Opioid Safety Initiative implementation was associated with a substantial reduction in high-dose opioid prescribing. Factors that contributed to initiative success included leadership support and active clinical pharmacy engagement.

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The SALT mass casualty triage system can be applied quickly in the field and appears to be safe, as measured by a low undertriage rate. There was, however, significant overtriage. Further refinement is needed, and effect on patient outcomes needs to be evaluated.

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BMI is an important factor that affects donor's response to mobilization and consequently the HPC yield. This effect may be due to a relatively high dose of G-CSF administered to donors with higher BMI or due to the presence of unknown intrinsic factors affecting mobilization that correlate with the amount of adipose tissue in each donor.

Methicillin-resistant Staphylococcus aureus (MRSA) is a rarely reported cause of necrotizing fasciitis. We report an unusually severe case of MRSA necrotizing fasciitis in a previously undiagnosed AIDS patient. Molecular analysis revealed that the strain had the USA300/spa1 genotype, now an abundant cause of community-acquired MRSA infection. CASE REPORTA 36-year-old Hispanic male with no previously recognized significant medical conditions presented to the emergency department (ED) of an outlying community hospital with a chief complaint of exquisite right arm pain, lethargy, fever, and shortness of breath. He had been treated 2 weeks previously with clindamycin for right axillary hidradenitis following a selfreported spider bite. The patient had no recent traumatic injury or known contact with methicillin-resistant Staphylococcus aureus (MRSA). Although the skin infection failed to resolve, he had been otherwise asymptomatic and did not seek further medical attention until awakening that morning with acute distress. Physical examination in the ED revealed a tensely edematous and markedly erythematous right upper arm and shoulder. The right hand and fingers were cool, but they retained complete range of motion. The results shown by a chest X ray were unremarkable despite coarse breath sounds and the deep soft tissue infection. All analytes measured in the initial chemistry and coagulation panels were within normal limits. He was diagnosed with severe cellulitis, septic shock (blood pressure, 58/32; pulse, 130; temperature, 99.4°F; white blood cell count, 1,600/l), and possible necrotizing fasciitis. Empirical antimicrobial treatment was initiated immediately with vancomycin, piperacillin-tazobactam, and clindamycin. However, his condition deteriorated quickly, and he required ventilator assistance with fluid and vasopressor support. Emergency surgical exploration was undertaken within 24 h of admission, and extensive soft tissue necrosis was observed intraoperatively. The right arm was amputated, and the chest wall was extensively debrided. Sputum and blood cultures collected in the ED prior to administration of empirical therapy, as well as intraoperative wound cultures, grew MRSA that was resistant to erythromycin, clindamycin, and levofloxacin (Table 1). The antimicrobial regimen was then switched to vancomycin, imipenem/cilastatin, rifampin, and voriconazole. Histologic analysis of the surgically excised tissue revealed features typical of necrotizing fasciitis (Fig. 1). Despite initial improvement following surgical intervention and antimicrobial therapy, the septic shock persisted (maximum temperature, 103.4°F; average blood pressure, 100/60) and the necrotizing fasciitis continued to spread to the bilateral chest walls, right abdomen, and right back. He was transferred to a tertiary-care hospital for continued evaluation and management of the severe MRSA infection. Nine additional debridement procedures were performed. Tissues collected during these surgical interventions grew rare MRSA strains with ide...

Introduction Thoracic ultrasound is frequently used in the emergency department (ED) to determine the etiology of dyspnea, yet its use is not widespread in the prehospital setting. We sought to investigate the feasibility and diagnostic performance of paramedic acquisition and assessment of thoracic ultrasound images in the prehospital environment, specifically for the detection of B-lines in congestive heart failure (CHF). Methods This was a prospective observational study of a convenience sample of adult patients with a chief complaint of dyspnea. Paramedics participated in a didactic and hands-on session instructing them how to use a portable ultrasound device. Paramedics assessed patients for the presence of B-lines. Sensitivity and specificity for the presence of bilateral B-lines and any B-lines were calculated based on discharge diagnosis. Clips archived to the ultrasound units were reviewed and paramedic interpretations were compared to expert sonologist interpretations. Results A total of 63 paramedics completed both didactic and hands-on training, and 22 performed ultrasounds in the field. There were 65 patients with B-line findings recorded and a discharge diagnosis for analysis. The presence of bilateral B-lines for diagnosis of CHF yielded a sensitivity of 80.0% (95% confidence interval [CI], 51.4–94.7%) and specificity of 72.0% (95% CI, 57.3–83.3), while presence of any B-lines was 93.3% sensitive (95% CI, 66.0–99.7%), and 50% specific (95% CI, 35.7–64.2%) for CHF. Paramedics archived 117 ultrasound clips of which 63% were determined to be adequate for interpretation. Comparison of paramedic and expert sonologist interpretation of images showed good inter-rater agreement for detection of any B-lines (k = 0.60; 95% CI, 0.36–0.84). Conclusion This observational pilot study suggests that prehospital lung ultrasound for B-lines may aid in identifying or excluding CHF as a cause of dyspnea. The presence of bilateral B-lines as determined by paramedics is reasonably sensitive and specific for the diagnosis of CHF and pulmonary edema, while the absence of B lines is likely to exclude significant decompensated heart failure. The study was limited by being a convenience sample and highlighted some of the difficulties related to prehospital research. Larger funded trials will be needed to provide more definitive data.

The association between donor specific antibodies (DSA) and renal transplant rejection has been generally established, but there are cases when a DSA is present without rejection. We examined 73 renal transplant recipients biopsied for transplant dysfunction with DSA test results available: 23 patients diffusely positive for C4d (C4d+), 25 patients focally positive for C4d, and 25 patients negative for C4d (C4d−). We performed C1q and IgG subclass testing in our DSA+ and C4d+ patient group. Graft outcomes were determined for the C4d+ group. All 23 C4d+ patients had IgG DSA with an average of 12,500 MFI (cumulative DSA MFI). The C4d− patients had average DSA less than 500 MFI. Among the patients with C4d+ biopsies, 100% had IgG DSA, 70% had C1q+ DSA, and 83% had complement fixing IgG subclass antibodies. Interestingly, IgG4 was seen in 10 of the 23 recipients' sera, but always along with complement fixing IgG1, and we have previously seen excellent function in patients when IgG4 DSA exists alone. Cumulative DSA above 10,000 MFI were associated with C4d deposition and complement fixation. There was no significant correlation between graft loss and C1q positivity, and IgG subclass analysis seemed to be a better correlate for complement fixing antibodies in the C4d+ patient group.