Mercy St. Charles Hospital

Group B streptococcus is currently the most common cause of sepsis and meningitis in newborns. How should mothers whose breast milk cultures show growth of this microorganism be managed regarding breastfeeding? This case study discusses the possible transfer of group B streptococcus to a preterm infant from mother's milk. It also describes the process that was taken to preserve the breastfeeding experience while the infant was treated. The questions provoked during this investigation prompted the authors to revise procedures in their special care nursery for dealing with infants and mothers presenting with signs of infection. In this case, providing treatment for the mother and infant and withholding breast milk from the infant until cultures were negative, while supporting the mother's milk supply, made it possible for this mother to continue to breastfeed.

Background: Direct anterior approach total hip arthroplasty (DAA THA) traditionally involves a longitudinal incision, but a bikini incision may improve postoperative scar cosmesis and patient satisfaction while reducing wound complications. This systematic review compares the clinical outcomes and surgical complications in patients undergoing DAA THA via a bikini vs longitudinal incision. Methods: A Preferred Reporting Items for Systematic Review and Meta-Analyses-compliant search of PubMed, Cochrane, and EMBASE was performed to identify original articles comparing patients undergoing DAA THA via a bikini vs longitudinal incision published from 2010 to 2021. Patient demographic data and postoperative outcomes (scar appearance, patient satisfaction, functional hip scores, and complications) were collected and qualitatively evaluated. Results: A total of 8 double-armed studies were included, allowing comparison of clinical outcomes of a bikini incision (n = 952) vs a longitudinal incision (n = 1361). Three out of 4 (75.0%) studies comparing postoperative scar appearance and patient satisfaction reported improvements following bikini incision, while 1 study reported comparable results between incision types. Postoperative hip function was similar between incision types in 3 of 4 (75.0%) studies comparing this outcome. Lateral femoral cutaneous nerve injury was the most frequently reported complication following anterior THA, but rates were low overall, and most injuries resolved. Conclusions: Bikini incision appears to be a safe alternative to the traditional longitudinal incision, with similar functional hip outcomes and potentially improved cosmesis and patient satisfaction while reducing wound complications. Current evidence suggests an elevated risk of lateral femoral cutaneous nerve injury with bikini incision, but this needs to be confirmed in further prospective randomized studies.

There is no sure foundation set on blood, No certain life achieved by others' death.(1) We would take the issue of brain death from the misty court of `philosophy'(2) and examine it in the cool light of medical science and clinical neurology, which will not cut corners and will be as exacting as is humanly possible. We are, after all, physicians and not metaphysicians. We also cannot be prophets of an ethical slippery slope, although we are well qualified to observe and interpret what has already occurred in these matters. At the very least, cessation of all functions of the entire brain (the language of the Uniform Determination of Death Act [UDDA]) should be present before declaring brain death. That such cessation is imminent is not sufficient or satisfactory as a criterion for organ donation.(3) Dying must never be confused with death.(4) This article focuses on the practical difficulties encountered by a neurosurgeon or a pediatrician, as potential donors' doctors, in a metropolitan or suburban community hospital. There is a nearby university hospital with a transplantation protocol. Such protocols put emphasis on the rapid acquisition of physiologically sound organs.(5) This puts the potential donor at risk. The declaration of brain death must be made as soon as possible, usually in less than twenty-four hours. According to the protocol, fresh vital organs should be obtained untainted by any measures the donor's doctor may have taken to preserve his patient's life: e.g., dopamine to maintain blood pressure or fluid intake at a reasonable level to prevent cerebral edema (rather than allowing a fluid overload so as to better preserve the kidneys for recipients). The statement is too easily made that if the donor's doctor has conscientious reservations regarding brain death, he should withdraw from the case. In a community hospital of two or three hundred beds, there are often only two neurosurgeons. The other neurosurgeon may have the same reservations, so that moral compunctions cannot be easily avoided as in a larger hospital with eight or nine neurosurgeons having a spectrum of opinions on the subject. Physicians in attendance on dying patients have to understand themselves and their positions regarding reverence for life. Sometimes they find themselves making the best compromise they can between their consciences and hospital and transplant team policy. Such a compromise, like all compromises, is too often unsatisfactory for a conscientious physician as well as the patient, who, if he is not already dead, will certainly be dead after lethal action has been carried out. Furthermore, a community hospital may not have the facilities to test all the functions of the entire brain, even of the brain stem, as the UDDA specifies.(6) Structure and Function of the Brain Stem Two and a half inches in length (6-1/2 cm), the brain stem extends at the base of the brain from the spinal cord at the foramen magnum to the upper border of the mesencephalon. It is a compact tube of neural tissue containing the nuclei of cranial nerves III-XII and ascending sensory and descending motor tracts, both giving collaterals to the reflex-integrating reticular formation. The reticular formation extends throughout the medullary, pontine, and mesencephalic portions of the brain stem and rostrally into the diencephalon so that functionally the brain stem extends higher than its anatomic upper border. The brain stem subserves cranial nerve functions (III-XII). Through afferent impulses from neck muscles, cervical vertebrae, and vestibules, its motor centers control body position in space.(7) By reflex adjustments in the reticular formation of the medulla oblongata and in the vagal nuclei, the blood pressure and heart rate can vary. (The heart, however, is driven by its own intrinsic pacemaker at a steady rate when central influences are lost. …

A 55-year-old woman was admitted with a 10-day history of colicky, left lower-quadrant abdominal pain and intermittent vomiting. She also reported a 2-month history of alternating diarrhea and constipation, with a 20-pound weight loss. She denied malena or hematemesis. She had a 40-pack year history of smoking. On admission, she was normotensive, tachycardic and appeared dehydrated. Generalized abdominal tenderness was noted on palpation, with hyperactive bowel sounds and no guarding or rigidity. There was no palpable lymphadenopathy. The remainder physical examination was unremarkable. Laboratory examination including a complete blood count, Erythrocyte sedimentation rate, liver and renal profile were normal. Stool was positive for occult blood with negative cultures. Multiple air fluid levels were noted on an upright abdominal radiograph. A computerized tomogram (CT) of the abdomen (Figure 1) demonstrated irregular thickened loops of small bowel with a mesenteric mass, suggestive of a primary mesenteric or small bowel tumor. The diagnosis of mechanical small bowel obstruction prompted an explorative laparotomy, which revealed multiple nodular masses in mesentery and small bowel causing luminal narrowing. A wedge resection of the small bowel was undertaken to relieve obstruction.

The donation of organs after cardiac death in infants is not morally justified and should not be continued.

A new procedure is described for the correction of stress urinary incontinence caused by hypermobility of the urethrovesical junction using an extraperitoneal laparoscopic approach with the use of a new needle. There has been no previous publication of this approach. The initial study shows that this procedure offers technical advantages over the existing procedures and requires short hospitalization, less use of postoperative pain medication, and early recovery. We hope to report a long-term follow-up in the future.

A Fort Lauderdale infant with anencephaly, Theresa Ann Campo Pearson, was recently the subject of many newspaper articles, television shows, and medical and legal discussions. Her parents had filed a petition in a Florida circuit court for the right to authorize the excision of Theresa Ann's unpaired vital organs.(1) The petition sought a judicial determination that anencephalic infants be considered legally for the purposes of organ transplantation.(2) The trial court's order denying the petition was summarily upheld on appeal.(3) The Florida Supreme Court affirmed, thus rejecting an expansion of Florida's common law to include anencephaly within the legal definition of death.(4) In this article, we will consider the case of Theresa Ann in the context of the death controversy. We will show how the attempt to declare death in a living baby with anencephaly is but another step in the growing acceptance of something less than actual death as legal death for the purpose of acquiring transplantable organs. Theresa Ann was diagnosed antenatally as having anencephaly. Soon thereafter, plans were made to remove her organs for transplantation following her birth. After she was born, Theresa Ann was intubated and received ventilatory support. The ventilator was removed after about one week. Theresa Ann then breathed on her own for a period of time, clearly indicating that the stem function governing spontaneous breathing was intact. Other stem functions that control heart rate, blood pressure, salt and water balance, pituitary-endocrine organ functions, as well as many other organs and systems, were presumably also intact and functioning in Theresa Ann's body. At least some of the physicians treating Theresa Ann knew, and made others aware, that her was functioning. Based on this, the Florida Supreme Court ruled that Theresa Ann could not be brain dead under Florida law.(5) Anencephaly Anencephaly results from a failure of the neural tissue to completely close at the cephalic end. Even though anencephaly literally means the absence of the brain, functioning neural tissue is always present. The telencephalon is usually absent, but the stem is present. Absence of the cranium (acrania) is a constant finding. Closure of the cephalic end of the neural tube normally occurs between the second and third week of development. Thus, anencephaly is a manifestation of an abnormality of development that occurs sometime between conception and two to three weeks of gestation.(6) Prenatal Diagnosis Alpha-fetoprotein (AFP) is a glycoprotein normally synthesized by the fetal liver but not by the adult liver. Some AFP is normally present in the amniotic fluid. When the neural tube remains open (in anencephaly or spina bifida with myelomeningocele), there can be abnormally large quantities of AFP in the amniotic fluid, and as a result there is elevation of AFP in maternal serum. Screening of maternal serum for elevated amounts of AFP, analysis of AFP in amniotic fluid, and ultrasound examination of the fetus can lead to a diagnosis of anencephaly. (One must be aware of the potential for error in all of these tests.) Postnatal Diagnosis The appearance of an infant with anencephaly is characterized by the absence of bone and scalp over the part of the head posterior to the forehead. The exposed is covered by a thickened angiofibrous stroma. Recognizable cerebral hemispheres are absent. Brain Death Law The Uniform Determination of Death Act (UDDA) was recommended for adoption in all jurisdictions of the United States by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.(7) The UDDA reads as follows: An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the stem, is dead. …

*Division of Thoracic and Cardiovascular Surgery, Medical College of Ohio, Toledo, OH. §Department of Surgery, Medical College of Ohio, Toledo, OH. †Department of Continuing Medical Education, St Charles Mercy Hospital, Toledo, OH. Correspondence address: S Amjad Hussain, MD, 2836 Manley Road, Maumee, OH 43537. E-mail: [email protected]

SIR—Winston and Schiller [1] report the results of the analysis of their institutions's data from a multicenter, randomized study that compared amphotericin B lipid complex (ABLC; The Liposome Company) with conventional amphotericin B (CAB; Apothecon) as empiric therapy for febrile neutropenic patients. They found a similar incidence of nephrotoxicity (defined as a doubling of the baseline serum creatinine concentration) and infusion-related reactions (fever and chills) in both treatment arms, which was surprising. This prompted us to undertake a detailed examination of the available data on nephrotoxicity associated with these agents. There is little comparative data available on nephrotoxicity associated with ABLC treatment, and, therefore, it is unfortunate that Winston and Schiller's study was prematurely discontinued by the sponsor (The Liposome Company), despite objections from the investigators. The data that we did find included the results of a comparative trial of ABLC and CAB as treatment for cryptococcal meningitis in patients with AIDS [2]. The authors of this study reported that, in the 2 treatment arms (patients who received ABLC at a dosage of 5 mg/kg/day those who received CAB at a dosage of 0.7 mg/kg/day), the mean increase in serum creatinine levels from baseline through week 1 was identical. Wingard and colleagues [3] reported results of a double-blind comparative trial that compared ABLC (5mg/kg/day) with lipid-associated amphotericin B (3 and 5 mg/kg/day) as empiric therapy for febrile neutropenic patients. They found that the incidence of nephrotoxicity (defined as a doubling of the baseline serum creatinine concentration) was 42% in the cohort of patients that received the amphotericin B lipid complex, 15% in the cohort that received lipid-associated amphotericin B at a dosage of 5 mg/kg/day, and 14% in the cohort that received lipid-associated amphotericin B at a dosage of 5 mg/kg/day. The result for the latter cohort was similar to that reported by Walsh and colleagues [4], who found an incidence of nephrotoxicity of 19% for patients who received a dosage of 5 mg/kg/day of lipid-associated amphotericin B and had a doubling of serum creatinine level from baseline. To further validate the nephrotoxicity findings of Wingard and colleagues [3] with other ABLC findings, we contacted the study sponsor and requested the data for the parameters defining nephrotoxicity that were reported in the ABLC package insert ([5]; personal communication, Fujisawa HealthCare). The package insert notes that there are data for patients with increases in serum creatinine level from normal baseline to >1.5 mg/dL and >2.0 mg/dL. These data are derived primarily from the unpublished results of 3 randomized comparative studies of ABLC therapy at a dosage of 5 mg/kg/day. Using an increase in serum creatinine level to >1.5 mg/dL as the definition of nephrotoxicity, the ABLC package insert calculated an incidence of 38% (47 of 124 patients) in the 3 unpublished studies, compared with an incidence of 44% in the study by Wingard and colleagues [3]. Using an increase in serum creatinine level of >2 mg/dL as the definition of nephrotoxicity, the incidence was 24% in the 3 unpublished studies and 21% in the study by Wingard and colleagues [3]. Of note, the incidence of nephrotoxicity among patients who received 3 mg/kg/day of lipid-associated AmB was 19% if the 1.5 mg/dL definition was used and 10% if the 2.0 mg/dL parameter was used; among patients treated with a dosage of 3 mg/kg/day, the incidence was 16% if the 1.5 mg/dL definition was used and 5% if the 2.0 mg/dL parameter was used. It appears that the incidence of nephrotoxicity that is associated with ABLC therapy when it is administered at the dosage approved by the US Food and Drug Administration (5 mg/kg/day) may be the same as the incidence associated with CAB therapy [5]. The results of a comparative study, such as the one which was prematurely discontinued by the ABLC's manufacturer, would be interesting to see.

In Brief BACKGROUND Preterm premature rupture of membranes leading to intraamniotic infection and fetal death may be due to unusual bacterial species. CASE A young multipara presented at 24 weeks and 6 days' gestation with rupture of membranes of 2 days' duration. She was febrile and hypotensive. No fetal heart activity was noted. Antibiotics, fluid resuscitation, and oxytocin were begun with delivery of a 798-g stillborn fetus. Maternal and fetal cultures demonstrated Streptococcus bovis as the infectious agent. CONCLUSION Unusual bacteria such as S bovis are sometimes responsible for severe maternal and fetal infections. Aggressive fluid resuscitation, uterine evacuation, and triple antibiotic therapy until culture results are available are indicated. Severe intraamniotic infection is treated by supportive measures, administration of broad-spectrum antibiotics, and uterine evacuation, even when unusual organisms are implicated. Unusual organisms such as Streptococcus bovis can cause chorioamnionitis, fetal death, and maternal septic shock.

Journal Article Teaching patients about blood glucose meters Get access Paula G. Sondergeld Paula G. Sondergeld Diabetes Care Pharmacist Outpatient Pharmacy St. Charles Mercy Hospital 2600 Navarre Avenue Oregon, OH 43616 Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, Volume 55, Issue 18, 15 September 1998, Pages 1877–1878, https://doi.org/10.1093/ajhp/55.18.1877 Published: 15 September 1998

Oseltamivir (Tamiflu) package labeling has a warning for neuropsychiatric adverse events (NPAE), most commonly in children and adolescents, especially males. There are several case reports of NPAE in adults treated with oseltamivir, but few document patients with preexisting neuropsychiatric conditions without additional contributing factors. This case report describes a 22-year-old male with a history of bipolar disorder, depression, and attention-deficit/hyperactivity disorder who had been stable on his medication regimen before experiencing sudden worsening of symptoms after the initiation of oseltamivir. The case adds to previous literature by strengthening the correlation between oseltamivir and a sudden increase in neuropsychiatric symptoms. Providers should be aware that oseltamivir may exacerbate symptoms of previously stable patients. Depending on the severity of neuropsychiatric effects, discontinuation of oseltamivir and symptom treatment with pharmacotherapy may be warranted.

Zbierajewski, Judy CNA, BC, BSN, MBA; Kachmarik, Vicki CCRN, CNA, BC, BSN, MBA; O'Dell, Susan APRN, BC, FNP, MSN Author Information

An instrument was developed and used to evaluate job performance of staff pharmacists, and the relationship between performance and job satisfaction was examined. In designing the performance rating instrument (PRI), 23 measurable work-related behaviors of hospital staff pharmacists were identified through interviews with pharmacy directors. For each of the 15 behaviors ranked most important by hospital pharmacy directors, a four-point scale of performance was defined. Job satisfaction was measured using the job descriptive index (JDI) augmented by questions specific to hospital pharmacy practice. Staff pharmacists at eight hospitals completed the JDIs, and their directors completed the corresponding PRIs. Of 66 sets of PRIs and JDIs distributed, 38 pairs of usable responses were returned. There were a number of significant correlations between individual items on the PRI and JDI, but the correlation between the composite scores for the two scales was not significant. JDI and PRI scores decreased with age and years of practice, but the decrease was not significant. The PRI is a short, understandable method of quantifying hospital staff pharmacist performance. No significant correlation between job satisfaction and performance was found.