Wayne Memorial Hospital

Real-time RT-PCR is considered the gold standard confirmatory test for coronavirus disease 2019 (COVID-19). However, many scientists disagree, and it is essential to understand that several factors and variables can cause a false-negative test. In this context, cycle threshold (Ct) values are being utilized to diagnose or predict SARS-CoV-2 infection. This practice has a significant clinical utility as Ct values can be correlated with the viral load. In addition, Ct values have a strong correlation with multiple haematological and biochemical markers. However, it is essential to consider that Ct values might be affected by pre-analytic, analytic, and post-analytical variables such as collection technique, specimen type, sampling time, viral kinetics, transport and storage conditions, nucleic acid extraction, viral RNA load, primer designing, real-time PCR efficiency, and Ct value determination method. Therefore, understanding the interpretation of Ct values and other influential factors could play a crucial role in interpreting viral load and disease severity. In several clinical studies consisting of small or large sample sizes, several discrepancies exist regarding a significant positive correlation between the Ct value and disease severity in COVID-19. In this context, a revised review of the literature has been conducted to fill the knowledge gaps regarding the correlations between Ct values and severity/fatality rates of patients with COVID-19. Various databases such as PubMed, Science Direct, Medline, Scopus, and Google Scholar were searched up to April 2021 by using keywords including "RT-PCR or viral load", "SARS-CoV-2 and RT-PCR", "Ct value and viral load", "Ct value or COVID-19". Research articles were extracted and selected independently by the authors and included in the present review based on their relevance to the study. The current narrative review explores the correlation of Ct values with mortality, disease progression, severity, and infectivity. We also discuss the factors that can affect these values, such as collection technique, type of swab, sampling method, etc.

Although many observations indicate that bile acids and their derivatives may be bound by serum proteins, little information upon the quantitative aspects of this reaction is available. Lecomte du Nofiy (1) observed that the activity of bile salts

Journal Article The Susceptibility of Bacteroides fragilis to 24 Antibiotics Get access Jay Ward Kislak Jay Ward Kislak From the Infectious Disease and Immunology Division, Department of Medicine, New York University School of Medicine; the Medical Service, Goldwater Memorial Hospital; and the Infectious Disease Research Laboratory, French Hospital Division of the French and Polyclinic Medical School and Health Center, New York, New York Search for other works by this author on: Oxford Academic PubMed Google Scholar The Journal of Infectious Diseases, Volume 125, Issue 3, March 1972, Pages 295–299, https://doi.org/10.1093/infdis/125.3.295 Published: 01 March 1972 Article history Received: 26 January 1971 Revision received: 30 September 1971 Published: 01 March 1972

Lack of specific analytic methods has hitherto prevented exact studies of the effect of liver dis- ease upon the concentration of bile acids in the serum. Until recently it has not been possible to measure the serum concentration of bile acids other than cholic acid. Various modifications-of the Pettenkofer reaction have been employed to deter- mine the serum concentration of cholic acid. Re- ports of "normal" serum cholic acid concentrations of 0.0 mg. per cent (1), 0.4 mg. per cent (2), 0.6 to 2.2 mg. per cent (3), and 3 to 6 mg. per cent (4) reflect the non-specific nature of this reaction.

A derivative of quinine formed in minced rabbit liver has been isolated by Kelsey et al. (I), and identified by Mead and Koepfli (2) as a carbostyril.Hence quinine is oxidized in liver with replacement of the hydrogen atom in position 2 of the quinoline ring by a hydroxy group.Analogous oxidation products are excreted by men receiving the four principal cinchona alkaloids.This change is important in the chemotherapy of malaria, because the oxidation of these compounds markedly reduces their antimalarial activity (3).The activity of some quinoline compounds can be greatly enhanced if this oxidation is prevented by appropriate substitution (4).The nature of the metabolic system able to perform this oxidation is consequently of considerable pharmacological interest, and it was hoped that its biochemical function as well could be approached by studying the reaction with a series of quinoline derivatives.By the use of such compounds as substrates, the enzyme responsible for their oxidation has been prepared in about 5 per cent purity.It specifically acts on unsaturated heterocyclic compounds with an active a-hydrogen and is intimately associated with the flavoprotein, liver aldehyde oxidase. MethodsReagent-The synthetic antimalarials used were supplied by various laboratories cooperating with the malaria program of the Office of Scientific Research and Development.These * 'SN number" compounds are described fully elsewhere (4), but were generally of a high degree of purity.Isoquinoline, quinaldine, quinoline, and crotonaldehyde were redistilled in uacuo, and the bases recrystallized as the acid salts before use.Coenzyme I (5) and diaphorase (6) were prepared by the standard methods.Other compounds were used as obtained commercially.Propamidine was kindly

Aggressive natural killer cell leukemia (ANKL) is a systemic NK-cell neoplasm, almost always associated with Epstein-Barr virus (EBV). Rare cases of EBV-negative ANKL have been described, and some reports suggested more indolent behavior. We report the clinicopathologic, immunophenotypic, and molecular characteristics of 7 EBV-negative ANKL. All patients were adults, with a median age of 63 years (range 22 to 83 y) and an M:F ratio of 2.5:1. Five patients were White, 1 Black, and 1 Asian. All patients presented acutely, with fever (6/7), cytopenias (6/7), and splenomegaly (4/7). Four patients had lymphadenopathy, 4 had extranodal disease. Bone marrow involvement was present in 5, with hemophagocytosis in 3. Peripheral blood was involved in 5 with the neoplastic cells containing prominent azurophilic granules. By immunohistochemistry and/or flow cytometry, the tumor cells lacked surface CD3 and were positive for CD56 (7/7), CD2 (5/5), CD8 (3/7), CD30 (4/5), and granzyme-B (6/6). They were negative for CD4, CD5, βF1, TCRγ, LMP1, and EBV-encoded RNA. Polymerase chain reaction for TCRG clonality was polyclonal. Mutational analysis revealed missense mutations in the STAT3 gene in both cases studied. Median survival was 8 weeks from the onset of disease. One patient received allogeneic bone marrow transplant and is alive with no disease (follow-up 15 mo). EBV-negative ANKL exists but is rare. It tends to occur in older patients and is indistinguishable clinically and pathologically from EBV-positive ANKL, with a similar fulminant clinical course. The high prevalence of Asian patients seen with EBV-positive disease seems less evident with EBV-negative cases.

UNLABELLED: Delayed closure of foot ulcers is a primary factor leading to lower extremity amputation in patients with diabetes, creating great demand for products or therapies to accelerate the rate of wound closure in this population. This study (ClinicalTrials.gov Identifier: NCT02209051) was designed to evaluate dehydrated amniotic membrane allograft (DAMA) (AMNIOEXCEL, Derma Sciences Inc, Princeton, NJ) plus standard of care (SOC) compared to SOC alone for the closure of chronic diabetic foot ulcers (DFUs). MATERIALS AND METHODS: This prospective, open-label, randomized, parallel group trial was implemented at 8 clinical sites in the United States. Eligibility criteria included adults with type 1 or type 2 diabetes mellitus who have 1 or more ulcers with a Wagner classification of grade 1 or superficial 2 measuring between 1 cm2 and 25 cm2 in area, presenting for more than 1 month with no signs of infection/osteomyelitis; ABI > 0.7; HbA1c Less than 12%; and serum creatinine less than 3.0 mg/dL. Eligible subjects were randomized (1:1) to receive either SOC alone (n = 14) or DAMA+SOC (n = 15) until wound closure or 6 weeks, whichever occurred first. The endpoint was the proportion of subjects with complete wound closure (defined as complete reepithelialization without drainage or need for dressings). RESULTS: Thirty-five percent of subjects in the DAMA+SOC cohort achieved complete wound closure at or before week 6, compared with 0% of the SOC alone cohort (intent-to-treat population, P = 0.017). There was a more robust response noted in the per protocol population, with 45.5% of subjects in the DAMA+SOC cohort achieving complete wound closure, while 0% of SOC-alone subjects achieved complete closure (P = 0.0083). No treatment-related adverse events were reported. CONCLUSION: The results suggest DAMA is safe and effective in the management of DFUs, but additional research is needed.

Sodium acetate-1-C 14 was administered to anesthetized rats by continuous intravenous infusion, with simultaneous administration of d,l-α-amino-γ-phenylbutyric acid. Radioactivity measurements were made of respiratory CO 2 , cholesterol, fatty acids and urinary acetylamino acid. From the radioactivity data, calculations were made of rates of acetate turnover and of synthesis of cholesterol and fatty acids from acetate. Data on these metabolic functions are given for normal rats on a stock diet and for animals on a lipid-free ration. Similar experiments were carried out in rats fed thyroid powder and thiouracil. The rate of acetate turnover, and rates of synthesis of cholesterol and fatty acids from acetate, were found to be directly proportional to the basal oxygen consumption rates of the animals. The altered rates of lipid synthesis from acetate resulted, in the main, from absolute changes in rates of the reactions involved, and only to a small extent from shifts in the relative magnitudes of different pathways of acetate metabolism.

Pamaquine (6-methoxy-8-amino [N-diethylaminoisopentyl] quinoline) is recognized to be a potentially dangerous drug. However, a definitive appraisal of its hazard had not been achieved at a time when the further exploration of the antima- larial activity of the 8-aminoquinolines was con- sidered advisable. Pamaquine toxicity can in- volve the gastro-intestinal tract, the central nerv- ous system, and the circulating blood. Symptoms referable to the gastro-intestinal tract and the cen- tral nervous system may be annoying, but there is no evidence that they constitute a hazard to life or persist beyond the termination of therapy. Effects on the blood do constitute a serious hazard and are considered in this paper.

The purpose of this quasi-experimental study was to determine the effects of a nurse-directed self-management program on dyspnea and self-efficacy levels in patients with chronic obstructive pulmonary disease (COPD). The Health Belief Model and the Theory of Self-Efficacy provided the theoretical framework for the study. The sample included 10 COPD patients from rural North Carolina who attended a 6-week nurse-directed self-management program. Dyspnea and self-efficacy were measured before and after the program by using a vertical visual analogue scale for dyspnea and the COPD Self-Efficacy Scale. A single-group quasi-experimental design that incorporated a pretest and a posttest was used. Paired t tests were used to compare the pretest and the posttest levels of dyspnea and self-efficacy. The findings revealed no significant change in levels of dyspnea after the program. Levels of self-efficacy, however, were found to have increased at a statistically significant level (p < .001) following the program. This study indicates that using a group teaching method to teach self-management skills improved self-efficacy levels.

Journal Article The Arterial Wall. Aging, Structure, and Chemistry Get access The Arterial Wall. Aging, Structure, and Chemistry, edited by Albert I. Lansing, The Williams & Wilkins Co., Baltimore, 1959, 259 pages, $7.50. J. Murray Steele, M.D. J. Murray Steele, M.D. Goldwater Memorial Hospital New YorkNew York Search for other works by this author on: Oxford Academic PubMed Google Scholar Journal of Gerontology, Volume 15, Issue 3, July 1960, Pages 280–281, https://doi.org/10.1093/geronj/15.3.280 Published: 01 July 1960

Granulocytic sarcoma is an unusual form of tumefaction caused by acute granulocytic leukemia. On rare occasions, the lesion precedes the leukemic phase and presents as a mass with a normal peripheral white cell count. This report describes the initial manifestation of granulocytic sarcoma by vaginal cytology in a 39-year-old female with Down's syndrome. Six days after admission, the patient died of acute peritonitis following spontaneous perforation of the bowel. Autopsy revealed involvement of cervix, vagina, bowel wall and one pelvic lymph node by granulocytic sarcoma. Bone marrow examination confirmed the preleukemic stage of the disease. Cytologically, the malignant cells occurred singly. No nucleoli were seen. The differential diagnosis between malignant lymphoma and granulocytic sarcoma rests upon a positive naphtol AS-D chloroacetate esterase stain in granulocytic sarcoma. This stain may be performed on paraffin-embedded sections or on smears.

PRINZMETAL and Kennamer1 first reported on the use of ACTH in 1954 to correct complete heart block secondary to myocardial infarction. They believed that, in incomplete septal infarction or in infarctions near the septum, the interference with atrioventricular conduction that often culminates in complete heart block may be due in many cases not to destruction but only to inflammation of the atrioventricular node and the specialized conductive tissue in the septum. If this is true, anything that reduces inflammation in body tissues should help re-establish normal conduction in these cases. The anti-inflammatory action of hormones elaborated by the adrenal cortex . . .

OBJECTIVE: To determine whether a skills laboratory for corneal foreign body and rust ring removal improves self-assessed skill and confidence. METHODS: A prospective trial was conducted as part of the didactic curriculum of a university-based residency program in emergency medicine (EM). A convenience sample of 26 EM residents and five fourth-year medical students participated. The skills laboratory used model corneas made by coating 3.2-cm glass spheres with a 1-2-mm film of paraffin. Foreign bodies were simulated by embedding small pieces of metal into the paraffin. Rust rings were simulated by dipping a hot, straightened paper clip into a rust-colored crayon and then into the paraffin. The model eyes fit into a life-sized model of a human head. Participants removed the foreign bodies and rus rings under supervision, using the slit lamp. Each participant anonymously completed a questionnaire before and after participating in the skills laboratory. The questionnaire recorded educational level, previous experience, and self-assessed comfort and skill levels (0 = lowest, 10 = highest). RESULTS: Most (66%) of the participants had not previously removed a corneal foreign body; 86% had not previously removed a rust ring. On a ten-point scale, the median comfort level for removing a foreign body rose from 2 to 7, and the self-assessed skill level rose from 1 to 7 (p = 0.0001). Similar improvements in self-assessed comfort and skill levels were seen for rust ring removal. CONCLUSIONS: Participation in this skills laboratory significantly improved the self-reported comfort and self-assessed skill levels in removing corneal foreign bodies and rust rings. This technique provides useful practice of a fine-motor procedural skill requiring eye-hand coordination prior to supervised application of these skills in clinical practice.

Journal Article The Peril of Deprofessionalization Get access R. David Anderson, B.S. R. David Anderson, B.S. Director of Pharmacy Waynesboro Community Hospital, Waynesboro, VA Address correspondence to Mr. Anderson at 6 Pelham Green, West, Waynesboro, VA 22980- 1561 rdandy1@cfw.com. Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, Volume 61, Issue 22, 15 November 2004, Pages 2373–2379, https://doi.org/10.1093/ajhp/61.22.2373 Published: 15 November 2004

Chronic regional pain syndrome refers to a class of disorders thought to involve common neuropathic and clinical features. These disorders usually are caused by injury, and they manifest in pain and sensory changes that are disproportionate in intensity, distribution, and duration to the underlying pathology. The result of these injuries is significant impairment of motor function over time. This article is divided into two parts. Part I discusses background information such as pain, pathophysiology, diagnosis, clinical stages, and the most common treatment modality, sympathetic nerve blocks. Part II, discusses alternate treatment modalities, such as sympathectomy, physical therapy, stimulators, trigger point injections, acupuncture, tourniquet effects, placebo effects, and amputation.

Many hematologic disorders are accompanied by coagulation defects which, in women of childbearing age, can lead to severe menorrhagia. We have found it desirable and possible to render and maintain such patients amenorrheic. Twenty-nine patients were treated by one of three drug regimens: A = norethynodrel + mestranol, B = depo-medroxyprogesterone acetate, and C = depo-medroxyprogesterone acetate + conjugated estrogens. Acute leukemia and immune thrombocytopenic purpura were the most frequent diagnoses. Significant breakthrough bleeding occurred in 7 women (24%). Two were in group A (22%), 3 in B (38%), and 2 in C (17%). Although not statistically significant, these differences suggest that concurrent administration of estrogen and progestin is attended by less breakthrough bleeding than the administration of progestin alone.

Malignant hyperthermia (MH) is a medical emergency that all perioperative nurses should be prepared to handle. Patients with the inherited MH trait have a rare skeletal muscle disease that causes them to develop life-threatening hyperthermia (ie, body temperatures of 43.3 degrees C [110.0 degrees F] or higher) at the time MH-triggering agents are administered to induce general anesthesia or shortly thereafter. The incidence of MH episodes is reported to be 1 in every 12,000 pediatric anesthetic procedures and 1 in every 40,000 adult anesthetic procedures. The MH syndrome also is characterized by continuous skeletal muscle rigidity, hypermetabolism, hypercapnia, tachypnea, and tachycardia that result in cardiac arrest and death if left untreated. Perioperative staff members' knowledge of MH, the care of MH-susceptible patients, and adequate preparation for MH crises are the cornerstones of successful patient outcomes to this life-threatening syndrome.

Sepsis affects 750 000 hospitalized patients in the United States every year, according to the Centers for Disease Control and Prevention.1 In addition, a survey of California hospitals by Kaiser Permanente found that sepsis was a factor in approximately 44% to 55% of hospital deaths between 2010 and 2012.1 From 1997 to 2005, the cost to the US health care system for pneumonia and sepsis grew twice as fast as the overall growth in hospital charges. By 2005 the cost for pneumonia and sepsis totaled $54 billion per year, an increase of approximately 180% from the 1997 cost.2,3Sepsis has been gaining national attention for various reasons. The substantial mortality rate, length of stay, and readmission rate are obvious patient factors contributing to this attention. The heightened awareness also reflects a financial motivation driven by Centers for Medicare & Medicaid Services regulations requiring hospitals to submit data related to sepsis treatment. With the concerning mortality rate and heavy focus on treatment of the septic patient, it is no secret that sepsis management is of top priority in many health care systems.Chambersburg Hospital is a 250-bed community care hospital within the Summit Health System. Sepsis is the most common admission diagnosis at our facility. We admitted 458 patients with severe sepsis and septic shock from October 2014 through September 2015. During that time, our mortality rate was 17.7%, our average length of stay was 7.51 days, and our 30-day all-cause readmission rate was 15.6%. Because of these compelling data and the national push from the Centers for Medicare & Medicaid Services, we decided to develop a team to focus on sepsis care.The newly formed team believed a standardized approach for managing sepsis patients would lead to improved patient outcomes, decreased morbidity and mortality, and decreased length of stay. The team’s goal was to develop tools and strategies to achieve standardized care of sepsis patients throughout our facility.An initial team was formed to develop a plan for implementing the 3-hour bundle in the emergency department. This bundle includes measurement of plasma lactate level, collection of a blood sample for culture before antibiotic treatment, administration of broad-spectrum antibiotics, and administration of intravenous crystalloid fluids at 30 mL/kg to treat hypotension.Several months after the rollout from the 3-hour bundle team, our team used lean methodology to standardize the 6-hour bundle process (vasopressor administration as needed, a focused examination by the health care provider, and measurement of a second plasma lactate level), to develop a process for sepsis detection on the floor, to improve handoff of patients with severe sepsis from the emergency department to the critical care department, and to standardize treatments such as administration of an intravenous fluid bolus of 30 mL/kg.Our multidisciplinary team consisted of critical care and medical-surgical leadership personnel, critical care and medical-surgical staff nurses, a clinical nurse specialist, a pulmonologist, a quality management registered nurse (RN), and a hospitalist physician. The team also used the expertise of personnel from other disciplines, including respiratory therapy, laboratory, pharmacy, and information technology.The team’s initial meeting took place in February 2016, around the same time as the publication of new sepsis definitions and assessment tools (the Sequential Organ Failure Assessment [SOFA] and Quick Sequential Organ Failure Assessment [qSOFA]) in the Journal of the American Medical Association.4 The team decided to adopt the qSOFA and SOFA tools to aid in more timely detection of sepsis in hospitalized patients. The qSOFA tool was built into our documentation system and implemented on 2 pilot units (Figure 1). Two months after our pilot program started we assessed the process, and after minor changes we implemented the qSOFA on 2 additional patient care units. We continued to roll out 2 units at a time until all adult inpatient units, excluding the behavioral health and family birthing units, were using the monitoring tool.A qSOFA score of 2 of more prompts the RN to activate a sepsis alert team (Figure 2). We designed the sepsis alert team to respond and assess patients with elevated qSOFA scores. The sepsis alert team was implemented simultaneously with the qSOFA monitoring tool. This team is composed of a critical care resource/charge nurse, a respiratory therapist, and a laboratory phlebotomist. The critical care RN evaluates the most recent qSOFA score, completes an assessment of the patient, and uses a standardized physician-approved protocol to order laboratory studies that are needed to complete the SOFA score. Once these studies are completed, the responding RN notifies the attending provider of the SOFA score. The physician can then use order sets created by the multidisciplinary team to include the most up-to-date recommendations for sepsis treatment. A provider who diagnoses sepsis can order an intravenous fluid bolus of 30 mL/kg, appropriate broad-spectrum antibiotics, follow-up plasma lactate level, and vasopressors as warranted. The responding critical care RN initiates fluid and antibiotic treatments and facilitates transfer to the appropriate level of care.The team felt that handoff was a key focus for effective continuation of care. We developed a checklist for handoffs between different levels of care (Figure 3). This tool effectively communicates care that has been completed and enables the primary RN to ensure completion of the bundle components.Within the first 5 months of implementation of the sepsis alert process, the critical care team responded to 30 sepsis alerts. Of those 30 patients, 25 received a change in their care; 15 of these had confirmed diagnoses of sepsis. The “false” alerts included conditions such as hypovolemia and respiratory distress, which still benefited from intervention from the critical care team.The mortality rate dropped from 17.7% (October 2014 through September 2015) to 12.9% (October 2015 through September 2016), which equates to 38 lives saved within that year. The mean length of stay at the hospital decreased from 7.51 days to 6.21 days, which represents 1035 days saved. This reduction in length of stay saved our facility approximately $517 500. Finally, the readmission rate decreased from 15.6% to 12.6%. These findings suggest that we have made progress in our efforts with sepsis. This progress could be attributed to the interventions we put in play, increased staff awareness, or a combination of both.Having bedside nurses use a clinically relevant tool can aid in early recognition and identification of sepsis.5 Our process implementation has shown us that a trained critical care nurse available to respond to this early recognition can effectively assess high-risk patients and initiate a preestablished protocol leading to early intervention and improved outcomes.Using the most recent guidelines to develop a standardized protocol that is embedded in the documentation can improve outcomes for this patient population. Our team recognizes that our successful outcomes were the result not only of the process improvements described above but also of the extensive education that we disseminated. We used newsletters, huddle talking points, computer-based learning, videos, and education stations to ensure that everyone had an opportunity to understand the new process. We also conducted a sepsis T-shirt campaign, giving all hospital staff T-shirts to promote sepsis awareness. The extensive educational campaign informed clinical staff that the critical care resource RN was their point of contact for questions related to sepsis.Beyond the challenge of educating all staff, the team was faced with skepticism from some of our providers. The protocol developed was nurse driven but needed to be approved by multiple physician groups before it could be implemented. Some providers expressed concerns related to large volumes of intravenous fluid and screening tools used for all admitted patients. The team enlisted the support of provider champions in different disciplines to help overcome these challenges.Early recognition and treatment of potential sepsis patients can decrease mortality, length of stay, and readmission rates. Assessment of high-risk patients and use of a standardized protocol improves outcomes for these patients.

Students who completed the live traditional laboratory course and those who completed the course in the virtually facilitated setting performed well. Course evaluations revealed student satisfaction with the course and instructor in both settings. These findings suggest that a virtually facilitated laboratory course does not hinder student performance and provides a similar experience as a traditional classroom.