Texas Health Harris Methodist Hospital Fort Worth

BackgroundData comparing clinical outcomes is limited in patients receiving empiric ceftriaxone versus carbapenems for confirmed ESBL UTIs. Given the prevalence and rising resistance rates of Enterobacterales spp. causing UTIs, empiric carbapenem use becomes increasingly utilized. While carbapenems remain the current standard of definitive care for ESBL infections, it is unclear whether their empiric use leads to improved clinical outcomes in patients with UTIs compared to empiric regimens lacking activity against ESBL isolates.MethodsA retrospective cohort study conducted at Texas Health Harris Methodist Hospital Fort Worth in patients with confirmed ESBL UTIs grouped by whether empiric therapy was determined to be susceptible (EMP-S) or nonsusceptible (EMP-NS) to the isolate per the final susceptibility report. Patients with concurrent sources of infection, pregnant, or received empiric cefepime or piperacillin/tazobactam were excluded. The primary clinical outcome evaluated was a composite of worsening symptoms documented by a provider and hemodynamic stability on the day that the ESBL isolate was identified. Other outcomes included in-hospital mortality and 30-day readmission for a UTI.Results214 patients met inclusion (124 and 90 in the EMP-NS and EMP-S groups, respectively) with ceftriaxone used most in the EMP-NS group and carbapenems in the EMP-S group. No significant difference was observed in patients meeting criteria for the primary outcome between the EMP-NS and EMP-S groups (25.0% vs 32.2%, p = 0.246). A higher baseline rate of sepsis was observed in the EMP-S group. When comparing the 51 patients in each group that had sepsis, there was no difference observed in the primary outcome between the EMP-NS and EMP-S groups (47.1% vs 54.9%, p = 0.428). No significant differences were observed regarding in-hospital mortality and 30-day readmissions due to a UTI between groups.ConclusionEmpiric antibiotic therapy later confirmed to be nonsusceptible showed no difference in clinical outcomes compared to empiric carbapenems for ESBL UTIs. Further evaluation of this approach could help offer a practical framework to preserve carbapenem efficacy through culture-guided therapy rather than empiric broad-spectrum use for a frequently encountered infectious etiology.DisclosuresAll Authors: No reported disclosures

Background: Ibogaine is a naturally occurring hallucinogenic alkaloid originally used in ritualistic ceremonies by West Central African tribes for centuries. Ibogaine’s rise in popularity in the 1960s was fueled by reports from those with a heroin addiction that claimed ibogaine stemmed their addiction. Currently, there is a renewed interest in ibogaine’s potential for treating opioid dependence. Methods: We reviewed ibogaine’s mechanism of action, potential drawbacks associated with its use, and recent progress in clinical trials. Results: Ibogaine acts on several neurotransmitters in the brain such as μ and κ opioid receptors, dopamine, serotonin, N-methyl-D-aspartate, and nicotinic acetylcholine receptors. Ibogaine’s anti-addictive effects are thought to be related to its activity on nicotinic acetylcholine receptors in the ventral tegmental region of the midbrain. Regarding its cardiotoxicity, ibogaine has shown to cause QTc prolongation leading to polymorphic ventricular tachycardia with cardiac arrest in one case. However, in an observational cohort study that included 30 participants, no serious adverse events occurred while taking ibogaine. Currently, there is a phase 1/2a study that has been completed, but no results regarding adverse events have been reported. Conclusion: Ibogaine is an interesting candidate that needs further study to determine its safety and potential for treating opioid dependence.

Cannabinoid hyperemesis syndrome (CHS) is a condition in which users of marijuana experience symptoms of nausea and vomiting. Due to the nature of the condition, patients may ultimately be admitted to the hospital for complications such as weakness and fluid loss. The usual treatment options for nausea and vomiting include fluids and a combination of metoclopramide, ondansetron, promethazine, or prochlorperazine. We present a case where fosaprepitant was utilized for intractable nausea and vomiting when other treatment modalities failed for CHS.

BackgroundBallistic embolism (BE) is a rare complication of firearm injuries notoriously associated with a vexing clinical picture in the trauma bay. Unless considered early, the associated confusion can lead to needless delay in the management of the patient with a gunshot wound. Despite this known entity, there is a relative paucity of high-grade evidence regarding complications, management, and follow-up in these patients.MethodsAn electronic database literature search was conducted to identify cases of acute intravascular BE in pediatric and adult civilians occurring during index hospitalization, filtered to publications during the past 10 years. Exclusion criteria included non-vascular embolization, injuries occurring in the military setting, and delayed migration defined as occurring after discharge from the index hospitalization.ResultsA total of 136 cases were analyzed. Nearly all cases of BE occurred within 48 hours of presentation. Compared with venous emboli, arterial emboli were significantly more likely to be symptomatic (71% vs. 7%, p<0.001), and 43% of patients developed symptoms attributable to BE in the trauma bay. In addition, arterial emboli were significantly less likely to be managed non-invasively (19% vs. 49%, p<0.001). Open retrieval was significantly more likely to be successful compared with endovascular attempts (91% vs. 29%, p<0.001). Patients with arterial emboli were more likely to receive follow-up (52% vs. 39%) and any attempt at retrieval during the hospitalization was significantly associated with outpatient follow-up (p=0.034). All but one patient remained stable or had clinically improved symptoms after discharge.ConclusionConsideration for BE is reasonable in any patient with new or persistent unexplained signs or symptoms, especially during the first 48 hours after a penetrating firearm injury. Although venous BE can often be safely observed, arterial BE generally necessitates urgent retrieval. Patients who are managed non-invasively may benefit from follow-up in the first year after injury.

Background Organs from extreme ages have been sought after to help increase the donor pool and alleviate transplantation wait times. There has been a growing evolution of the use of pediatric donor kidneys, including the use of en bloc kidneys (EBK), to now separating them into single kidneys (SKT), allowing for transplantation of two recipients. This study reports our outcomes utilizing SKT. Methods A retrospective review of all SKT performed from 2014 to 2022 at our center was conducted. Donors >8 years of age or >25 kg in weight were excluded. Donor and recipient characteristics and outcomes were analyzed, comparing <18 kg and ≥18 kg donor cohorts. Results Between 2014 and 2022, 81 adults received SKT. Recipients' mean age, weight, and body mass index were 49 years (22-74), 74 kg (39-136), and 26.4 mg/m2 (19.6- 39.8), respectively. Donors' mean age, weight, and kidney size were 35.7 months (8-96), 17.8 kg (8-25), and 7.2 cm (4.5-8.5), respectively. At one year post-transplant, patient survival was 100%, graft survival was 98.7%, mean serum creatinine was 1.25 mg/dL, and mean glomerular filtration rate (GFR) was 68.3 ml/min. Hyperfiltration injury was seen in 43.75% of recipients. None of the outcomes correlated with any of the donor or recipient characteristics. Conclusion Our study shows excellent short-term outcomes of single pediatric kidney transplantation inadult recipients. Exploring a lower donor weight cut-off for SKT, compared to the current Organ Procurement and Transplantation Network's (OPTN's)≥18 kg, could expand the organ pool and lead to an increased number of transplants.

Guidelines provide varying recommendations for the prophylactic antimicrobial treatment of open fractures. This single-center, retrospective cohort study was conducted to determine how well an institutional prophylactic antibiotic protocol covered pathogens associated with open fractures. The authors included adult trauma patients with one or more open fractures and a positive culture from the site of the open fracture, and compared outcomes between patients who were covered by prophylactic antibiotics with patients not covered by prophylactic antibiotics. Of 957 patients evaluated, 75 were included, with 40 patients (53%) covered by the prophylactic antibiotics received. Multidrug-resistant pathogens were isolated in 23 (58%) patients covered versus 26 (74%) patients not covered (p = 0.128). The median time to positive culture was less in patients not covered by initial antibiotics compared with those who were covered (30.2 vs. 102.1 days; p = 0.003). Over half of the patients developed cultures with pathogens that were covered by their initial antibiotic prophylaxis. (Journal of Surgical Orthopaedic Advances 33(2):084-087, 2024).