SummaryBackgroundStaphylococcus aureus bacteraemia is a common cause of severe community-acquired and hospital-acquired infection worldwide. We tested the hypothesis that adjunctive rifampicin would reduce bacteriologically confirmed treatment failure or disease recurrence, or death, by enhancing early S aureus killing, sterilising infected foci and blood faster, and reducing risks of dissemination and metastatic infection.MethodsIn this multicentre, randomised, double-blind, placebo-controlled trial, adults (≥18 years) with S aureus bacteraemia who had received ≤96 h of active antibiotic therapy were recruited from 29 UK hospitals. Patients were randomly assigned (1:1) via a computer-generated sequential randomisation list to receive 2 weeks of adjunctive rifampicin (600 mg or 900 mg per day according to weight, oral or intravenous) versus identical placebo, together with standard antibiotic therapy. Randomisation was stratified by centre. Patients, investigators, and those caring for the patients were masked to group allocation. The primary outcome was time to bacteriologically confirmed treatment failure or disease recurrence, or death (all-cause), from randomisation to 12 weeks, adjudicated by an independent review committee masked to the treatment. Analysis was intention to treat. This trial was registered, number ISRCTN37666216, and is closed to new participants.FindingsBetween Dec 10, 2012, and Oct 25, 2016, 758 eligible participants were randomly assigned: 370 to rifampicin and 388 to placebo. 485 (64%) participants had community-acquired S aureus infections, and 132 (17%) had nosocomial S aureus infections. 47 (6%) had meticillin-resistant infections. 301 (40%) participants had an initial deep infection focus. Standard antibiotics were given for 29 (IQR 18–45) days; 619 (82%) participants received flucloxacillin. By week 12, 62 (17%) of participants who received rifampicin versus 71 (18%) who received placebo experienced treatment failure or disease recurrence, or died (absolute risk difference −1·4%, 95% CI −7·0 to 4·3; hazard ratio 0·96, 0·68–1·35, p=0·81). From randomisation to 12 weeks, no evidence of differences in serious (p=0·17) or grade 3–4 (p=0·36) adverse events were observed; however, 63 (17%) participants in the rifampicin group versus 39 (10%) in the placebo group had antibiotic or trial drug-modifying adverse events (p=0·004), and 24 (6%) versus six (2%) had drug interactions (p=0·0005).InterpretationAdjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S aureus bacteraemia.FundingUK National Institute for Health Research Health Technology Assessment.

Background: Dogs with protein-losing enteropathy (PLE) have previously been reported to present with thromboembolism; however, the prevalence and pathogenesis of hypercoagulability in dogs with PLE have not been investigated so far.Hypothesis: Dogs with PLE are hypercoagulable compared with healthy control dogs. Animals: Fifteen dogs with PLE. Thirty healthy dogs served as controls (HC). Methods: A prospective study was performed including 15 dogs with PLE. All dogs were scored using the canine chronic enteropathy activity index (CCECAI). Thromboelastography (TEG) and other measures of coagulation were evaluated. Recalcified, unactivated TEG was performed and reaction time (R), kinetic time (K), alpha angle (a), and maximum amplitude (M A ) values were recorded. Nine dogs were reassessed after initiation of immunosuppressive treatment.Results: All dogs with PLE in the study were hypercoagulable with decreased R ( [33.5-49]) (all P o .001). Median antithrombin (AT) concentration was borderline low in PLE dogs; however, mean serum albumin concentration was severely decreased (mean 1.67 g/dL AE 5.1, reference range 2.8-3.5 g/dL). Despite a significant improvement in serum albumin and CCECAI, all 9 dogs with PLE were hypercoagulable at re-examination.Conclusions and Clinical Importance: The hypercoagulable state in dogs with PLE cannot be solely attributed to loss of AT. Despite good clinical response to treatment, dogs remained hypercoagulable and could therefore be predisposed to thromboembolic complications.

Oral analgesia with OOXY after THR offers non-inferior analgesia to IVPCA and may offer some logistical and cost advantages.

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of Anaesthetists (NAP3) published prospective data on the number of central neuraxial blocks (CNBs) performed each year in the United Kingdom National Health Service (NHS) and the incidence of major complications. Various methods were used to disseminate the results (academic article published, full report sent to each UK NHS hospital anesthetic department, report able to be downloaded on the Royal College of Anaesthetists [RCoA] Web site, executive summary sent to NHS hospital chief executives, summary slide set sent to anesthetic departments or downloadable on RCoA Web site, and presentation of results at lectures). This current survey examines the effectiveness of this dissemination to departments of anesthesia, whether the results of NAP3 changed practice in CNBs, and anesthetists' attitudes about different methods of dissemination.The electronic survey was sent to a network of local reporters at 309 NHS hospitals 1 year after publication of the NAP3 report. The questionnaire included check-box responses and free-text comment. The survey explored and differentiated between personal and departmental practices.The survey was sent to 288 reporters who had responsibility for the 309 hospitals. A total of 217 responses were received for a response rate of 75.3%. A total of 214 respondents reported that they personally perform CNBs (96% adult perioperative, 51% obstetric, 14% pediatric perioperative, and 10% chronic pain management). With regard to dissemination of results, 99.5% of respondents had heard of NAP3, and 97.7% were aware of the results. The most common ways they knew of the results were reading the original article, departmental presentation, and reading the original report (51.2%, 49.3%, and 46.1%, respectively). The NAP3 results were reported in 174 (80.2%) of the respondents' hospitals. Overall, 82% of respondents thought that the results were disseminated satisfactorily, and 50.2% said dissemination could not be improved. Changes in departmental practice in their hospital were reported by about 50% of respondents, with the most frequent change being in the information provided to patients before CNB. These included development of an information leaflet for patients, changes in management of CNBs, nursing monitoring of CNBs, or investigation of potential complications. About 66% of respondents changed the information they personally offered to patients before the CNB; 16% to 25% also changed their management of CNB or their own investigations of complications. No change in overall use of CNB in their department was reported by 194 (89%) of respondents; 20 (9.2%) and 3 respondents (1.4%) reported a reduction or an increase in the number of CNBs performed, respectively. On a personal basis, 29 respondents (13.4%) had decreased and 3 (1.4%) had increased the use of CNBs; 185 (85.3%) had not changed their use of CNBs. When asked which has more effect in changing practice, learning points or recommendations, 70.5% considered both to be equally effective, 15.7% preferred recommendations, and 13.8% preferr...

SummaryA 37-year-old female presented following a witnessed generalised tonic clonic seizure while washing her car. Witnesses reported the patient hit her head on the car bumper upon falling. She was investigated for a cause of a second seizure with blood tests, CT and MR brain which were normal. On day 3 of her admission she was still unable to walk since the seizure and a neurological examination was performed which revealed signs consistent with a cervical myelopathy. A cervical MRI scan revealed a disc prolapse with cord compression at C5/6. This was successfully operated and the patient made a good recovery. Given that many of our medical assessment units and emergency department frequently assess patient with seizures, there was an important lesson for us to be more aware of the consequences as well as the cause of seizures.

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