Sentara Rockingham Memorial Hospital Medical Center

: Alprazolam is one of the most widely prescribed benzodiazepines for the treatment of generalized anxiety disorder and panic disorder. Its clinical use has been a point of contention as most addiction specialists consider it to be highly addictive, given its unique psychodynamic properties which limit its clinical usefulness, whereas many primary care physicians continue to prescribe it for longer periods than recommended. Clinical research data has not fully shed light on its "abuse liability," yet it is one of the most frequently prescribed benzodiazepines. "Abuse liability" is the degree to which a psychoactive drug has properties that facilitate people misusing it, or becoming addicted to it, and is commonly used in the literature. We have replaced it in our manuscript with "misuse liability" as it reflects a more updated terminology consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In this paper, we have reviewed alprazolam's indications for use, its effect on pregnant women, misuse liability, withdrawal syndrome, pharmacodynamic properties, and suggest better clinical prescription practice of alprazolam by presenting an indepth theory of its clinical effects with use and withdrawal.

New England Sanitarium and Hospital School of Nursing, Stoneham, Massachusetts; Ph.D., University of Michigan, Ann Arbor, Michigan Rockingham Memorial Hospital, Harrisonburg, Virginia; B.S. Columbia Union College, Takoma Park, Maryland

We present a case report of a patient on long-term dialysis who underwent percutaneous vertebroplasty to treat a painful intrabody vertebral cleft and who subsequently experienced a refracture of the posterior portion of the same vertebral body, resulting in anterior displacement of the cement through the anterior cortex. The case raises the question whether, in some patients, the marrow space should be filled with cement in addition to the cleft.

CT fluoroscopy may be used as a rapid and effective means of guiding needle placement when performing selective lumbar nerve root blocks. In this set of patients, the average external radiation dose was 0.73 mrem per procedure, with an average of 2 seconds of CT-fluoroscopy time and four images per procedure. Average physician room time was 7 minutes. Use of intermittent CT fluoroscopy during lumbar selective nerve root blocks can result in minimal radiation dose levels and procedure times that are comparable to fluoroscopic guidance.

Lumbar epidural injections are typically performed blindly or with fluoroscopic guidance. CT fluoroscopy (CTF) can be used to guide needle placement precisely and rapidly, allowing visualization of the optimal needle path and identifying potential problems such as severe stenosis and synovial cysts before needle insertion. Operator and patient radiation dose is minimal when using the intermittent CTF technique and low mAs. By using this technique, just more than 2000 epidural steroid injections have been performed with no major complications. CTF is a useful guidance tool when performing lumbar epidural injections.

While both fluoroscopic and CT-guidance during cervical nerve root blocks have been well documented in the literature, the use of CT fluoroscopy (CTF) has not. CTF is well suited to provide imaging guidance during these procedures due to its combination of excellent anatomic detail, relatively low radiation dose and the ability to perform an initial dynamic contrast injection, and is a viable alternative to fluoroscopic guidance. Details of the technique along with the initial experience at one institution are presented.

Due to increasing concern over potential cross-infection during cardiopulmonary resuscitation (CPR), a number of disposable resuscitators have become commercially available. The wearing of disposable medical gloves by persons performing CPR has also become commonplace. In this study, we evaluated the effects of hand size, use of disposable medical gloves, and number of hands used (one versus two) on the volumes delivered by five adult disposable resuscitators. METHOD: Persons familiar with bag-valve ventilation were recruited to participate in the study—eight with small hands, eight with medium hands, and eight with large hands. Ventilation was delivered to one side of a Vent-Aid training test lung (TTL), and volumes were measured with a BEAR VM-90. In random order, each participant ventilated the TTL with all combinations of one hand/two hands, gloves/no gloves, and each of the following resuscitators: Code Blue, Hospitak, Pulmanex, Mercury, and Ambu SPUR. The participants were instructed to ventilate the TTL as they would ventilate a patient. RESULTS: The mean ± SD volumes (in liters) were small hands = 0.68 ± 0.15, medium hands = 0.71 ± 0.18, large hands = 0.81 ± 0.19 (p=0.006); gloves = 0.73±0.19, no gloves = 0.73±0.18 (p = 0.80); one hand = 0.62 ± 0.12, two hands = 0.84 ± 0.17 (p<0.0001; Code Blue = 0.79 ± 0.14, Hospitak = 0.56±0.11, Pulmanex = 0.71 ±0.15, Mercury = 0.77 ± 0.18, SPUR = 0.83 ± 0.2 (p < 0.0001). CONCLUSIONS: The use of gloves did not significantly affect volume delivery. Delivered volumes did increase significantly as hand size increased and as number of hands used to squeeze the bag increased, and observed differences in volume delivery between brands of resuscitators may be clinically important in some cases. This study emphasizes the importance of squeezing the resuscitator with two hands during bag-valve ventilation .

Background Parenteral polymyxin use declined after the 1960s, due to safety concerns. An increase in multidrug-resistant (MDR) gram-negative infections and a shortage of new agents have prompted increased use of parenteral polymyxin. Objective TO describe our clinical experience with parenteral polymyxin B for MDR gram-negative bacteremia and urinary tract infection (UTI). Methods Paper pharmacy records were used to identify patients aged 18 years or older, presence of MDR gram-negative bacteremia or UTI, and use of parenteral polymyxin B for at least 48 hours. Electronic and paper patient records were then retrospectively reviewed. Polymyxin B susceptibility was evaluated using the Kirby-Bauer method. MDR isolates were defined as resistant to at least 3 antimicrobial classes, excluding polymyxin B. Microbiologic clearance was defined by 1 repeat urine or 2 repeat blood cultures that were sterile or growing different organisms. Secondary outcomes included hospital mortality and nephrotoxicity, defined as an increase in serum creatinine of 0.5 mg/dL or more, or a 50% reduction in creatinine clearance. Results: Seventeen infections in 16 patients were treated with polymyxin B (1 pt. had 2 infections that were analyzed separately). Microbiologic clearance occurred in 14 of 16 (88%) cases of MDR gram-negative bacteremia or UTI in which repeat cultures were done. Ten of 16 patients died (all-cause mortality 63%). Five patients required hemodialysis prior to polymyxin B use. Six (55%) of the remaining 11 patients with baseline renal insufficiency developed nephrotoxicity, and none of them required hemodialysis. The mean ± SD number of days from the initiation of therapy to the onset of nephrotoxicity was 7.5 ± 2.3 (range 4–10) days. Three (50%) of 6 patients with nephrotoxicity died. Conclusions: Our data suggest that polymyxin B may be effective for MDR gram-negative infections in patients with limited therapeutic options, but precautions should be taken to avoid toxicity.

Needle biopsy to evaluate findings on MRI that could alter surgical planning has been recommended. This study is a retrospective review to evaluate MRI preoperative staging with biopsy confirmation of suspicious findings. A total of 184 women were diagnosed with breast cancer between January 2004 and June 2008. Of these, 79 underwent bilateral MRI before definitive surgery and 105 did not. Suspicious findings on MRI, mammography, or clinical exam underwent additional needle biopsy at the discretion of the surgeon. A retrospective chart review was performed to compare the two groups with respect to rates of reoperative surgery, successful breast conservation, and confirmatory biopsies. Sensitivity and specificity of MRI for preoperative staging is 0.81 and 0.84, respectively. There were no significant differences in demographics or cancer characteristics between the MRI and non-MRI groups. Fewer women who underwent preoperative MRI staging required repeat breast surgery (11% versus 26%, p = .04) or repeat axillary surgery (10% versus 20%, p = .05). There is no difference in the proportion of women who successfully completed conservative therapy and those treated radically (52% versus 53%), but there is a significant increase in women who undergo additional needle biopsy to confirm suspicious findings after initial diagnosis in the MRI group (25% versus 11% p = .04). In this study, mastectomy rates are not increased; suggesting that women who undergo mastectomy following staging would undergo mastectomy following failed conservative therapy if they were not staged. The downside of this improvement is a 14% increase in women who require confirmatory biopsy.

Staphylococcus warneri does not generally cause serious infections in humans. We report a case of endocarditis in a healthy individual with no known past medical history. S. warneri was identified in her blood cultures and echocardiographic evidence confirmed the diagnosis of bacterial endocarditis. There was no apparent cause for her infection, and risk factors such as invasive treatment or medical implant were not present. This rare clinical presentation illustrates the importance of not overlooking low virulence species of Staphylococcus, as they can potentially serve as opportunistic etiological agents for endocarditis, especially among the elderly population.

BACKGROUND: US Latinos have greater prevalence of type 2 diabetes (diabetes), uncontrolled diabetes and diabetes co-morbidities compared to non-Latino Whites. They also have lower literacy levels and are more likely to live in poverty. Interventions are needed to improve diabetes control among low-income Latinos. METHODS AND DESIGN: This randomized clinical trial tested the efficacy of a culturally- and literacy-tailored diabetes self-management intervention (Latinos en Control) on glycemic control among low-income Latinos with diabetes, compared to usual care (control). Participants were recruited from five community health centers (CHCs) in Massachusetts. The theory-based intervention included an intensive phase of 12 weekly sessions and a follow-up maintenance phase of 8 monthly sessions. Assessments occurred at baseline, and at 4 and 12 months. The primary outcome was glycosylated hemoglobin (HbA1c). Secondary outcomes were self-management behaviors, weight, lipids and blood pressure. Additional outcomes included diabetes knowledge, self-efficacy, depression and quality of life. The study was designed for recruitment of 250 participants (estimated 20% dropout rate) to provide 90% power for detecting a 7% or greater change in HbA1c between the intervention and control groups. This is a difference in change of HbA1c of 0.5 to 0.6%. DISCUSSION: Low-income Latinos bear a great burden of uncontrolled diabetes and are an understudied population. Theory-based interventions that are tailored to the needs of this high-risk population have potential for improving diabetes self-management and reduce health disparities. This article describes the design and methods of a theory driven intervention aimed at addressing this need.

Seizures in the pediatric population commonly occur, and when proper rescue medication is not administered quickly, the risk of neurologic compromise emerges. For many years, rectal diazepam has been the standard of care, but recent interest in a more cost-effective, safe alternative has led to the investigation of intranasal midazolam for this indication. Although midazolam and diazepam are both members of the benzodiazepine class, the kinetic properties of these 2 anticonvulsants vary. This paper will review available data pertaining to the efficacy, safety, cost, and pharmacokinetics of intranasal midazolam versus rectal diazepam as treatment for acute seizures for children in the prehospital, home, and emergency department settings.

BACKGROUND: Patients in intensive care units are 5 times more likely to have skin integrity issues develop than patients in other units. Identifying the most appropriate assessment tool may be critical to preventing pressure injuries in intensive care patients. OBJECTIVES: To validate the Cubbin-Jackson skin risk assessment in the critical care setting and to compare the predictive accuracy of the Cubbin-Jackson and Braden scales for the same patients. METHODS: In 5 intensive care units, the Cubbin-Jackson and Braden assessments were completed by different clinicians within 61 minutes of each other for 4137 patients between October 2017 and March 2018. Bivariate correlations and the Fisher exact test were used to check for associations between the scores. RESULTS: The Cubbin-Jackson and Braden scores were significantly and positively correlated (r = 0.80, P < .001). Both tools were significant predictors of skin changes and identified as "at risk" 100% of the patients who had a change in skin integrity occur. The specificity was 18.4% for the Cubbin-Jackson scale and 27.9% for the Braden scale, and the area under the curve was 0.75 (P < .001) for the Cubbin-Jackson scale and 0.76 (P < .001) for the Braden scale. These findings show acceptable construct validity for both scales. CONCLUSIONS: The predictive validities of the Cubbin-Jackson and Braden scales are similar, but both are sub-optimal because of poor specificity and positive predictive value. Change in practice may not be warranted, because there are no differences between the 2 scales of practical benefit to bedside nurses.

The persistent hypoglossal artery is a rare perseverance of an embryonic vessel connecting the anterior and posterior circulations and is generally considered to be an incidental finding. This is a case of a patient with an atherosclerotic narrowing at the origin of the persistent hypoglossal artery seen at 3D CT angiography. The pertinent findings and clinical implications of this anomalous vessel are discussed.

AIM: The purpose of this project was to evaluate a partnership model of care delivery on nurse and patient satisfaction and clinical outcomes. BACKGROUND: Care delivery models result in practical staff assignment decisions based on perceived fairness. The division of labour lies in social interaction of participants. Research notes that partnership team models require effective communication skills and delegation abilities to sustain. METHOD: This project used multiple methods in two study sites. A convenience sample was used to assess measures. Institutional Review Board approval obtained. RESULTS: Nurse satisfaction statistically increased in one setting and statistically decreased in the other setting. One statistically significant difference in a clinical outcome was noted. Patient satisfaction, nurse turnover and vacancy rates failed to reveal anything of statistical significance. Observed operational care components improved in both settings. CONCLUSIONS: Care delivery models are determined by a variety of factors of resource availability, unit culture, and quality and patient safety priorities. Identification of preferential structural approaches to guide nursing workflow is needed. IMPLICATIONS FOR NURSING MANAGEMENT: Innovative models of care delivery must be predicated on new role skills of delegation and negotiation for nurses, purposeful oversight and mentoring for sustainable success. Staffing can influence the integrity of care delivery models.

Summary Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis . The cellular immune response to mycobacteria has been characterized extensively, but the antibody response remains underexplored. The present study aimed to examine whether host or bacterial phospholipids induce secretion of IgM, and specifically anti‐phospholipid IgM, antibodies by B cells and to identify the responsible B‐cell subset. Here we show that peritoneal B cells responded to lipid antigens by secreting IgM antibodies. Specifically, stimulation with M. tuberculosis H37Rv total lipids resulted in significant induction of total and anti‐phosphatidylcholine IgM. Similarly, IgM antibody production increased significantly with stimulation by whole Mycobacterium bovis bacillus Calmette–Guérin. The B‐1 subset was the dominant source of IgM antibodies after exposure to cardiolipin. Both CD 5 + B‐1a and CD 5 − B‐1b cell subsets secreted total IgM antibodies after exposure to M. tuberculosis H37Rv total lipids in vitro . Overall, our results suggest that the poly‐reactive B‐1 cell repertoire contributes to non‐specific anti‐phospholipid IgM antibody secretion in response to M. tuberculosis lipids.

OBJECTIVE: To determine the visual, spatial, and/or statistical relationships between food availability/dietary patterns and cardiovascular disease (CVD) in Latin America and the Caribbean (LAC). METHODS: CVD mortality rates and diet information (the number of kilocalories and amount of alcohol, fats, fish, fruits, meats, sugars, and vegetables available per person daily) were obtained from internationally available databases. The analyses included 32 LAC countries with sufficient data (15 of 47 had been excluded for incomplete data). Pearson's correlations (r) were used to determine relationships between diet and CVD mortality, and multiple linear regression analysis was conducted to identify predictors of mortality. ArcGIS version 9.2 (Environmental Systems Research Institute, Inc., Redlands, California, United States) was used to construct maps to explore visual relationships between CVD and diet. RESULTS: No relationships were found between CVD and alcohol, fruit, meat, sugar, or vegetable intake. Statistically significant, positive correlations were found between oil-crops (r = 0.680, P = 0.000) and fish and seafood (r = 0.411, P = 0.019) and CVD mortality. Regression analysis revealed that high kilocalorie availability was a predictor of low CVD mortality (P = 0.020). High oil-crop availability was a predictor of high CVD mortality (P = 0.000). Maps constructed show visual relationships between availability of fish and seafood, kilocalories, and oil-crops, and CVD mortality. CONCLUSIONS: Fish and seafood, kilocalorie, and oil-crop availability appear to be related to CVD mortality, but further investigation is needed. Associations between diet and CVD mortality create the opportunity to target specific countries for nutrition education and CVD prevention programs.

Screening for serum lipid disorders is recommended by numerous specialty societies to identify patients at risk for coronary heart disease (CHD). The best screening tests will identify patients at highest risk for CHD who would benefit from intervention. This report discusses an appropriate test panel to use as the initial screen on a healthy outpatient population, and the required accuracy and precision of the tests from the Laboratory Medicine perspective. Controversy exists regarding which methods to use and at what age testing should begin. The following parameters will be modified as studies continue and new tests are developed. The recommendations are as follows: (1) Total serum cholesterol (TC) and high density lipoprotein-cholesterol (HDL-C) are presently the recommended screening tests for dyslipidemia in the general population; (2) The National Cholesterol Education Program (NCEP) recommends measuring TC and HDL-C in adults with a single sample at 5-year intervals beginning at age 20; (3) The NCEP recommends measuring TC in children with at least one parent having TC > or = 6.24 mmol/L (> or = 240 mg/dL); (4) The NCEP recommends a lipoprotein analysis consisting of a 12-hour fasting TC, HDL-C, triglyceride, and estimated low density lipoprotein-cholesterol (LDL-C) in adults with the following results: (a) TC > or = 6.24 mmol/L (> or = 240 mg/dL); (b) borderline TC of 5.20-6.23 mmol/L (200-239 mg/dL) and HDL-C < 0.91 mmol/L (< 35 mg/dL) or two or more risk factors; (c) desirable TC of < 5.20 mmol/L (< 200 mg/dL), but HDL-C < 0.91 mmol/L (< 35 mg/dL); (5) The NCEP recommends a lipoprotein analysis in children with documented CHD in a parent or grandparent, or in children that have a TC of > or = 5.20 mmol/L (> or = 200 mg/dL); (6) Two or three separate lipoprotein analyses should be done to confirm the LDL-C result before therapeutic intervention. Specimens should be tested from 1 to 8 weeks apart and the results averaged to account for physiologic variability; (7) Enzymatic methods are preferred for TC determination, and should be standardized and traceable to the reference method and materials at the Centers for Disease Control and Prevention (CDC); (8) The analytic method for TC should have a bias against the reference method of < 3% and a within laboratory reproducibility of < 3% coefficient of variation; (9) Chemical precipitation methods are preferred for HDL-C determination.(ABSTRACT TRUNCATED AT 250 WORDS)

As a coagulase negative Staphylococcus species, S. caprae is not considered as a clinically-significant member, unlike S. epidermidis. In this report, we describe a case of sepsis resulting from S. caprae infection. This relatively young woman was in generally good health and contracted S. caprae most probably during her treatment of an acute pulmonary embolism. The purpose of this report is to raise awareness of this otherwise innocuous staphylococcal species in clinical settings.

Over the past 40 years, surgical reconstruction of the breast following mastectomy has become an important aspect of the cancer patient's rehabilitation process. While the surgical emphasis remains on a cure for the cancer, experience with breast reconstruction has not demonstrated any increased rate of cancer recurrence, even when reconstruction is performed immediately following tumor resection. Advances in surgical technique and biotechnology have made post-mastectomy reconstruction possible. The development of silicone gel and saline-filled implants as well as tissue expanders has revolutionized breast reconstruction. The elucidation of musculocutaneous flaps now provides the surgeon with the ability to transfer adequate quantities of vascularized tissue to reconstruct the surgical defects. The advent of microsurgical techniques has provided an additional reconstructive option, with free tissue transfer allowing the plastic surgeon to move musculocutaneous flaps from remote or distant sites to reconstruct the defect. The option of having the reconstruction immediately following the mastectomy procedure is now available to the patient. When reviewing the anatomy of the breast region, the surgeon must consider the mammary gland, its vascular supply, and its lymphatic system. The surgical techniques involved in reconstruction after mastectomy include the use of breast implants and tissue expansion, as well as reconstruction with autogenous tissues. Reconstruction with autogenous tissues includes the use of latissimus dorsi musculocutaneous flap, transverse rectus abdominus musculocutaneous flap, free flap transfer, as well as nipple-areola reconstruction. Breast reconstruction after mastectomy should be undertaken by a plastic and reconstructive surgeon with considerable training and experience with these diversified procedures.