We present a case of late initiation of remdesivir antiviral therapy in the successful treatment of a patient with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) in a mixed medical intensive care unit of a community teaching hospital. A previously healthy 40‐year‐old man was admitted to the hospital 3 days after the onset of coronavirus disease 2019 (COVID‐19) symptoms including dry cough, fever, and shortness of breath progressing to intubation and increased mechanical ventilator support. A request for compassionate use remdesivir was submitted on the same hospital day as the positive COVID‐19 polymerase chain reaction result. Supportive measures, in addition to a 5‐day course of hydroxychloroquine, were maintained until remdesivir could be supplied on day 9 of hospitalization, 13 days after symptom onset. Sixty hours after initiating remdesivir, the patient was successfully extubated and able to transition to room air within 24 hours of extubation. Late initiation of remdesivir may be effective in treating SARS‐CoV‐2, unlike antivirals utilized for different disease states, such as oseltamivir, that are most effective when started as soon as possible following symptom onset. Urgent action is needed by regulatory agencies to work with drug manufacturers to expedite the study and approval of investigational agents targeting SARS‐CoV‐2 as well as to meet manufacturing demands.
This study sought to determine if there were any changes in opioid prescribing habits of providers at a single institution after the implementation of legislation to increase opioid prescribing regulations. Our study demonstrated a 39.5 percent decrease in overall morphine milligram equivalent (MME) prescribed the year after the laws took effect when compared with the year prior. It is clear that these laws have been effective in decreasing the number of opioids prescribed at discharge from Mercy Health Grand Rapids.Introduction: Opioid use disorder has become an epidemic with approximately 130 people dying every day in the United States due to prescription and illegal opioid overdoses. In December 2017, the Michigan legislature ratified a package of 10 acts to address a variety of problems through several layers of regulations including more restrictive prescribing rules, which took effect in June 2018. Objective: To evaluate the impact of legislation on the opioid prescribing habits of providers who discharged patients from a community-based academic teaching hospital.Design, setting, and participants: A retrospective cohort study was performed using data from a community-based academic teaching hospital with 303 beds, a medical ICU, labor and delivery unit, and a 42-room emergency department. All patients discharged from in-patient or observation status in the 12 months before and after June 1, 2018 were included.Main outcomes and measures: The primary outcome was MMEs of opioids prescribed at discharge before (June 1, 2017 to May 31, 2018) and after (June 1, 2018 to May 31, 2019) legislation. Medications included morphine, hydrocodone, oxycodone, fentanyl, methadone, hydromorphone, tramadol, codeine, and meperidine.Results: There were 17,227 patients discharged during the first 12-month period and 15,855 patients discharged in the second 12-month period. There were 14,064 new opioid prescriptions in total during these time periods. Total MME prescribed during the study period showed a 39.5 percent decrease from pre- (2,268,460 MME) to post-legislation (1,372,424 MME), while average MMEs/discharge significantly decreased (135.1 ± 321.2 vs. 87.6 ± 187.4; p 0.001). Total pill/patch count decreased by almost 40 percent. For patients who were prescribed opioids, average MME/discharge showed significant decline after legislation implementation (309.6 ± 427.1 vs. 212.2 ± 242.1; p 0.001). Average daily MME/patient prescribed an opioid remained similar between the time periods (52.4 ± 37.0 vs. 51.6 ± 35.0; p = 0.21). Significant reductions (p 0.05) were seen in MMEs for each individual medication with the exception of acetaminophen-codeine and methadone.Conclusions and relevance: Our results indicate that the legislation implemented in Michigan to regulate opioid prescriptions was associated with a reduction in opioids prescribed to patients discharged from a community-based academic teaching hospital.
Rationale: Nervous system toxicity is a rare complication of metronidazole. Prompt identification of metronidazole toxicity combined with a comprehensive physical rehabilitation program is essential to maximizing the patient’s functional outcome. Patient concerns: A 58-year-old female was treated with metronidazole for embolic versus hematogenous spread of bacteria resulting in multifocal brain abscesses. Two weeks after discharge, the patient returned to the emergency department with slurred speech, muscle aches, generalized weakness, inability to ambulate, and poor oral intake. Diagnosis: Head magnetic resonance imaging revealed symmetric enhanced T2/FLAIR signaling in the dentate nuclei were also present bilaterally, a finding pathognomonic for metronidazole toxicity. Intervention: Metronidazole was discontinued, and the patient was enrolled in a comprehensive rehabilitation program. Outcomes: She began inpatient rehabilitation dependent for all activities of daily living and requiring moderate assistance for transfers. She could only walk 10 feet with a front-wheeled walker with a 2-person assist. The patient rapidly improved with a comprehensive rehabilitation program, and due to these improvements, she was discharged after 5 days of inpatient rehabilitation. At the time of discharge, she was independent with all activities of daily living and could walk 160 feet independently with a front-wheeled walker. Lessons: Prompt recognition and discontinuation of metronidazole remains the only known effective treatment. A comprehensive approach to treatment and rehabilitation is achieved with an early referral to rehabilitation services. This is crucial to minimize morbidity and optimize functional outcomes in this patient population.
BackgroundSleep disturbances are common in patients with traumatic brain injury (TBI). In an inpatient rehabilitation setting, clinicians often use information from sleep logs filled out by trained nurses to identify and treat sleep disturbances. However, there are limited data related to accuracy of sleep logs, and patient‐reported sleep diaries are poor predictors of total sleep time, which raises concern about the accuracy of sleep logs filled out by a third party.ObjectiveTo examine the reliability of sleep logs for participants with TBI by comparing total sleep time determined by sleep logs versus actigraphy.DesignProspective, cross‐sectional study.SettingFree‐standing, academic inpatient rehabilitation facility.ParticipantsThirty individuals (n = 30) participated in the study. Inclusion criteria were (1) diagnosis of moderate‐to‐severe TBI; (2) age ≥ 18 years at the time of TBI; and (3) participating in inpatient rehabilitation with no prior inpatient rehabilitation admissions.InterventionsActigraph monitoring using ActiGraph GT9X Link devices was initiated within 72 hours of admission and continued for 7 consecutive days. Sleep logs were concurrently filled out by trained nurses.Main Outcome MeasuresSleep parameter correspondence between actigraphy and sleep logs in moderate‐to‐severe TBI.ResultsOnly 51.4% of participants' sleep logs and actigraph total sleep time measurements were within 1 hour of each other, and only 23.8% were within 30 minutes. On average, sleep logs overestimated actigraphy‐determined total sleep time by 60 minutes compared to actigraphic measurement.ConclusionsFor those with moderate‐to‐severe TBI undergoing inpatient rehabilitation, sleep logs are poor predictors of sleep time because they overestimate total sleep time compared to actigraphy. Therefore, clinicians should use caution when using sleep log data to make decisions regarding treatment for sleep disturbances in TBI.
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