Nocardia can cause systemic infections with varying manifestations. Resistance patterns vary by species. We describe N. otitidiscavarium infection with pulmonary and cutaneous manifestations in a man ...in the United States. He received multidrug treatment that included trimethoprim/sulfamethoxazole but died. Our case highlights the need to treat with combination therapy until drug susceptibilities are known.
Systemic capillary leak syndrome is a rare disorder characterized by dysfunctional inflammatory response, endothelial dysfunction, and extravasation of fluid from the vascular space to the ...interstitial space leading to shock, hemoconcentration, hypoalbuminemia, and subsequent organ failure. The condition may be idiopathic or secondary to an underlying cause, which can include viral infections. Here we describe a patient with acute coronavirus disease 2019 (COVID-19) infection who presented with hemoconcentration, shock, and hypoalbuminemia. The patient subsequently developed rhabdomyolysis and compartment syndrome of all four extremities, requiring fasciotomies. This is the first reported case of systemic capillary leak syndrome associated with COVID-19 infection. This case adds to the evolving spectrum of inflammatory effects associated with this viral infection.
We consider a nanostructure of two coupled ring waveguides with constant linear gain and nonlinear absorption - the system that can be implemented in various settings including polariton condensates, ...optical waveguides or atomic Bose-Einstein condensates. It is found that, depending on the parameters, this simple configuration allows for observing several complex nonlinear phenomena, which include spontaneous symmetry breaking, modulational instability leading to generation of stable circular flows with various vorticities, stable inhomogeneous states with interesting structure of currents flowing between rings, as well as dynamical regimes having signatures of chaotic behavior.
Maximizing Efficiency on Trauma Surgeon Rounds Ramaniuk, Aliaksandr, DO, MBA; Dickson, B.J., CNP; Mahoney, Sean, MSN, RN ...
The Journal of surgical research,
01/2017, Volume:
207
Journal Article
Peer reviewed
Abstract Background Rounding by Trauma surgeons is a complex multidisciplinary team based process in the inpatient setting. Implementation of lean methodology aims to increase understanding of the ...value stream and eliminate non-value added components. We hypothesized that analysis of trauma rounds with education and intervention would improve surgeon efficacy. Materials and Methods Level one trauma center with 4300 admissions per year. Average non-ICU census was 55. Five full-time attending trauma surgeons were evaluated. Value added and non-value added components of rounding were identified. The components of each patient interaction during daily rounds were documented. Summary data were presented to the surgeons. An action plan of improvement was provided at group and individual interventions. Change plans were presented to the multidisciplinary team. Data were re-collected six months after intervention. Results The percent of interactions with non-value added components decreased (16.0% to 10.7%, p=0.0001). There was no change between the two time periods in time of evaluation of individual patients (4.0 to 3.5 minutes, p=0.43). Overall time to complete rounds did not change. There was a reduction in the number of interactions containing non-value added components (OR = 2.5). Conclusions The trauma surgeons were able to reduce the non-value added components of rounds. We did not see a decrease in rounding time or individual patient time. This implies that surgeons were able to re-invest freed time into patient care, or that the non-value added components were somehow not increasing process time. Direct intervention for isolated improvements can be effective in the rounding process, and efforts should be focused upon improving the value of time spent rather than reducing time invested.
Abstract
Introduction
The effects of supine, left lateral decubitus (LLD), and right lateral decubitus (RLD) positions on cardiovascular and autonomic activity have long been recognized. Decubitus ...positioning has been shown to increase vagal enhancement in recovery positioning following cardiac resuscitation, to reduce myocardial oxygen consumption, and to decrease probability of ventricular arrhythmias. This case demonstrates the unique utility of polysomnography (PSG) in assessing positional influences during unexplained bradyarrhythmic episodes, and stresses the importance of increasing the recognition of PSG’s value outside of sleep specialists and sleep disordered breathing assessments.
Report of Case
A 60-year-old male with past medical history of coronary artery disease presented for sleep evaluation and CPAP titration. Medications include aspirin 81mg, metoprolol 24 mg daily, clopidogrel 75 mg daily, isosorbide mononitrate ER 30 mg daily.
During overnight PSG recording, total sleep time -391 minutes, AHI - 20, and lowest SaO2 - 86.9%. Patient’s resting heart rate (HR) was 62 at time of lights out, remaining in range of 60–67 while in RLD position. Bradycardia was noted with sudden decrease to HR of 48, immediately following positional change to LLD. Patient’s PSG shows clear, recurrent association between positional change, specifically LLD position and profound bradycardia. This association would not be identified by continuous cardiac monitoring or home sleep testing.
Conclusion
The specific mechanisms and influences of recumbent positions on the autonomic nervous system are currently being debated. One recent explanation of LLD positional bradycardia was attributed to echocardiographically confirmed decrease in the diameter and area of the inferior vena cava, resulting in increased flow and reflexive bradycardia. (Sazaki J. Exp. Med., 2017) The case demonstrates that PSG is exclusive in its comprehensive assessment capacity and in the ability to present complex and under-recognized physiologic associations to the clinician.
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