St. Mary's Hospital Medical Center

Abstract The Gram‐negative bacteria are a heterogeneous group of organisms consisting of numerous families, genera, and species, many of which cause serious disease and endotoxic shock. The accurate, rapid identification of Gram‐negative bacilli, coccobacilli, and diplococci makes it possible to provide timely, meaningful treatment and diagnosis of disease. Commercial kit‐based identification systems do an excellent job of identifying most pathogens with minimal work and are often a major tool in the laboratory's identification system. Deciding when to use a commercial system and which system to use for identification is key to success in providing the identification in a timely manner. The speed of identification and extremely low reagent cost make the technology a desirable means of organism identification in the clinical microbiology setting. In the course of the potential rapid identification of Gram‐negative coccobacilli and Gram‐negative bacilli, the clinical microbiology laboratory may encounter isolates that are potential agents of bioterrorism.

Abstract The Gram‐negative bacteria are a heterogeneous group of organisms consisting of numerous families, genera, and species, many of which cause serious disease and endotoxic shock. The accurate, rapid identification of Gram‐negative bacilli, coccobacilli, and diplococci makes it possible to provide timely, meaningful treatment and diagnosis of disease. Commercial kit‐based identification systems do an excellent job of identifying most pathogens with minimal work and are often a major tool in the laboratory's identification system. Deciding when to use a commercial system and which system to use for identification is key to success in providing the identification in a timely manner. The speed of identification and extremely low reagent cost make the technology a desirable means of organism identification in the clinical microbiology setting. In the course of the potential rapid identification of Gram‐negative coccobacilli and Gram‐negative bacilli, the clinical microbiology laboratory may encounter isolates that are potential agents of bioterrorism.

The Centers for Medicare and Medicaid mandated that nursing homes implement antibiotic stewardship programs (ASPs) by November 2017. We conducted surveys of Wisconsin nursing-home stewardship practices before and after this mandate. Our comparison of these surveys shows an overall increase in ASP implementation efforts, but it also highlights areas for further improvement.

INTRODUCTION: Cutaneous leukocytoclastic vasculitis (CLCV) is a disorder of perivascular leukocyte invasion and inflammatory damage to small cutaneous vessels. It typically manifests as palpable purpura starting in the extremities. It may idiopathic, autoimmune, or a hypersensitivity reaction to medications, infections or allergens. It has also be associated with underlying malignancy, including solid organ tumors like colon cancer. An elderly man presented with anemia and a rash which was later diagnosed as CLCV. Further workup with colonoscopy lead to a diagnosis of colon adenocarcinoma. CLCV should be considered as a possible paraneoplastic phenomenon in the appropriate setting, to avoid delays in diagnosis and treatment of underlying malignancy. CASE DESCRIPTION/METHODS: An 84-year-old man with multiple comorbidities including coronary artery disease and diabetes mellitus presented to the emergency room with a 1-month history of worsening rash and exertional dyspnea. He had stable vital signs. Severe pallor and generalized maculopapular rash, especially in the extremities (Figure 1) was noted on examination. Hemoglobin was 5.0g/dl (13.5-18). He denied any known source of bleeding. Fecal occult blood was negative. No clear explanation for anemia was found and occult gastrointestinal bleed was suspected. Colonoscopy revealed a large semi-circumferential mass in the transverse colon (Figure 2) and biopsies confirmed a moderately differentiated invasive adenocarcinoma of the colon. No obvious metastasis was noted on CT scans. Skin biopsies showed perivascular infiltration by neutrophils, lymphocytes and nuclear debris, consistent with CLCV. Hemoglobin improved with blood transfusions. Surgical resection of tumor was discussed but deferred because of comorbidities and overall deconditioned state. Patient was discharged in stable condition for outpatient subspecialist follow up. DISCUSSION: Colon adenocarcinoma causes significant morbidity and mortality and early diagnosis is crucial for effective treatment and patient survival. Paraneoplastic CLCV is rare but may develop in patients with colon adenocarcinoma and in a few cases has been the major presenting symptom or reflect recurrent disease. Treatment is mostly supportive and tumor resection may lead to resolution of rash. Underlying malignancy should be considered especially if a patient is not up to date with age-appropriate cancer screening. Increasing provider awareness of this uncommon association may help improve clinical outcomes.Figure 1.: Photograph of lower extremities showing coalescing maculopapular rash of cutaneous leukocytoclastic vasculitis.Figure 2.: Photograph showing adenocarcinoma (white arrows) in transverse colon during colonoscopy.

As a community hospital and a major employer, St. Mary's Hospital Medical Center in Green Bay, Wisconsin, assumes responsibility not only for the health of people in the community but also for the health of the environment in which they live. Demonstrating reverence for the earth is a primary strategic goal, originating with its sponsoring organization, Hospital Sisters Health System, Springfield, Illinois. St. Mary's Hospital Medical Center is one of 13 hospitals in this system dedicated to healing ministries. Healing the earth is as important to this mission as is prevention and treatment to heal the human body. Over the past 25 years, St. Mary's Hospital Medical Center has brainstormed and implemented innovative ideas to mend the earth, improving the health of air, water, and land, and ultimately improving the health of the people who come into contact with our dynamic environment. It is a passion and commitment of time and resources, but one in which there is no question that it is the right thing to do.

The study objectives were (a) to describe the occurrence, types, and preventability of adverse drug events (ADEs) in hospitalized patients 70 years of age and older; (b) to examine the association between potential risk factors and ADEs; and (c) to examine the relationship of an ADE occurrence and hospital length of stay (LOS) and functional decline. Consecutive general medical admissions (n = 157) of community-dwelling persons were prospectively monitored daily for ADE occurrence. Admission assessment included demographic factors, cognition, preadmission medication use, and functional status. Discharge assessment included functional status. LOS, discharge diagnoses, and medication use during the hospitalization. Twenty-three patients (14.6%) experienced 28 probable ADEs, of which 54.2% (13/24) were judged to be potentially preventable. Patients experiencing an ADE had a significantly lower mean Mini-Mental State Examination score (23.6 +/- 4.3 vs 25.5 +/- 3.6, p = .039) and were prescribed significantly more new inpatient medications (4.0 +/- 2.3 vs 2.6 +/- 1.7, p = .01) compared to non-ADE patients. Age, gender, functional status prior to admission, percent with more than four active diagnoses, or number of preadmission medications were not associated with ADE status. Upon discharge, 50.0% of ADE patients experienced a decline in one or more activities of daily living (ADLs), compared with 24.1% of non-ADE patients (p = .017). ADE patients had a longer LOS (8.7 +/- 4.9 vs 6.6 +/- 3.0 days, p = .022) compared to non-ADE patients. ADEs were associated with number of new inpatient medications and admission cognitive status, but not demographic, disease, or physical function variables. Patients experiencing an ADE were more likely to experience a longer LOS and to decline in ADL function. ADEs may be one factor contributing to functional decline during hospitalization. Future research in this area should include larger samples and multivariable analyses controlling for potential confounders.