EXECUTIVE SUMMARY 1) When ultrasound equipment is available, along with providers who are appropriately trained to use it, we recommend that ultrasound guidance should be used for site selection of lumbar puncture to reduce the number of needle insertion attempts and needle redirections and increase the overall procedure success rates, especially in patients who are obese or have difficult‐to‐palpate landmarks. 2) We recommend that ultrasound should be used to more accurately identify the lumbar spine level than physical examination in both obese and nonobese patients. 3) We suggest using ultrasound for selecting and marking a needle insertion site just before performing lumbar puncture in either a lateral decubitus or sitting position. The patient should remain in the same position after marking the needle insertion site. 4) We recommend that a low‐frequency transducer, preferably a curvilinear array transducer, should be used to evaluate the lumbar spine and mark a needle insertion site. A high‐frequency linear array transducer may be used in nonobese patients. 5) We recommend that ultrasound should be used to map the lumbar spine, starting at the level of the sacrum and sliding the transducer cephalad, sequentially identifying the lumbar spine interspaces. 6) We recommend that ultrasound should be used in a transverse plane to mark the midline of the lumbar spine and in a longitudinal plane to mark the interspinous spaces. The intersection of these two lines marks the needle insertion site. 7) We recommend that ultrasound should be used during a preprocedural evaluation to measure the distance from the skin surface to the ligamentum flavum from a longitudinal paramedian view to estimate the needle insertion depth and ensure that a spinal needle of adequate length is used. 8) We recommend that novices should undergo simulation‐based training, where available, before attempting ultrasound‐guided lumbar puncture on actual patients. 9) We recommend that training in ultrasound‐guided lumbar puncture should be adapted based on prior ultrasound experience, as learning curves will vary. 10) We recommend that novice providers should be supervised when performing ultrasound‐guided lumbar puncture before performing the procedure independently on patients.

Measles (rubeola) continues to be endemic and epidemic in many regions of the world. Measles is primarily a disease of childhood, but it can also affect adult populations, and therefore it is important that both adult and pediatric hospitalist physicians be able to recognize it. Although the disease is rarely encountered in the United States, measles infection can spread rapidly across vulnerable populations. In addition, infected adults can develop complications that may require hospitalization for treatment. This review summarizes the typical clinical course and complications of measles infection, along with recommendations for diagnosis and management for both adult and pediatric hospitalists. Journal of Hospital Medicine 2017;12:472-476.

The large-scale resurgence of diphtheria in the former Soviet Union offered a unique opportunity to evaluate risk factors for the transmission of respiratory diphtheria; therefore, a prospective case-control study was done in the republic of Georgia. In total, 218 diphtheria cases (hospitalized between October 1995 and March 1996) and 408 matched controls participated. One hundred cases (45%) were /=15 years of age (range: <1 to 75 years). In the multivariate analyses, the following risk factors were found to be significant: lack of vaccination (matched odds ratio [mOR]=19.2), household exposure to diphtheria (mOR=7.4), exposure to skin lesions (mOR=5.8), history of eczema (mOR=3.4), fever with myalgia prior to illness (mOR=2.6), having tonsils (mOR=4.4), sharing a bed (mOR=1.9), sharing cups and glasses (mOR=2.7), and taking a bath less than once a week (mOR=2.6). These findings emphasize primary prevention through immunizations, secondary prevention following exposure to diphtheria (and to suspicious skin lesions), and adherence to strict standards of personal hygiene.

Epidemic diphtheria reemerged in the republic of Georgia in November 1993. To identify risk factors for fatal outcomes, clinical and epidemiologic data on all hospitalized diphtheria patients were examined. Medical charts of patients from 1993-1995 were reviewed. A total of 659 cases and 68 deaths were identified (case fatality rate [CFR] = 10.3%). Fifty-two percent of all cases and 68% of deaths were in children 3 days) between onset of symptoms to antitoxin treatment were significantly associated with fatal outcomes. Immunization of children and 40- to 49-year-old adults was required to rapidly control the epidemic.

Georgia, a country of 4.5 million people, has a high incidence of tuberculosis (TB) including drug resistant cases. Easy access and inappropriate use of anti-TB drugs are risk factors for further development of multidrug resistant (MDR)-TB. We carried out an investigation to assess the availability of over the counter anti-TB agents in pharmacies in Tbilisi. During February 2006, 15 pharmacies were randomly selected and the pharmacist at each store was interviewed. We found that all anti-TB medications stocked by these pharmacies were available and sold without a prescription. All 15 pharmacies sold isoniazid, rifampicin, and streptomycin; 13 (87%) of 15 pharmacies also sold pyrazinamide, ethambutol. Second line anti-TB drugs such as amikacin and kanamycin (injectable agents) and older fluoroquinolones (ofloxacin and ciprofloxacin) were available at 13 pharmacies while newer generation fluoroquinolones were less available(3 sold leovofloxacin, none sold moxifloxacin). The ease access and availability of anti-TB agents is of a great concern given the high prevalence of TB including MDR-TB in Georgia. The potential for misuse of these anti-TB drugs can lead to the development of further drug resistance. These drugs should only be available by prescription in order to reduce the chance of amplifying drug resistance.