient had somatic MLH1 methylation. Four hundred two patients (89.3%) had MMR-proficient tumors, and 32 patients (8%) had at least 1 gene mutation: 9 had mutations in high-penetrance CRC genes (5, APC; 1, APC/PMS2; 2, biallelic MUTYH; 1, SMAD4); 13 patients had mutations in high- or moderate-penetrance genes not traditionally associated with CRC (3, ATM; 1, ATM/CHEK2; 2, BRCA1; 4, BRCA2; 1, CDKN2A; 2, PALB2); 10 patients had mutations in low-penetrance CRC genes (3, APC c.3920T>A, p.I1307K; 7, monoallelic MUTYH). Importantly, 24 of 72 patients (33.3%) who were mutation positive did not meet established genetic testing criteria for the gene(s) in which they had a mutation. CONCLUSIONS AND RELEVANCE: Of 450 patients with early-onset CRC, 72 (16%) had gene mutations. Given the high frequency and wide spectrum of mutations, genetic counseling and testing with a multigene panel could be considered for all patients with early-onset CRC.

Listerial brainstem encephalitis is a rare disease. Only 62 cases have been reported previously; all were in adults, only 8% of whom were immunosuppressed. The disease has a characteristic biphasic course: a nonspecific prodrome of headache, nausea or vomiting, and fever lasting for several days is followed by progressive asymmetrical cranial-nerve palsies, cerebellar signs, hemiparesis or hypesthesia, and impairment of consciousness. Neck stiffness was initially present in only 55% of the cases described thus far. Studies of cerebrospinal fluid often revealed only mild abnormalities. Cultures of cerebrospinal fluid and blood were positive in 41% and 61% of cases, respectively. Respiratory failure occurred in 41% of cases. Initial computed tomography of the brain often gave normal results; magnetic resonance imaging better demonstrated brainstem abnormalities. Overall mortality was 51%. All untreated patients died. When treatment with ampicillin or penicillin was initiated early, the rate of survival was > 70%; however, neurological sequelae developed in 61% of survivors.

OBJECTIVE: To establish the prevalence and distribution of uterine anomalies in the general population and to enumerate them among septate, bicornuate, didelphic, unicornuate, hypoplastic/aplastic and solid forms. STUDY DESIGN: A Medline search and standard reference tracing were employed to locate 47 studies from 14 countries regarding the prevalence and distribution of uterine anomalies. Twenty-two studies involving 573,138 women undergoing universal screening for uterine malformations were analyzed to establish the prevalence of uterine anomalies among fertile women. A separate analysis of uterine anomalies among 6,512 infertile women was also performed. Nineteen studies incorporating 1,092 fertile and 456 infertile women with unselected uterine anomalies were reviewed to establish the distribution of müllerian malformations among major subtypes. Seventeen studies incorporating 161 women with unicornuate uteri were analyzed to establish the distribution of unicornuate müllerian defects among various subtypes, including those with and without cavitary contralateral uterine horns. RESULTS: Uterine anomalies were identified in 1 in 594 fertile women (0.17%) and in 1 in 29 infertile women (3.5%). This difference was statistically significant (chi 2 = 3,424, df = 1, P < .00001). The prevalence of uterine anomalies in the general population was 1 in 201 women (0.50%). Their distribution was: 7% arcuate, 34% septate, 39% bicornuate, 11% didelphic, 5% unicornuate, and 4% hypoplastic/aplastic/solid and other forms. CONCLUSION: Congenital uterine malformations are more common than generally recognized. Knowledge concerning their prevalence and varieties is important in recognizing and managing the obstetric and gynecologic complications that may result.

BACKGROUND: Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH). OBJECTIVE: To determine the safety and efficacy of MMA embolization. METHODS: Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes. RESULTS: A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities. CONCLUSION: MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.

During a 4-year study of 4,256 knee arthroscopies, eighteen patients became infected (infection rate 0.42%). Occurrence of infection was strongly associated with use of long-acting intraarticular intraoperative corticosteroids. Infection was more common among patients with longer surgery operating times, increased numbers of procedures during surgery, prior procedures, and performance of chondroplasty or soft tissue debridement. Subsequent to the study, the infection rate fell to 0.1%. Twenty-four infections were studied (our eighteen plus six other concurrent community cases); twelve were due to Staphylococcus aureus, eleven to coagulase-negative staphylococci, and one to Enterobacter cloacae. Seventy percent of the patients had onset of symptoms within 3 days of surgery. Most patients with coagulase-negative staphylococcal infections had fevers less than 38.3 degrees C (101 degrees F), negative Gram stains on synovial fluid, normal peripheral leukocyte counts, and somewhat indolent, mild clinical syndromes, while most patients with S. aureus infections had higher fevers, positive synovial Gram stains, peripheral leukocytosis, and more acute and severe clinical syndromes. Knee pain, swelling, and warmth always occurred, but erythema was noted in only 30% of patients. Treatment with 2 weeks of intravenous antibiotics was successful in all but one patient. Long-term results were excellent in sixteen of twenty-two patients.

OBJECTIVE: The aim of this study was to compare outcomes of infants pre and post initiation of a feeding protocol providing an exclusive human milk-based diet (HUM). MATERIALS AND METHODS: In a multicenter retrospective cohort study, infants with a birth weight <1,250 g who received a bovine-based diet (BOV) of mother's own milk fortified with bovine fortifier and/or preterm formula were compared to infants who received a newly introduced HUM feeding protocol. Infants were excluded if they had major congenital anomalies or died in the first 12 hours of life. Data were collected 2-3 years prior to and after introduction of an exclusive HUM diet. Primary outcomes were necrotizing enterocolitis (NEC) and mortality. Secondary outcomes included late-onset sepsis, retinopathy of prematurity (ROP), and bronchopulmonary dysplasia (BPD). RESULTS: A total of 1,587 infants were included from four centers in Texas, Illinois, Florida, and California. There were no differences in baseline demographics or growth of infants. The HUM group had significantly lower incidence of proven NEC (16.7% versus 6.9%, p < 0.00001), mortality (17.2% versus 13.6%, p = 0.04), late-onset sepsis (30.3% versus 19.0%, p < 0.00001), ROP (9% versus 5.2%, p = 0.003), and BPD (56.3% versus 47.7%, p = 0.0015) compared with the BOV group. CONCLUSIONS: Extremely premature infants who received an exclusive HUM diet had a significantly lower incidence of NEC and mortality. The HUM group also had a reduction in late-onset sepsis, BPD, and ROP. This multicenter study further emphasizes the many benefits of an exclusive HUM diet, and demonstrates multiple improved outcomes after implementation of such a feeding protocol.

OBJECTIVE: To compare management based on maternal glycemic criteria with management based on relaxed glycemic criteria and fetal abdominal circumference (AC) measurements in order to select patients for insulin treatment of gestational diabetes mellitus (GDM) with fasting hyperglycemia. RESEARCH DESIGN AND METHODS: In a pilot study, 98 women with fasting plasma glucose (FPG) concentrations of 105-120 mg/dl were randomized. The standard group received insulin treatment. The experimental group received insulin if the AC, measured monthly, was > or =70th percentile and/or if any venous FPG measurement was >120 mg/dl. Power was projected to detect a 250-g difference in birth weights. RESULTS: Gestational ages, maternal glycemia, and AC percentiles were similar at randomization. After initiation of protocol, venous FPG (P = 0.003) and capillary blood glucose levels (P = 0.049) were significantly lower in the standard group. Birth weights (3,271 +/- 458 vs. 3,369 +/- 461 g), frequencies of birth weights >90th percentile (6.3 vs 8.3%), and neonatal morbidity (25 vs. 25%) did not differ significantly between the standard and experimental groups, respectively. The cesarean delivery rate was significantly lower (14.6 vs. 33.3%, P = 0.03) in the standard group; this difference was not explained by birth weights. In the experimental group, infants of women who did not receive insulin had lower birth weights than infants of mothers treated with insulin (3,180 +/- 425 vs. 3,482 +/- 451 g, P = 0.03). CONCLUSIONS: In women with GDM and fasting hyperglycemia, glucose plus fetal AC measurements identified pregnancies at low risk for macrosomia and resulted in the avoidance of insulin therapy in 38% of patients without increasing rates of neonatal morbidity.

AIMS: The terminology in current use for sexual function and dysfunction in women with pelvic floor disorders lacks uniformity, which leads to uncertainty, confusion, and unintended ambiguity. The terminology for the sexual health of women with pelvic floor dysfunction needs to be collated in a clinically-based consensus report. METHODS: This report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Importantly, this report is not meant to replace, but rather complement current terminology used in other fields for female sexual health and to clarify terms specific to women with pelvic floor dysfunction. RESULTS: A clinically based terminology report for sexual health in women with pelvic floor dysfunction encompassing over 100 separate definitions, has been developed. Key aims have been to make the terminology interpretable by practitioners, trainees, and researchers in female pelvic floor dysfunction. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible. CONCLUSION: A consensus-based terminology report for female sexual health in women with pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

From 25 August to 28 September 1994, 7 cardiovascular surgery (CVS) patients at a California hospital acquired postoperative Serratia marcescens infections, and 1 died. To identify the outbreak source, a cohort study was done of all 55 adults who underwent CVS at the hospital during the outbreak. Specimens from the hospital environment and from hands of selected staff were cultured. S. marcescens isolates were compared using restriction-endonuclease analysis and pulsed-field gel electrophoresis. Several risk factors for S. marcescens infection were identified, but hospital and hand cultures were negative. In October, a patient exposed to scrub nurse A (who wore artificial fingernails) and to another nurse-but not to other identified risk factors-became infected with the outbreak strain. Subsequent cultures from nurse A's home identified the strain in a jar of exfoliant cream. Removal of the cream ended the outbreak. S. marcescens does not normally colonize human skin, but artificial nails may have facilitated transmission via nurse A's hands.

Stress is an inevitable part of our personal and professional lives. When poorly managed, stress will accumulate to levels that become injurious to our health and well-being. Burnout is one such consequence. However, because stress is an active process, with the proper knowledge and skills, we can learn to better manage and control its level of intensity. This paper examines the stress cycle and especially those aspects that are unique to the practice of medicine and anaesthesia. Sleep deprivation and physical fatigue are analyzed as key stressors. The role of the medical marriage and dual-career relationships are scrutinized. The importance of retaining the humanistic essence of medicine is emphasized. Stress management strategies and coping responses, including self-care and humor, are discussed.

PURPOSE: Failure mode and effects analysis (FMEA) was used to identify dosing and administration errors associated with i.v. medications and evaluate the effectiveness of subsequent system improvements. SUMMARY: A multidisciplinary medication safety team conducted an FMEA to identify and reduce common medication errors and selected wrong-dose errors for process improvement. In 2002, wrong-dose errors comprised 17% of all medication errors at the hospital (59 of 347 errors). The most common reason for administering the wrong dose was error in programming the i.v. infusion pump (41%). Potential errors (i.e., failures) identified were misinterpretation of the order, removing the wrong medication or wrong concentration of the correct medication, using the wrong diluent or drug to prepare the drip, and entering the wrong concentration or infusion rate on the pump. Errors in programming the i.v. infusion pump was the step in the medication-use process associated with the highest criticality index. Based on the results of the FMEA, two main interventions were performed. First, standard order sets were revised after streamlining the formulary and eliminating the use of unapproved abbreviations. Second, an i.v. pump with enhanced safety features was implemented. One-year follow-up data revealed that the number of medication errors related to dosing (wrong dose or incorrect infusion rate) had decreased slightly (from 59 in 2002 to 46 in 2003); however, a dramatic reduction was noted in the percentage of pump-related errors. In 2003, pump-related errors accounted for 22% of dosing errors, compared with 41% in 2002. CONCLUSION: Medication errors related to i.v. infusion pumps were reduced by conducting an FMEA and implementing the process changes needed.

Epithelioid glioblastoma (eGBM) and pleomorphic xanthoastrocytoma (PXA) with anaplastically transformed foci (ePXA) show overlapping features. Eleven eGBMs and 5 ePXAs were reviewed and studied immunohistochemically. Fluorescence in situ hybridization for EGFR amplification, PTEN deletion and ODZ3 deletion was also performed, with Ilumina 450 methylome analysis obtained in five cases. The average age for eGBM was 30.9 (range 2-79) years, including five pediatric cases and a M : F ratio of 4.5. The ePXA patients had a M : F ratio of 4 and averaged 21.2 (range 10-38) years in age, including two pediatric cases. Six eGBMs and two ePXAs recurred (median recurrence interval of 12 and 3.3 months, respectively). All tumors were composed of solid sheets of loosely cohesive, "melanoma-like" cells with only limited infiltration. ePXAs showed lower grade foci with classic features of PXA. Both tumor types showed focal expression of epithelial and glial markers, retained INI1 and BRG1 expression, occasional CD34 positivity, and lack of mutant IDH1 (R132H) immunoreactivity. BRAF V600E mutation was present in four eGBMs and four ePXAs. ODZ3 deletion was detected in seven eGBMs and two ePXAs. EGFR amplification was absent. Methylome analysis showed that one ePXA and one eGBM clustered with PXAs, one eGBM clustered with low-grade gliomas, and two eGBMs clustered with pediatric-type glioblastomas. Common histologic, immunohistochemical, molecular and clinical features found in eGBM and ePXA suggest that they are closely related or the same entity. If the latter is true, the nomenclature and WHO grading remains to be resolved.

OBJECTIVE: The incidence of already common chronic subdural hematomas (CSDHs) and other nonacute subdural hematomas (NASHs) in the elderly is expected to rise as the population ages over the coming decades. Surgical management is associated with recurrence and exposes elderly patients to perioperative and operative risks. Middle meningeal artery (MMA) embolization offers the potential for a minimally invasive, less morbid treatment in this age group. The clinical and radiographic outcomes after MMA embolization treatment for NASHs have not been adequately described in elderly patients. In this paper, the authors describe the clinical and radiographic outcomes after 151 cases of MMA embolization for NASHs among 121 elderly patients. METHODS: In a retrospective review of a prospectively maintained database across 15 US academic centers, the authors identified patients aged ≥ 65 years who underwent MMA embolization for the treatment of NASHs between November 2017 and February 2020. Patient demographics, comorbidities, clinical and radiographic factors, treatment factors, and clinical outcomes were abstracted. Subgroup analysis was performed comparing elderly (age 65-79 years) and advanced elderly (age > 80 years) patients. RESULTS: MMA embolization was successfully performed in 98% of NASHs (in 148 of 151 cases) in 121 patients. Seventy elderly patients underwent 87 embolization procedures, and 51 advanced elderly patients underwent 64 embolization procedures. Elderly and advanced elderly patients had similar rates of embolization for upfront (46% vs 61%), recurrent (39% vs 33%), and prophylactic (i.e., with concomitant surgical intervention; 15% vs 6%) NASH treatment. Transfemoral access was used in most patients, and the procedure time was approximately 1 hour in both groups. Particle embolization with supplemental coils was most common, used in 51% (44/87) and 44% (28/64) of attempts for the elderly and advanced elderly groups, respectively. NASH thickness decreased significantly from initial thickness to 6 weeks, with additional decrease in thickness observed in both groups at 90 days. At longest follow-up, the treated NASHs had stabilized or improved in 91% and 98% of the elderly and advanced elderly groups, respectively, with > 50% improvement seen in > 60% of patients for each group. Surgical rescue was necessary in 4.6% and 7.8% of cases, and the overall mortality was 8.6% and 3.9% for elderly and advanced elderly patients, respectively. CONCLUSIONS: MMA embolization can be used safely and effectively as an alternative or adjunctive minimally invasive treatment for NASHs in elderly and advanced elderly patients.

INTRODUCTION: One of the limitations reported with cardiotocography is the modest interobserver agreement observed in tracing interpretation. This study compared agreement, reliability and accuracy of cardiotocography interpretation using the International Federation of Gynecology and Obstetrics, American College of Obstetrics and Gynecology and National Institute for Health and Care Excellence guidelines. MATERIAL AND METHODS: A total of 151 tracings were evaluated by 27 clinicians from three centers where International Federation of Gynecology and Obstetrics, American College of Obstetrics and Gynecology and National Institute for Health and Care Excellence guidelines were routinely used. Interobserver agreement was evaluated using the proportions of agreement and reliability with the κ statistic. The accuracy of tracings classified as "pathological/category III" was assessed for prediction of newborn acidemia. For all measures, 95% confidence interval were calculated. RESULTS: Cardiotocography classifications were more distributed with International Federation of Gynecology and Obstetrics (9, 52, 39%) and National Institute for Health and Care Excellence (30, 33, 37%) than with American College of Obstetrics and Gynecology (13, 81, 6%). The category with the highest agreement was American College of Obstetrics and Gynecology category II (proportions of agreement = 0.73, 95% confidence interval 0.70-76), and the ones with the lowest agreement were American College of Obstetrics and Gynecology categories I and III. Reliability was significantly higher with International Federation of Gynecology and Obstetrics (κ = 0.37, 95% confidence interval 0.31-0.43), and National Institute for Health and Care Excellence (κ = 0.33, 95% confidence interval 0.28-0.39) than with American College of Obstetrics and Gynecology (κ = 0.15, 95% confidence interval 0.10-0.21); however, all represent only slight/fair reliability. International Federation of Gynecology and Obstetrics and National Institute for Health and Care Excellence showed a trend towards higher sensitivities in prediction of newborn acidemia (89 and 97%, respectively) than American College of Obstetrics and Gynecology (32%), but the latter achieved a significantly higher specificity (95%). CONCLUSIONS: With American College of Obstetrics and Gynecology guidelines there is high agreement in category II, low reliability, low sensitivity and high specificity in prediction of acidemia. With International Federation of Gynecology and Obstetrics and National Institute for Health and Care Excellence guidelines there is higher reliability, a trend towards higher sensitivity, and lower specificity in prediction of acidemia.

We describe 4 patients with encephalitis due to possible reactivation of human herpesvirus 6 (HHV-6) infection who were enrolled in the California Encephalitis Project. All were immunocompetent and had HHV-6 loads determined in cerebrospinal fluid specimens. Tests for detection of HHV-6 should be considered for individuals with encephalitis.

OBJECTIVE: To evaluate the effectiveness of the California Perinatal Quality Care Collaborative quality-improvement model using a toolkit supplemented by workshops and Web casts in decreasing nosocomial infections in very low birth weight infants. DESIGN: This was a retrospective cohort study of continuous California Perinatal Quality Care Collaborative members' data during the years 2002-2006. The primary dependent variable was nosocomial infection, defined as a late bacterial or coagulase-negative staphylococcal infection diagnosed after the age of 3 days by positive blood/cerebro-spinal fluid culture(s) and clinical criteria. The primary independent variable of interest was voluntary attendance at the toolkit's introductory event, a direct indicator that at least 1 member of an NICU team had been personally exposed to the toolkit's features rather than being only notified of its availability. The intervention's effects were assessed using a multivariable logistic regression model that risk adjusted for selected demographic and clinical factors. RESULTS: During the study period, 7733 eligible very low birth weight infants were born in 27 quality-improvement participant hospitals and 4512 very low birth weight infants were born in 27 non-quality-improvement participant hospitals. For the entire cohort, the rate of nosocomial infection decreased from 16.9% in 2002 to 14.5% in 2006. For infants admitted to NICUs participating in at least 1 quality-improvement event, there was an associated decreased risk of nosocomial infection (odds ratio: 0.81 [95% confidence interval: 0.68-0.96]) compared with those admitted to nonparticipating hospitals. CONCLUSIONS: The structured intervention approach to quality improvement in the NICU setting, using a toolkit along with attendance at a workshop and/or Web cast, is an effective means by which to improve care outcomes.

Gestational diabetes mellitus (GDM) has increased dramatically in the past 20 years together with the obesity epidemic. Mirroring the increase in incidence of GDM is increasing use of endocrine disrupting chemicals (EDCs). EDCs are structurally similar to endogenous hormones and interfere with synthesis, secretion, activity, or elimination of natural hormones, resulting in adverse health effects, including diabetes, obesity, developmental disorders, etc. Although the association between bisphenol A (BPA), a well-studied EDC, and type 2 diabetes has been repeatedly investigated in epidemiological and animal studies, there is a dearth of studies examining EDCs and GDM. In fact, the impact of environmental toxins on perinatal health outcomes has largely been overlooked. Recognizing this research gap, the American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, and International Federation of Gynecology and Obstetrics recently joined leading scientists and clinicians in a call for action to prioritize research in the consequences of exposure to toxic environmental agents on women's health. Evidence is emerging to suggest signaling molecules and EDCs are involved in the control of microRNA (miRNA) expression in trophoblast cells. We reviewed existing scientific evidence of EDCs as a risk factor for GDM as well as the potential role of miRNA in this association.

BACKGROUND: Peramivir, an investigational intravenous neuraminidase inhibitor in Phase 3 trials for hospitalized patients, was made available during the 2009 H1N1 influenza pandemic under the Emergency Investigational New Drug (eIND) regulations. We describe the clinical characteristics and outcomes of all patients for whom peramivir was requested under the eIND. METHODS: After obtaining eIND approval from the Food and Drug Administration and local institutional review board approval, clinicians caring for hospitalized patients with influenza administered intravenous peramivir and collected information on demographic characteristics, clinical characteristics, and outcomes. RESULTS: From April through October 2009, peramivir was requested for 42 patients and administered to 20 adults and 11 children. At hospitalization, all patients had rapidly progressing, radiographically confirmed viral pneumonia with respiratory failure, and all but 1 patient required mechanical ventilation. In most patients, including 1 person with documented oseltamivir-resistant infection, the illness had progressed despite oseltamivir treatment. Peramivir was administered for 1-14 days (median duration, 10 days). The 14-day, 28-day, and 56-day survival rates were 76.7%, 66.7%, and 59.0%, respectively. Peramivir was generally well tolerated. CONCLUSIONS: Intravenous peramivir was well tolerated and was associated with recovery in most patients hospitalized with severe 2009 H1N1 influenza viral pneumonia and treated under an eIND.

Of 33 patients who underwent 49 breast implantations for reconstructive surgery, 8 (24%) patients developed implant infections. All 8 of these patients were among a subgroup of 15 having immediate breast reconstructions with tissue expander implants after simple or modified radical mastectomy (a 53% infection rate). The infection rate increased substantially when bilateral procedures involving implants were performed as opposed to unilateral implants. Nine implants were removed (an overall implant loss rate of 18%). Patients who underwent other breast reconstruction techniques (i.e., including immediate reconstruction with permanent implants or delayed reconstruction with or without tissue expanders) did not develop infection unless they had had simultaneous immediate reconstruction with a tissue expander in the contralateral breast. The most frequently isolated organism was the coagulase-negative staphylococcus. The study concludes that neither the tissue expander nor immediate reconstruction is a risk factor, but the combination may lead to an unacceptable infection rate, especially in the face of bilateral breast procedures.

BACKGROUND: Aprotinin is frequently used in high-risk cardiac surgery patients to decrease bleeding complications and transfusions of packed red blood cells (PRBC). Transfusions of PRBC are known to directly increase the risk of new onset postoperative renal failure (ARF) in cardiac surgery patients. A recent highly publicized report implicated aprotinin as an independent causal factor for postoperative renal failure, but ignored the potential confounding affect of numerical PRBC data on ARF. We sought to investigate that claim with an analysis that included all perioperative risk factors for renal failure, including PRBC transfusion data. METHODS AND RESULTS: Prospectively collected patient data from 12 centers contributing to the Merged Cardiac Registry, an international multicenter cardiac surgery database, operated on between January 2000 and February 2006 were retrospectively analyzed. A previously published risk model for ARF incorporating 12 variables was used to calculate a baseline ARF risk score for each patient in whom those variables were available (n=15,174). After adding transfused PRBC data 11,198 patients remained for risk-adjusted assessment of ARF in relation to aprotinin use. Risk-adjusted multivariable analyses were carried out with, and without, consideration of transfused PRBC. Aprotinin was used in 24.6% (2757/11,198). The overall incidence of ARF was 1.6% (180/11,198) and was higher in the aprotinin subset (2.6%, 72/2757 versus 1.3%, 108/8441; P<0.001). The incidence of ARF directly and significantly increased with increasing transfusions of PRBC (P<0.001). Risk-adjusted analysis without transfused PRBC in the model suggests that aprotinin significantly impacts ARF (P=0.008; OR=1.5). However, further risk adjustment with the addition of the highly significant transfused PRBC variable (P<0.0001; OR=1.23/transfused PRBC) to the model attenuates the purported independent affect of aprotinin (P=0.231) on ARF. CONCLUSIONS: The increase in renal failure seen in patients who were administered aprotinin was directly related to increased number of transfusions in that high-risk patient population. Aprotinin use does not independently increase the risk of renal failure in cardiac surgery patients.