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A sixty-one year-old Hispanic female with Waldenstrom’s Macroglobulinemia diagnosed in 2011 and successfully treated with 6 monthly cycles of Cyclophosphamide, Rituximab and Dexamethasone (CDR) from 12/11 through 5/12 was then put on a two-year maintenance scheme with Rituximab every three months. In February, 2014 (six months before the end of the planned treatment), she came to the ER complaining with severe headache, aphasia and blurred vision. A stroke was initially ruled out and she received Paracetamol with partial improvement. Nonetheless, symptoms re-appeared accompanied with disorientation and agitation. Antipsychotic medication was given with no improvement. On PE she was disoriented with aphasia, paraparetic and neck stiffness suggestive of meningitis. Blood tests, a MRI and lumbar puncture were performed showing leptomeningeal hyperintensity with no signs of encephalitis (Figure 1). Figure 1 Leptomeningeal reinforcement as seen in MRI. Figure 1. Leptomeningeal reinforcement as seen in MRI. CSF analysis showed WBC 64 cells/µL, (95% MNC), glucose= 9.8 mg/dL and proteins= 110 g/dL. Gram dye was negative. A geneXpert for Tuberculosis was negative. CSF cytology showed an infiltration of lymphoid neoplastic cells confirmed by cytochemistry (Figures 2a and 2b). Figure 2a: CD 20+ and 2b: kappa + neoplastic cells in CSF Figure 2a:. CD 20+ and 2b: kappa + neoplastic cells in CSF Figure 3 Figure 3. With these results a Bing Neel syndrome was diagnosed and IT Methotrexate was given for a total of 6 doses resulting in a nice reduction of the neoplastic cells. However, she relapsed in April/2014 and IV Fludarabine was started. We are planning to add IT liposomal Cytarabine. Additionally, MYD 88 gene mutation was detected. DISCUSSION: There are only 33 reported cases of Bing-Neel syndrome in the medical literature for the last 80 years and this one has been confirmed with the newest tools such as: MRI, cytochemistry and gene mutation. CONCLUSION: Bing-Neel syndrome should be suspected in every patient with Waldenstrom’s Macroglobulinemia and CNS impairment. Disclosures No relevant conflicts of interest to declare.
BackgroundReal-time antimicrobial stewardship programs are associated with improved time to optimal an effective therapies and decreased unnecessary antimicrobial use. However, these programs are often expensive and need special hardware or software for their implementation. Real-time communication technologies based on smartphones and texting media applications have not been used previously as a tool that emulates these clinical decision support programs (CDSP). We evaluated the clinical impact of implementing this technologies as fundamental part of an ASP in a Secondary Healthcare Hospital. Preauthorization, prospective audit, and feedback interventions were combined into a texting media group alert, composed by infectious diseases physicians, pharmacists, microbiologist and epidemiology department, which evaluated and decided the best treatment option in a real-time period consisting of 2 hours for each patient. Preauthorization rules included carbapenems, glycopeptides, quinolones, clindamycin, Linezolid, and amphotericin.MethodsWe conducted an observational and descriptive study for the total number of interventions in a 3-year period. Data collection included hospital service for application, authorization or restriction, consumption in terms of defined daily dose, economic outcomes, nosocomial bacteria’s resistance patterns, and overall mortality rates.ResultsA total of 8,004 interventions were carried out; only 7.7% (636) were unanswered within the 2 hour period. Emergency department (34.35%) and Internal Medicine (24.6%) were the most monitored services. The most restricted ones were Surgery and Intensive Care Unit with at least 25% of prescriptions. The most restricted antibiotics were piperacillin/tazobactam, clindamycin and quinolones, restraining up to 80%. Saving cost represents US$130,000.00 for colisitin and US$64,800.00 for carbapenems. The isolates of P. aeruginosa and A. baumanii resistant decreased by 75% and the overall mortality rate for nosocomial infections, were not increased.ConclusionThis is the first report in Mexico of an ASP that incorporates mobile phone technology as a part of real-time surveillance program that emulates CDSP and allows to know in detail the correct use of antibiotics, saving costs and decreasing bacterial resistancesDisclosures All authors: No reported disclosures.
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