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By: John Walter Krakauer, M.A., M.D.

  • Director, the Center for the Study of Motor Learning and Brain Repair
  • Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/9121870/john-krakauer

I was careful to treatment diabetic neuropathy generic sustiva 600 mg begin with some questions about other medicine emoji sustiva 600 mg otc, unrelated procedures on the ward medications zanx order sustiva 200 mg with visa. Eventually treatment lupus buy discount sustiva 200 mg, I asked the critical question, “Could you tell me about the insertion and maintenance of heparin locks on the unitfi The only difference between the maintenance of an intravenous line and a heparin lock was that the barrel of the heparin lock tube was flushed at regular intervals using heparin solution. This is done so that the blood in the heparin lock barrel will not clot off and eliminate access to the vein. I probed further and asked whether the heparin flush solution came directly from the pharmacy. The nurse stated that no, in general, the heparin solution was prepared on the unit once a day, usually just after the morning change of shifts. Trying to sound offhand, I asked whether each patient had his or her own designated heparin flush solution vial or whether one vial served as the flush solution for all patients on the ward who needed heparin lock maintenance. She stated that the heparin flush solution was kept at the nurse’s station and that nurses would draw up solution as they needed it. I asked whether the same syringe was used to flush multiple heparin locks and received a shocked look. A new, prepackaged, sterile syringe is used to draw up heparin flush solution, and the same syringe is never inserted into the heparin lock of different patients. The April 26 to May 2nd interval that we were scrutinizing coincided with Passover, an important Jewish holiday. As a result, ward A staffing was minimal, much as it would have been during the Christmas Holidays in the United States. If one of the hepatitis B carriers housed on ward A had a heparin lock in place during this interval, an overburdened staff member might have reused a syringe that had been contaminated while flushing that carrier’s heparin lock. By readvancing it into the multidose heparin/saline flush solution, the solution itself would have been contaminated. Adding to the plausibility of this mechanism was the fact that additional medical record reviews revealed that of the four hepatitis B carriers on medicine A in late April and early May, only one was in the hospital on April 29, the day when all five cluster patients had been on the unit on the same day. This carrier individual had a heparin lock in place from April 23 through the morning of May 1. Although there was no way to definitively prove it, I had a highly plausible explanation for the first cluster. This explanation was biologically plausible, consistent with available data, and credible given the tendency for error when staff are rushed or overburdened. With some excitement, I called my supervisor, Steve Hadler, and he agreed that I had identified the probable cause of the outbreak but suggested one additional analysis to bolster my case. He speculated that the kind of mistake I was hypothesizing would probably be a one-time event because it represented a gross breach of standard practice. Steve therefore suggested that I examine the association between heparin lock placement on each day of the April 26 to May 2 interval (Table 9-1). Of special interest were the data from April 29th, the only day when all five cluster patients were on the unit. On this date, the Table 9-1 Percentage of Cases and Susceptible Controls With InDwelling Heparin-Lock Placement on Medicine A on Consecutive Days in late April and Early May Date 4/26 4/27 4/28 4/29 4/30 5/1 5/2 % Cases (n) 75 (4) 100 (4) 100 (4) 80 (5) 67 (3) 100 (3) 100 (3) % Controls (n) 11 (9) 36 (11) 9 (11) 0 (9) 11 (9) 11 (9) 14 (14) P (Fisher’s exact). Specifically, four of five cases had a heparin lock on that day compared to none of nine controls. How could I explain the one patient who did not have a heparin lock in place on the 29thfi I carefully reviewed the medical record again and found that he was admitted to medicine A from the coronary care unit on the 29th on continuous intravenous therapy. From my own experience as a resident, I knew that when a patient is transferred from one unit to another the patient is jostled and transferred from bed to stretcher and that transient interruptions in intravenous fluid administration may frequently occur. It was possible that while being transported, this case patient’s intravenous line clotted off. If so, a staff person on ward A may have flushed the line with the contaminated heparin normal saline solution soon after the patient arrived on ward A. This would be done to salvage the line and avoid the need to reinsert an intravenous line at a different site. Statistically, significant associations are demonstrated on other calendar days in the April 26 through May 2 interval, but no other date included all five case patients. Furthermore, it did not surprise me that other days would show an association; a patient who requires a heparin lock on any given day is likely to continue to require it on ensuing days. Although I remained busy during the following days, it mainly amounted to tying up loose ends. Death certificates from those 18 medicine A patients who had died after their April/May admission did not reveal any hint of a liver-related cause of death. Furthermore, the hepatitis B serologic testing performed on patients who had been co-residents of the patients who died of fulminant hepatitis in the June cluster on ward A revealed no other patients with evidence of acute hepatitis B. Thus, the sixth case that had occurred in August was an isolated event, not part of a second cluster, and in fact, he did not have a heparin lock in place. He did, however, undergo a bone marrow biopsy during his stay, had a permanent cystostomy in place, and had an indwelling intravenous line for much of his stay. Three of the dying June cluster patients were present on the ward during his admission. All of these patients had marked coagulopathies, and one was noted to have ongoing blood oozing from his intravenous line insertion site. We hypothesized that the sixth case may have acquired hepatitis B through cross-contamination with blood derived from the June cluster hepatitis patients. After completing the basic investigation, it was time to brief the staff of the Rambam Hospital on my findings and to make recommendations. In that presentation, I reviewed my findings carefully, not only summarizing my positive findings but refuting other potential mechanisms. Further strengthening the case for a common-source, multidose exposure was the tight temporal clustering of the cases and the short incubation periods. The short incubation period favored a high inoculum exposure like that which might result from the direct injection of a contaminated injectable, rather than that which would result if small amounts of infected materials were splashed or rubbed onto an intravenous site. After completing my presentation, I was taken aback when the chief of staff raised his hand and said that I had left out one important possible explanation for the outbreak—intentional sabotage. He was concerned that a disgruntled or criminal employee had obtained hepatitis B contaminated fluid and intentionally injected it into these patients. I thought about this and asked why a saboteur would inoculate only those with a heparin lock when intravenous lines would provide equivalent ease of access to the blood stream of patients. Without hesitation, he stated that heparin locks have a flat rubberized port, whereas intravenous systems have a rounded rubberized section for introducing needles. With the latter, it is easier to poke yourself, which might have deterred a saboteur. I advanced other arguments against the sabotage theory, pointing to the fact that use of potassium chloride or poisons would be a more typical approach, but these were countered by the assertion that they would have raised greater suspicion of foul play. I had acquitted myself well during the investigation and had made a good impression. Before I departed, I was offered a position at the Rambam Hospital and the challenge of developing an infectious disease service there. I seriously considered this offer and even inquired about potential positions for my wife, Judy, who was also a physician. At the end of my stay in Israel, I was told that the outbreak investigation was to be kept strictly confidential. Families of the cases would have to be told first and then the decision about publication would be reassessed. I was disappointed in part because it meant that the work might not be published, which affected me personally, but also because the wider world could not benefit from the findings of our investigation. At the airport, when I was getting ready to board my airplane to return to the United States, I was interviewed by security. With some trepidation, I told them that I had been working on a scientific investigation in Haifa with colleagues at the Rambam Hospital. The security agent must have sensed my unease and continued to probe for increasingly specific details of my investigation. Eventually, I divulged that I had been working on an outbreak at the Rambam Hospital.

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T Unlike navigation on the Internet, this program “remembers” only the last slide you visited. Therefore, if you follow a hyperlink to a second slide, you can return to the first with the icon. However, if you follow a link to a third slide, you will not be able to immediately go back to the first slide, unless a “hard” return link has been provided. Several pictures were scanned from 35-mm slides, and the adult Ascaris lumbricoides and Dirofilaria immitis were photographed with a hand-held Olympus digital camera. Unfortunately, some of these slides are no longer commercially available, and now exist only in teaching collections. For the following specific topics, additional sources were consulted: Diagnosis of malaria parasites Cuviello, P. DeGennaro, PhD President and Chief Executive Ofcer The Leukemia & Lymphoma Society Table of Contents 2 Introduction 2 Here to Help 5 Leukemia 6 Acute Myeloid Leukemia 9 Diagnosis 12 Treatment 29 Research and Clinical Trials 31 Normal Blood and Marrow 33 Medical Terms 51 More Information Acknowledgement The Leukemia & Lymphoma Society gratefully acknowledges, for their critical review and important contributions to the material presented in this publication, Judith Karp, M. Here to Help this booklet will help you talk to your doctor about the tests and treatment you need. We encourage you to take the lead in asking questions and discussing your fears and concerns. Tese actions will give members of your healthcare team the opportunity to answer your questions, extend emotional support and provide any needed referrals. Denial, depression, hopelessness and fear are some of the reactions people may have. Keep in mind that {{Many people are better able to cope once they begin treatment and can look forward to recovery. New approaches to therapy are being studied in clinical trials for patients of all ages and at every stage of treatment. You may have questions about your treatment and want to have friends, family members or caregivers help you get information. Making treatment choices, paying for medical care, communicating with healthcare providers, family members and friends—these are some of the stressors that go along with a cancer diagnosis. They provide accurate up-to-date disease and treatment information and are available to speak with callers Monday through Friday, 9 a. Free language services are available when you speak with an Information Specialist. Let your doctor know if you want a professional healthcare interpreter who speaks your native language or uses sign language to be present during your visit. Your chapter can arrange for peer-to-peer support through the Patti Robinson Kaufmann First Connection Program. Our Information Specialists help patients work with their doctors to fnd out about specifc clinical trials. This program is designed to increase communication among parents, children, adolescents, young adults, healthcare professionals and school personnel. Seek medical advice if your mood does not improve over time—for example, if you feel depressed every day for a 2-week period. The four major types of leukemia are acute myeloid leukemia, chronic myeloid leukemia, acute lymphoblastic leukemia and chronic lymphocytic leukemia. Acute leukemias are rapidly progressing diseases that afect cells that are not fully developed. Chronic leukemias usually progress more slowly, and patients have greater numbers of mature cells. In general, these more mature cells can carry out some of their normal functions (see Normal Blood and Marrow on page 31). With myeloid leukemia, a cancerous change begins in a marrow cell that normally forms certain blood cells—that is, red cells, some types of white cells and platelets. With lymphocytic (lymphoblastic) leukemia, the cancerous change begins in a marrow cell that normally forms lymphocytes (another type of white cell). Once the marrow cell becomes a leukemic cell, it multiplies into 11 billion or more cells. The medical term for I Is Low red cell count I Anemia Low platelet count I Trombocytopenia (“thrombocyte” is another word for platelet) Low neutrophil count I Neutropenia (a neutrophil is a type of white cell) Causes and Risk Factors. According to the Agency for Toxic Substances and Disease Registry, despite the fact that petroleum products contribute to the majority of benzene in the atmosphere, half of the total national personal exposure to benzene comes from cigarette smoke. Benzene is also found in certain industrial settings; however, the strict regulation of its use has decreased benzene exposure in the workplace. For people over 70, the incidence rate continues to increase, peaking between the ages of 80 and 84 (see Figure 1). A person with signs or symptoms that suggest the possibility of leukemia is usually referred to a specialist. The person may tire more easily and have shortness of breath during normal physical activities. However, such bleeding is usually preceded by minor bleeding, such as nose bleeds, blood in the urine or bruises (see Disease and Treatment Side Efects on page 23). Severe infection can occur at the time of diagnosis but becomes more common and often more serious during treatment, when the bone marrow is completely suppressed. Other names for a myeloid sarcoma are “chloroma,” “granulocytic sarcoma,” “myeloblastoma” or “monocytoma. The exact diagnosis helps the doctor to {{Estimate how the disease will progress {{Determine the appropriate treatment. Talk to your The diagnostic tests that are being done doctor about What the results mean Getting copies of the test results. Some of these tests may be repeated during and after therapy to measure the efects of treatment. Some of the nuclei are circular and some are horseshoe shaped, refecting the diferent developmental stages and the diferent types of cells. To do the tests, blood samples are generally taken from a vein in the patient’s arm. Samples of marrow cells are obtained by bone marrow aspiration and biopsy (see page 36). Too many immature white cells I Peripheral Blood Smear – A test called a and too few mature white cells “peripheral white cells blood smear” (an examination of the stained [dyed] blood cells with a microscope) usually shows the presence of leukemic blast cells (myeloblasts). A hematopathologist is a specialist who studies blood cell diseases by looking at samples of blood and marrow cells and other tissues. Myeloblastic, I M2 – many myeloblasts, but some cells are with maturation developing toward fully formed blood cells. Promyelocytic I M3 – leukemic cells have a translocation between chromosomes 15 and 17. Myelomonocytic I M4 – leukemic cells often have a translocation or an inversion of chromosome 16. Monocytic I M5 – leukemic cells have features of developing monocytes (white cells). When one cell line is dominant, the disease may be referred to as acute erythroid leukemia, acute megakaryocytic leukemia, acute monocytic leukemia and so forth.

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