Infections with Clostridium perfringens usually manifest locally or spread to sepsis with multiorgan involvement, hemolysis or septic shock. Central nervous system (CNS) manifestations are rare and most frequently comprise meningitis with or without pneumencephalon, encephalitis, plexitis, cerebral abscess, or subdural empyema. The course of CNS affections is usually foudroyant and the outcome fatal. Neuromuscular manifestations of C. perfringens infections are much more frequent than CNS manifestations and comprise myonecrosis (gas gangrene), rhabdomyolysis, myositis, fasciitis, affection of the neuromuscular transmission, or affection of the peripheral nerves. C. perfringens infections usually start from the site of a recent surgical wound or trauma, a gastrointestinal or urogenital problem, or occur in association with malignancy. In quite a number of cases the source of origin remains speculative. Treatment of choice is surgical debridement of the infectious focus with radical removal of all necrotic tissue, resection of the corresponding lymphatics in addition to antibiotic therapy with penicillin G, aminoglycosides, or clindamycin or hyperbaric oxygenation. Despite these therapeutic options, the prognosis of CNS and neuromuscular involvement in an infection with C. perfringens is still poor. Only focal infections or clostridial brain abscesses may eventually have a more favorable outcome, if surgery and antibiotics are instantly provided. Generally, early recognition of the infectious agent is of paramount importance to prevent from spreading and the development of severe hemolysis, septic shock, or death.
bWeeksella virosa is an aerobic Gram-negative rod that has rarely been reported to cause infection. We describe a fatal case of W. virosa sepsis in a young female with end-stage renal disease, report three additional cases of W. virosa infection, and review the literature regarding this infection. CASE REPORTA 31-year-old female with a history of end-stage-renal disease on hemodialysis, hepatitis C virus infection, and myocardial infarction presented to an affiliate hospital's emergency department complaining of chest pain and shortness of breath. On physical examination, the patient was afebrile, with a heart rate of 74 beats per minute, a blood pressure of 89/47 mmHg, and a respiratory rate of 38 breaths per minute with an oxygen saturation of 98% on 4 liters via nasal cannula. The patient quickly decompensated and required support for worsening blood pressure and intubation for respiratory distress. Blood cultures were drawn in the emergency room, and the patient was transferred to the intensive care unit with a temperature of 39.5°C.The patient was started empirically on aztreonam, daptomycin, and tobramycin because of reported penicillin and vancomycin allergies. Laboratory studies revealed a white blood cell count of 21.4 mg/dl, a hemoglobin level of 9.1 mg/dl, and a platelet count of 69 ϫ 10 9 /liter. A chest X-ray revealed bilateral airspace opacities consistent with pneumonia. No sputum culture or bronchial lavage specimen was obtained during the hospitalization. The patient continued to deteriorate and expired 2 days after admission secondary to overwhelming sepsis. Postmortem, the blood cultures drawn on admission were reported to be positive for a Gramnegative rod after 36 h of incubation in 2 sets in the aerobic bottles only. The bacterial isolate was identified as Weeksella virosa via the BD Phoenix automated microbiology system. Because this was a rare isolate, the identification was confirmed by 16S rRNA gene sequencing with the B162 forward primer (5=-CGCTCGTTGCG GGACTTAACCCAACATCTC-3=) and BR16SR reverse primer (5=-GAGAGTTTGATCGTGGCTCAGATTGAACGC-3=), which produced a 100% 936-bp sequence match with W. virosa using the SmartGene bacterial sequence database (SmartGene, Inc., Raleigh, NC).The strain was retested with a MicroScan Gram Negative Combo panel (MicroScan Microbiology Solutions, Tarrytown, NY) in order to obtain the following susceptibility report and MICs (g/ml):
The large amount of scientific literature regarding vitamin D can be overwhelming and confusing. Some organizations have made specific guidelines and recommendations regarding optimal blood levels of vitamin D. In the sports medicine literature, new information about the effects of vitamin D on performance and bone health abound. Most of these articles seem to raise more questions than they answer. Are athletes at increased risk of vitamin D deficiency? Does vitamin D deficiency affect athletic performance? Should athletes be tested for deficiency? What is the optimal goal for vitamin D levels in athletes and is this different from the general population? The goal of this article is to provide clinical insight and clarity, both for those practicing in the primary care setting as well as for those taking care of athletes.
Introduction During the early months of the COVID-19 pandemic, mortality associated with the disease declined in the United States. The standard of care for pharmacological interventions evolved during this period as new and repurposed treatments were used alone and in combination. Though these medications have been studied individually, data are limited regarding the relative impact of different medication combinations. The objectives of this study were to evaluate the association of COVID-19-related mortality and observed medication combinations and to determine whether changes in medication-related practice patterns and measured patient characteristics, alone, explain the decline in mortality seen early in the COVID-19 pandemic. Methods A retrospective cohort study was conducted at a multi-hospital healthcare system exploring the association of mortality and combinations of remdesivir, corticosteroids, anticoagulants, tocilizumab, and hydroxychloroquine. Multivariable logistic regression was used to identify predictors of mortality for both the overall population and the population stratified by intensive care and non-intensive care unit admissions. A separate model was created to control for the change in unmeasured variables over time. Results For all patients, four treatment combinations were associated with lower mortality: Anticoagulation Only (OR 0.24, p < 0.0001), Anticoagulation and Remdesivir (OR 0.25, p = 0.0031), Anticoagulation and Corticosteroids (OR 0.53, p = 0.0263), and Anticoagulation, Corticosteroids and Remdesivir (OR 0.42, p = 0.026). For non-intensive care unit patients, the same combinations were significantly associated with lower mortality. For patients admitted to the intensive care unit, Anticoagulation Only was the sole treatment category associated with decreased mortality. When adjusted for demographics, clinical characteristics, and all treatment combinations there was an absolute decrease in the mortality rate by 2.5% between early and late periods of the study. However, when including an additional control for changes in unmeasured variables overtime, the absolute mortality rate decreased by 5.4%. Conclusions This study found that anticoagulation was the most significant treatment for the reduction of COVID-related mortality. Anticoagulation Only was the sole treatment category associated with a significant decrease in mortality for both intensive care and non-intensive care patients. Treatment combinations that additionally included corticosteroids and/or remdesivir were also associated with decreased mortality, though only in the non-intensive care stratum. Further, we found that factors other than measured changes in demographics, clinical characteristics or pharmacological interventions accounted for an additional decrease in the COVID-19-related mortality rate over time.
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