Oral anticoagulation (OAC) prevents stroke in atrial fibrillation, yet a residual stroke risk remains. In this single-center retrospective analysis of acute ischemic stroke patients despite OAC, suboptimal OAC treatment is common (30%: inappropriate dosing (17%); patient non-adherence (13%)). Other causes of stroke included OAC interruption (14.5%), a competing stroke mechanism (11.0%), and undetermined breakthrough stroke in 44.5%. Overall, easily modifiable causes of ischemic stroke despite OAC are common. Accordingly, strategies to improve treatment compliance, including appropriate dosing along with guideline-based risk factor and periprocedural OAC management, should be emphasized to improve secondary stroke prevention in this patient population.

Bovine respiratory disease (BRD) treatment failure occurs when animals receiving a treatment regimen for BRD fail to directly return to health, resulting in chronic illness and a requirement for repeated treatments, sale for salvage slaughter, euthanasia or death. BRD treatment failure has both direct and indirect impacts. Direct impacts include costs to manage chronically ill animals, including those associated with BRD relapse treatment; reduced returns from animals sent for salvage slaughter, loss of the initial investment to purchase the animal and feed and other accumulated expenses to death, and costs associated with carcass disposal. Indirect impacts include costs of infrastructure requirements, and negative effects on animal welfare and employee morale.

The risk of metronidazole treatment failure in Clostridium difficile infection (CDI) patients with chronic kidney disease (CKD) or end-stage renal disease in Korea has not been established. We evaluated 481 patients who had been admitted to two secondary hospitals with a diagnosis of, and treatment for, CDI during 2010–2016. CDI patients were divided into three groups according to CKD status: non-CKD (n = 363), CKD (n = 55) and those requiring dialysis (n = 63). Logistic regression analyses were performed to examine the association of CKD status with treatment failure. CDI patients receiving dialysis tended to have increased odds of metronidazole and overall treatment failure compared to non-CKD patients; adjusted odds ratios and 95% confidence intervals were 2.09 (1.03–4.21) and 2.18 (1.11–4.32) for metronidazole and overall treatment failure, respectively. However, CKD patients did not have increased odds of metronidazole or overall treatment failure compared to non-CKD patients, even where severe CDI was more prevalent in CKD patients. The incidence of symptomatic ileus or toxic megacolon did not differ among groups. Our results suggest that initial metronidazole therapy may be considered in CDI patients with non-dialysis CKD, but should not be considered in CDI patients undergoing dialysis.

Introduction: Current guideline recommendations for optimal management of non-purulent skin and soft tissue infections (SSTIs) are based on expert consensus. There is currently a lack of evidence to guide emergency physicians on when to select oral versus intravenous antibiotic therapy. The primary objective was to identify risk factors associated with oral antibiotic treatment failure. A secondary objective was to describe the epidemiology of adult emergency department (ED) patients with non-purulent SSTIs. Methods: We performed a health records review of adults (age 18 years) with non-purulent SSTIs treated at two tertiary care EDs. Patients were excluded if they had a purulent infection or infected ulcers without surrounding cellulitis. Treatment failure was defined any of the following after a minimum of 48 hours of oral therapy: (i) hospitalization for SSTI; (ii) change in class of oral antibiotic owing to infection progression; or (iii) change to intravenous therapy owing to infection progression. Multivariable logistic regression was used to identify predictors independently associated with the primary outcome of oral antibiotic treatment failure after a minimum of 48 hours of oral therapy. Results: We enrolled 500 patients (mean age 64 years, 279 male (55.8%) and 126 (25.2%) with diabetes) and the hospital admission rate was 29.6%. The majority of patients (70.8%) received at least one intravenous antibiotic dose in the ED. Of 288 patients who had received a minimum of 48 hours of oral antibiotics, there were 85 oral antibiotic treatment failures (29.5%). Tachypnea at triage (odds ratio [OR]=6.31, 95% CI=1.80 to 22.08), chronic ulcers (OR=4.90, 95% CI=1.68 to 14.27), history of MRSA colonization or infection (OR=4.83, 95% CI=1.51 to 15.44), and cellulitis in the past 12 months (OR=2.23, 95% CI=1.01 to 4.96) were independently associated with oral antibiotic treatment failure. Conclusion: This is the first study to evaluate potential predictors of oral antibiotic treatment failure for non-purulent SSTIs in the ED. We observed a high rate of treatment failure and hospitalization. Tachypnea at triage, chronic ulcers, history of MRSA colonization or infection and cellulitis within the past year were independently associated with oral antibiotic treatment failure. Emergency physicians should consider these risk factors when deciding on oral versus intravenous antimicrobial therapy for non-purulent SSTIs being managed as outpatients.

Management of Clostridium difficile infection (CDI) involves discontinuation of the offending antibiotic agent as soon as possible. However, the ongoing infection does not allow discontinuation of the offending antibiotic. We aimed to retrospectively investigate the predictors of treatment failure and impact of the concomitant use of systemic antibiotics in patients receiving metronidazole therapy. This study was conducted among patients hospitalised at a second care academic hospital from January 2013 to December 2014. Eligible patients were identified by reviewing stool toxin enzyme immunoassay results for C. difficile. Diarrhoea was defined as the passage of at least three loose or watery stools within 24 h. Among 314 patients with CDI receiving metronidazole therapy, 62 (19.7%) showed treatment failure and 105 (33.4%) received concomitant antibiotics. Underlying dialysis, fever >38.3 °C, low median serum albumin levels and concomitant use of antibiotics were independent predictors of treatment failure in patients with CDI receiving metronidazole therapy. The concomitant use of antibiotics increased the rates of treatment failure and 30-day mortality in patients receiving metronidazole therapy. These results suggest that metronidazole should be used in mild cases of CDI only after discontinuation of the offending antibiotics.

Background: Understanding successful and unsuccessful behavioural treatment for pain is essential. Aims: We carried out a retrospective survey of 130 people who had undergone pain rehabilitation based on acceptance and commitment therapy, aiming to identify factors associated with non-response. Method: The sample was selected using the reliable change index to define ‘responders’ and ‘non-responders’ to key outcome measures. We surveyed a range of treatment-related, systemic, practical and personal factors that may have affected their treatment, and then compared ‘non-responders’ with ‘responders’, controlling for factors that might not be causal or specific to non-response. Results: Logistic regression analysis showed two themes that distinguished the groups, ‘people outside programme’ and ‘emotional state’. Conclusions: These data have clinical implications, as such factors can be addressed directly or incorporated into an assessment of treatment ‘readiness’. This study introduced a novel methodology for the investigation of pain treatment response, which allowed a broad study of clinically relevant variables, but with greater rigour than conventional self-reports of ‘helpful factors’ in treatment.

Introduction: Most patients with acute renal colic are discharged from the ED after initial diagnosis and symptom control, but 20-30% require repeat ED visits for ongoing pain, and 15-25% require rescue intervention (ureteroscopic intervention or lithotripsy). If patients destined for failure of outpatient management could be identified based on information available during their ED visits, they could be prioritized early for intervention to reduce short term pain and disability. Our objective was to identify predictors of outpatient treatment failure, defined as the need for hospitalization or rescue intervention within 60 days of ED discharge. Methods: We collated prospectively gathered administrative data from all Calgary region patients with an ED diagnosis of renal colic over a one-year period. Demographics, arrival mode, triage category, vital signs, pain scores, analgesic use and ED disposition were recorded. Research assistants reviewed imaging reports and documented stone characteristics. These data were linked with regional hospital databases to identify ED revisits, hospital admissions, and surgical procedures. The primary outcome was hospitalization or rescue intervention within 60 days of ED discharge. Results: Of 3104 patients with first ED visit for acute renal colic, 1296 had CT or US imaging and were discharged without intervention. Median age was 50 years and 69% were male. 325 patients (25.1%) required an ED re-visit and 11.8% required admission or rescue intervention. Patients with small (<5mm), medium (5-7mm) and large (>7mm) stones failed in 9.0%, 14.4% and 9.9% of cases respectively. The only factor predictive of treatment failure in multivariable models was stone position in the proximal or mid-ureter. Age, sex, vital signs, pain score, WBC, creatinine, history of prior stone or intervention, stone side, stone size, presence of stranding and degree of hydronephrosis were not associated with outpatient failure. Conclusion: Outpatient treatment failure could not be predicted based on any of the predictors studied.

Since clinical trials have demonstrated that breast conservation is safe and effective for treatment of invasive breast cancer, there has been considerable disagreement and controversy about what constitutes an acceptable margin in breast cancer. Dogmatic adherence to a set margin for all patients may cause a higher mastectomy rate than necessary, and thus it is important to understand how various clinical and pathologic factors affect local recurrence and outcome. This review discusses that controversy, as well as what factors should be considered when evaluating patients on an individual basis.

Little is known of the aetiology, serotypes or susceptibility of the pathogens causing non-resolving otitis media in children receiving care from specialists in private practice in developed or in developing countries. Increased access to antibiotics in the community amongst children receiving such private care in South Africa may be anticipated to lead to levels of resistance similar to those found in countries with similar models of private practice, such as the United States. This study was conducted to determine the aetiology of non-resolving otitis media in South African children receiving private care and to determine the antimicrobial resistance patterns and serotypes of the bacterial isolates.

Middle-ear fluid was cultured from 173 children aged two months to seven years with non-resolving acute otitis media accompanied by persistent pain or fever who were referred to otorhinolaryngologists for drainage of middle-ear fluid within 14 days of the start of symptoms. While 92 per cent of the children had recently received antibiotics and 54 per cent were currently receiving them, bacteria were isolated from 47 children (27 per cent). Streptococcus pneumoniae was the most common pathogen (35), followed by Haemophilus influenzae (nine), Staphylococcus aureus (six), Moraxella catarrhalis (two), Streptococcus pyogenes (two) and Pseudomonas aeruginosa (one). Two isolates were identified in each of eight children. Antimicrobial resistance to one or more antibiotics was found in 33/35 (94 per cent) of the pneumococci isolated, with resistance to penicillin in 86 per cent, resistance to trimethoprim-sulfamethoxazole in 54 per cent and to erythromycin and clindamycin in 69 per cent and 57 per cent, respectively. The pneumococcal serotypes found were 19F (28 per cent), 14 (26 per cent), 23F (23 per cent), 6B (nine per cent), 19A (87 per cent), and four (three per cent). Children with a bacterial pathogen isolated were younger (mean age of 17 months) than children from whom no bacteria were isolated (mean age of 23 months; p = 0.03). Isolation of a pneumococcus was also significantly associated with younger age (mean = 16 months versus 22 months, p = 0.03), the presence of fever (OR = 2.15, p = 0.049), and having one or more prior episodes of otitis media within the six months before tympanocentesis (OR = 7.72, p = 0.03). Almost all pneumococci isolated from non-resolving acute otitis media in this community are antibiotic-resistant and should be considered especially in young children who have failed previous therapy and who have non-resolving pain or fever.

The aim of this retrospective study was to determine the possible causes of failure of antibiotic therapy in children with acute otitis media (AOM). Thirty-nine samples of middle-ear fluid were obtained by myringotomy from 31 children suffering from AOM, unrelieved by antibiotic therapy administered for over 48 hours. The samples were analysed by the usual microbiological techniques, including cultures, tests for beta-lactamase producing strains and the determination of the minimal inhibitory concentration of penicillin for Streptococcus pneumoniae. In 14 samples, no bacterial strains were detected in the cultures of middle-ear fluid; and in two samples the cultures revealed two strains of bacteria. The bacteria most frequently identified were Haemophilus influenzae, found in 11 samples, and Streptococcus pneumoniae, found in seven samples, of which four produced strains with reduced susceptibility to penicillin. The failure of antibiotic therapy in AOM appears to be related to the increased resistance of Haemophilus influenzae and to the reduced susceptibility of Streptococcus pneumoniae to penicillin. Other factors contributing to the failure of antibiotic therapy in AOM may be the viruses or the bacteria that produce multiple pathogens in the middle ear.

A cognitive perspective of cognitive therapy training stress disorder (CTTSD) is presented. The authors present a cognitive model of CTTSD, preliminary data from randomized treatment trials, and discuss implications for effective treatment of CTTSD trainees.

We have reviewed our experience of tracheostomy in children over the past 20 years at Sheffield Children’s Hospital. One hundred and forty-eight tracheostomies were performed in 143 children aged one day to 13 years old (average 27 months). Sixty-five per cent of patients were <one year old. The indications for tracheostomy were upper airways’ obstruction in 72 per cent, and assisted ventilation/bronchopulmonary toilet in 28 per cent. The commonest single reason was acquired subglottic stenosis (SGS) in infants, accounting for 25 per cent of tracheostomies (36/143). The complication rate of tracheostomy was 46 per cent, most commonly granulation tissue formation. There were four deaths directly due to the tracheostomy: two accidental decannulations and two obstructions. Eighty-nine children were decannulated under our care. The average time until decannulation was 25 months.

The goal of the present work was to investigate possible risk factors for the poor response of some cases of chronic sinusitis to endoscopic sinus surgery in spite of the precision of the surgical technique. Eleven adult patients who were scheduled for revision endoscopic sinus surgery underwent a complete allergy workup. At the time of surgery, a tiny biopsy was taken from the maxillary sinus mucosa close to the middle turbinate. The specimens were processed for histochemical and transmission electron microscopic examination.

Six patients (55 per cent) proved to be allergic. Their sinus mucosa showed eosinophilic infiltration (6.1 cells/mm2), and mast cell degranulation. This proves that allergens can reach the sinus mucosa and have a direct impact on it. Another three patients (27 per cent) were non-allergic but exhibited mucosal eosinophilia (5.0 cells/mm2), and two of them showed mast cell degranulation. These patients were diagnosed as having nonallergic rhinosinusitis with eosinophilia (NARSE). The nasal mucosa of the remaining two patients did not reveal any characteristic pathological findings, and no pathologic diagnosis could be established for them. None of the patients showed electron microscopic evidence of purulent inflammatory changes, and the bacterial cultures recovered normal respiratory flora in nine patients (82 per cent).

The present research spotlights the importance of allergy and nonallergic eosinophilic infiltration of the mucosa as possible risk factors that may degrade the results of endoscopic sinus procedures and discusses some pertinent pathological and clinical aspects.

Psychological treatment that reduces anxiety has been found to be beneficial to benzodiazepine withdrawal. High drop-out and relapse rates, however, have also been reported. They might be due to a heightened anxiety level maintaining the drug-taking habit or to the addictive potency of the drug, which is not addressed by the intervention strategies. In the present study, initial assessment data were compared among treatment refusers, drop-outs and completers – successful as well as unsuccessful ones – of a psychological treatment programme in support of benzodiazepine withdrawal. Treatment refusers showed a more negative current mood state than those consenting to treatment. Internal locus of control was predictive of premature termination and unsuccessful completion of the treatment trial. Neither medication-related variables nor anxiety or depression were found to influence the success of treatment. Perceived control over medication intake is thought to reduce compliance with the treatment regimen – a pattern that may be consistent with the addiction hypothesis.