Gabriel Weber

Introduction: Due to the increasing burden on hospital systems, most elderly patients with non-surgical sepsis are admitted to general internal medicine departments. Disease-severity scoring systems are used for stratification of patients for utilization management, performance assessment, and clinical research. Some widely used scoring systems for septic patients are inappropriate when rating non-surgical patients in a non-intensive care unit (ICU) environment mainly because their calculations require types of data that are frequently unavailable. This study aimed to assess the fitness of four scoring systems for septic patients hospitalized in general internal medicine departments: modified early warning score (MEWS), simple clinical score (SCS), mortality in emergency department sepsis (MEDS) score, and rapid emergency medicine score (REMS). Methods: We prospectively collected computerized data of septic patients admitted to general internal medicine departments in our community-based university hospital. We followed 28-day in-hospital mortality, overall in-hospital mortality, and 30- and 60-day mortality. Using a logistic regression procedure we calculated the area under ROC curve (AUC) for every scoring system. Results: Between February 1^st, 2008 and April 30^th, 2009 we gathered data of 1,072 patients meeting sepsis criteria on admission to general internal medicine departments. The 28-day mortality was 19.4%. The AUC for the MEWS was 0.65-0.70, for the SCS 0.76-0.79, for the MEDS 0.73-0.75, and for the REMS, 0.74-0.79. Using Hosmer-Lemeshow statistics, a lack of fit was found for the MEDS model. All scoring systems performed better than calculations based on sepsis severity. Conclusions: The SCS and REMS are the most appropriate clinical scores to predict the mortality of patients with sepsis in general internal medicine departments.

The purpose of this study was to identify differences in the sensitivity of anatomical sites sampling for methicillin-resistant Staphylococcus aureus (MRSA) colonization related to age, gender, clinical situation, and acquisition source as a base for screening protocols. We used a database that included all MRSA-positive cultures (Carmel Medical Center, 2003–2006) taken from nares, throat, perineum, and infection sites. The study population of 597 patients was divided into: “screening sample” (SS), which were cases of routine screening, and “clinical diagnostic sample” (CDS), which were patients with concurrent MRSA infection. MRSA acquisition sources were classified as internal medicine, surgical, referral patients, or intensive care unit (ICU). CDS patients were older than SS patients (median age 78 vs. 74 years, p = 0.0002), more commonly throat colonized (47.5% vs. 31.8%, p = 0.0001), and colonized in more multiple sites (65.7% vs. 43.3% were colonized in three sites in the CDS and SS groups, respectively, p < 0.001) than SS patients. In the SS, group throat colonization was higher in internal medicine wards than in the ICU (odds ratio [OR] = 3.98, p < 0.0001). In the CDS group, perineal colonization was more common in referral patients than in the ICU (OR = 4.52, p < 0.05). Patient age was the most influential factor on nares and multiple sites colonization in the SS and CDS groups, respectively. Our data support multiple sites sampling. Throat cultures are crucial in MRSA-infected patients and internal medicine ward patients. Multiple body sites colonization is more likely in older or MRSA-infected patients, affecting decisions regarding eradication using topical antibiotics.

The glutamatergic antagonist riluzole was approved in 1995 for the management of ALS and has become its standard therapy.1 Common side effects of the drug are nausea, asthenia, and reversible liver enzyme elevation.2,3⇓ Neutropenia is an extremely rare, not well-described, life-threatening adverse reaction of the drug. Only one case of reversible neutropenia associated with an inadvertent dose increase of riluzole to 200 mg/d has been reported previously.4 A review of the pharmacodynamic and pharmacokinetic properties of riluzole in ALS reported only 3 cases of neutropenia among 4,000 patients who received the drug without any additional details.5 We report a patient who developed severe neutropenia in association with a standard dose (100 mg/d) of riluzole. A woman aged 71 years with ALS was admitted to the hospital because of fever. She had a medical history of arterial hypertension and hypercholesterolemia and had undergone left mastectomy and breast reconstruction because of breast cancer 22 years earlier. She did not receive chemotherapy or radiotherapy. Three months before her admission, a diagnosis of ALS was …

The incidence of Pneumocystis Carinii pneumonia (PCP) may rise due to a more extensive use of immunosuppressive therapy. Information and guidelines in the last decade regarding prevention, diagnosis and treatment of the disease were based upon data collected in patients with Acquired Immuno Deficiency Syndrome (AIDS). However, scientific data regarding risk factors, clinical manifestations and treatment of PCP in patients without AIDS is accumulating. The major risk factors for acquiring PCP are hematological malignancies and treatment with immunosuppressive drugs, especially corticosteroids. The clinical course deteriorates more rapidly than in patients with AIDS and many patients have other opportunistic coinfections, especially with Cytomegalovirus and Candida. The duration of treatment may be shorter and drug tolerance is usually better than in patients with AIDS. However, mortality remains high even with appropriate treatment and necessitates a high index of suspicion and the use of empiric treatment even before a definitive diagnosis is made.