The American journal of medicine
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Multicenter Study
Characterization of ischemic colitis associated with myocardial infarction: an analysis of 23 patients.
The study characterizes the clinical presentation of ischemic colitis (IC) associated with myocardial infarction (MI) and helps determine whether the primary mechanism for this association is thrombus, embolus, or localized nonocclusive mesenteric ischemia (NOMI) associated with systemic hypotension. ⋯ Patients with both IC and MI present as a clinically distinct group from patients with either IC alone or MI alone. They have significantly more complications and worse in-hospital prognoses. They present with a dramatically lower MAP and a higher frequency of hypotension. This last finding suggests that the most common and most important mechanism for IC with MI may be hypotension from cardiogenic shock. Hypotension is the cardinal risk factor for generalized NOMI with acute mesenteric ischemia and may be an important risk factor for localized NOMI with IC. An APACHE II score greater than 15 may be a predictor of mortality from IC after MI.
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Editorial Historical Article
Departments, divisions and centers in the evolution of medical schools.
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The emergence and spread of resistance in Enterobacteriaceae are complicating the treatment of serious nosocomial infections and threatening to create species resistant to all currently available agents. Approximately 20% of Klebsiella pneumoniae infections and 31% of Enterobacter spp infections in intensive care units in the United States now involve strains not susceptible to third-generation cephalosporins. Such resistance in K pneumoniae to third-generation cephalosporins is typically caused by the acquisition of plasmids containing genes that encode for extended-spectrum beta-lactamases (ESBLs), and these plasmids often carry other resistance genes as well. ⋯ Carbapenem resistance, although rare, appears to be increasing. Particularly troublesome is the emergence of KPC-type carbapenemases in New York City. Better antibiotic stewardship and infection control are needed to prevent further spread of ESBLs and other forms of resistance in Enterobacteriaceae throughout the world.
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Nonfermenting gram-negative bacteria pose a particular difficulty for the healthcare community because they represent the problem of multidrug resistance to the maximum. Important members of the group in the United States include Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia, and Burkholderia cepacia. These organisms are niche pathogens that primarily cause opportunistic healthcare-associated infections in patients who are critically ill or immunocompromised. ⋯ Multidrug resistance in gram-negative nonfermenters makes treatment of infections caused by these pathogens both difficult and expensive. Improved methods for susceptibility testing are needed when dealing with these organisms, including emerging strains expressing metallo-beta-lactamases. Improved antibiotic stewardship and infection-control measures will be needed to prevent or slow the emergence and spread of multidrug-resistant, nonfermenting gram-negative bacilli in the healthcare setting.
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Insomnia is a prevalent problem in late life. Sleep problems in the elderly are often mistakenly considered a normal part of aging. ⋯ Despite the fact that more than 50% of elderly people have insomnia, it is typically undertreated, and nonpharmacologic interventions are underused by health care practitioners. This article will review the causes of insomnia in the elderly, the approach to patient evaluation, and the nonpharmacologic and pharmacologic treatment of insomnia.