Four-year trends of inappropriate proton pump inhibitor use after hospital discharge.

BACKGROUND: Several hospital-based studies have determined that physicians often inappropriately prescribe acid-suppressive medications for stress ulcer prevention in hospitalized patients and continue these drugs after discharge. We sought to determine the frequency of inappropriate proton pump inhibitor (PPI) use continued at discharge within our geographic region. METHODS: We undertook a retrospective review of the medical records and pharmacy prescription database of a large regional insurance carrier from January 2005 through December 2008 (total hospital admissions 96,669). The primary inclusion criterion was hospital-initiated PPI therapy and continuation on hospital discharge without an appropriate indication. Patients receiving a PPI at the time of admission were excluded from the analysis. RESULTS: The number of patients per year discharged on a PPI decreased during the study period: 876 (2005), 763 (2006), 562 (2007), and 485 (2008). Of the patients discharged on a PPI, the number (%) of patients receiving PPIs inappropriately were 695 (79%; 2005); 627 (82%; 2006), 441 (78%; 2007), and 397 (82%; 2008). The annual number of PPI prescriptions and PPI doses dispensed decreased from 2015 to 1263 and from 60,608 to 38,742, respectively, during the study period. The estimated 4-year cost of inappropriate PPI use was $595,809, although cost savings from the absolute reduction in inappropriate PPI use over time was $65,598. CONCLUSIONS: We report a significant decrease of 39% in the number of inappropriate discharge prescriptions for PPIs during the study period; however, the percentage of inappropriate use of PPIs remains high. There is room for improvement in cost-effective use of PPIs.

Rhinocerebral zygomycosis in Pakistan: clinical spectrum, management, and outcome.

OBJECTIVE: To study the disease spectrum and salient management features of 36 patients with histopathologically-confirmed rhinocerebral zygomycosis seen at our academic center over a 16-year period. METHODS: Retrospective review of patients admitted to the Aga Khan University Hospital in Karachi, Pakistan from January 1991 to December 2006 with histopathologically-confirmed zygomycosis of the head and neck. RESULTS: Mean patient age was 40 +/- 5.0 years (range, 34-63 years), and 23 (64%) patients were male. Thirty-two (89%) patients were referred from clinical services other than otolaryngology. Underlying predisposing conditions included diabetes mellitus (21 patients), haematologic diseases (9), and renal failure (6). Twenty (55%) patients had limited sinonasal disease, ten (28%) had orbital involvement, and six (17%) had intracranial extension. All patients underwent rigid nasal endoscopy and biopsy, and black necrotic tissue was seen in 22 (61%) instances warranting endoscopic or open surgical debridement. Four of 6 patients undergoing open surgery required orbital exenteration. Overall patient survival was 56% (20/36 patients). Diabetic patients had improved survival (17/21, or 81%) compared to patients with haematologic disorders (3/9, or 33%) (p = 0.001). All six patients with intracerebral disease died. Eighteen of the 22 (82%) patients treated with surgery plus amphotericin B survived vs. two of 14 (14%) receiving amphotericin B alone (p < 0.001). CONCLUSIONS: In rhinocerebral zygomycosis, an aggressive, multidisciplinary, diagnostic and therapeutic approach that utilizes CT or MRI staging, and combines endoscopic or open surgical debridement with amphotericin B-based antifungal therapy offers the best chance of recovery.

Predictors of poor neurologic outcome in patients undergoing therapeutic hypothermia after cardiac arrest.

BACKGROUND: Therapeutic hypothermia (TH) has been shown to reduce the degree of anoxic brain injury, decrease mortality, and improve neurologic recovery in patients surviving cardiac arrest. However, there is a paucity of data on potential markers of neurologic outcome that physicians can use in this setting. METHODS: A retrospective medical records review of 41 consecutive survivors of cardiac arrest treated with TH (2004-08) was examined. RESULTS: Mean patient age was 66 years old. Most subjects had an out-of-hospital, witnessed cardiac arrest, and two-thirds had received bystander cardiopulmonary resuscitation (CPR). About half of the patients had nonventricular tachycardia/fibrillation (VT/VF) arrests. Fifty-nine percent (24 of 41 subjects) died or experienced severe neurologic impairment. By bivariate analysis, factors associated with a poor neurologic prognosis included: 1) a first rhythm at cardiac arrest other than VT/VF (P = 0.01); 2) the presence of acute kidney injury (AKI) in the intensive care unit (ICU) (P < 0.001); 3) any treated cardiac arrhythmia after admission (P = 0.05); and 4) a Glasgow Coma Score <8 determined 12 hours after rewarming (P < 0.001). Using multiple regression analysis, non-VT/VF arrest, AKI, and cardiac arrhythmia remained significant risk factors for poor neurologic recovery. The cumulative risk of death or poor neurologic outcome increased with the presence of two or more risk factors. CONCLUSION: Several simple, reproducible clinical markers can help predict neurologic recovery, during and after treatment, in patients managed with TH for cardiac arrest.

Community-based application of mild therapeutic hypothermia for survivors of cardiac arrest.

OBJECTIVE: To demonstrate that the application of therapeutic hypothermia is technically feasible in a community-based setting. BACKGROUND: Implementation of therapeutic hypothermia for survivors of cardiac arrest in the United States has been slow, at least partially because of the perception that this therapy is technically difficult, especially at the community level. STUDY DESIGN: Retrospective cohort study with historical controls. METHODS: At our three community hospitals and after return of spontaneous circulation (ROSC), survivors of cardiac arrest were treated with therapeutic hypothermia using ice and cooling blankets or suits in order to cool patients to 32 degrees C-34 degrees C within 4 hours to achieve goal temperature within 8 hours and to maintain goal temperature for 24 hours. RESULTS: Beginning in 2004, 44 survivors of cardiac arrest were managed with therapeutic hypothermia. The mean time from ROSC to initiation of therapeutic hypothermia was 2.8 hours (range, 0.2-7.8 hours), the mean time from ROSC to goal temperature was 7.2 hours (range, 0.8-15.1 hours), and the mean time maintained at goal temperature was 24.5 hours (range, 9-28 hours). Once patients achieved goal temperature, 4.4% of the temperature readings were above 34 degrees C, reflecting undercooling, while 16.4% of the readings were below 32 degrees C, indicative of overcooling. Overall survival until hospital discharge with good neurologic outcome was 43%, compared to only 13% (P < 0.001) among selected controls. There were no major complications directly attributable to the induction of hypothermia or rewarming. CONCLUSION: A simple protocol of mild therapeutic hypothermia using locally available resources is technically feasible and safe in a community-based setting.

A volunteer-based Hospital Elder Life Program to reduce delirium.

A community hospital with nearly 50% of its admitted patients 70 years or older adapted the well-established Hospital Elder Life Program (HELP). The primary adaptation entailed an enhanced participation of trained volunteers in HELP interventions designed to prevent and reduce delirium. Integral program elements include detailed volunteer training, required demonstration of competencies, and regular evaluation and feedback of volunteers provided by program staff. Nurse satisfaction with HELP increased from 64% to 91% in the second year of implementation, and a survey of patients and families indicated that 95% were satisfied with HELP. This innovative volunteer-assisted model of elder care support was positively embraced by patients, their families, and the nursing staff and supported by nursing administration. The use of volunteers is a cost-effective method of enhancing the nursing care of vulnerable elders during hospitalization.

Enoxaparin dosing in the elderly using adjusted body weight.

We prospectively compared anti-Xa activity in 61 elderly (>65 years) subjects receiving enoxaparin according to standard or adjusted body weight (ABW) dosing. In the ABW dosing group, mean patient age was 76 years, mean weight 80 kg, mean serum creatinine 1.0 mg/dl, and mean CrCl 48 ml/min. ABW dosing resulted in 57% of elderly study subjects achieving anti-Xa activity of 0.5-1.0 IU/ml, and 80% achieving anti-Xa activity of 0.5-1.2 IU/ml. Compared to standard dosing, for all subjects ABW dosing of enoxaparin was associated with a more favorable mean anti-Xa activity (0.98 IU/ml vs. 1.28 IU/ml, P = 0.001), fewer highest-risk (>1.5 IU/ml) supratherapeutic anti-Xa levels (0% vs. 28%, P = 0.001), and more frequent therapeutic levels among women (64% vs. 25%, P = 0.001). ABW dosing of enoxaparin may be beneficial in elderly patients aged 65 and older, and its benefit appears to be more pronounced in female patients.

A personal computer-based undergraduate medical school curriculum using SOLE.

BACKGROUND: We describe our experience with a personal computer and Web-based undergraduate curriculum for preclinical medical students using the Secure Online Environment (SOLE) education and information system. DESCRIPTION: To test the potential effectiveness of SOLE as a learning tool, we analyzed the patterns of SOLE usage, usage intensity, and consistency among medical students in two preclinical courses (4th-year Human Function and 5th-year Pathology) and attempted to link these indicators to academic performance. Categories of SOLE usage included number of website log-ins and number of pages viewed per course. EVALUATION: We found that A- and B-grade 4th-year students accessed course materials more frequently than did C- to failing-grade students, and both median and mean number of SOLE log-ins declined as student performance decreased. Higher-graded students were also more consistent in their usage of SOLE than were lower graded students. The range of log-in numbers (variability in frequency of usage) was greater for C- to failing-grade students than for A- and B-grade students. Compared to their 4th-year counterparts, 5th-year students increased their intensity of SOLE usage (indicated by the number of pages viewed) dramatically and numbers were comparable for A- and B-grade and for C- to failing-grade students. Consistency of usage, however, still remained higher for better performing students. Furthermore, students preferred SOLE to a traditional paper-based curriculum and felt it improved teaching effectiveness. Based on usage data and student preferences and perceptions we found Web-based SOLE to be an effective and well-accepted educational tool for preclinical medical students. CONCLUSIONS: This integrative, online educational and information system offers numerous opportunities and advantages for self-assisted instruction that can serve as a foundation for clinical training and professional lifelong learning.

Epidemiology of meningitis in Al-Ain, United Arab Emirates, 2000-2005.

OBJECTIVE: To describe the epidemiologic features of meningitis in Al-Ain Medical District, United Arab Emirates from January 2000 through June 2005. METHODS: A retrospective review of clinical records and notification forms for cases of meningitis reported to the Department of Preventive Medicine, Al-Ain. Data collected and compiled included demographic features, causative microbiologic agents, and annual incidence rates of meningitis, by etiology. RESULTS: Ninety-two cases of meningitis were reported during the study period; 53% were bacterial and 37% were viral in origin. Neisseria meningitidis was the leading bacterial pathogen (35%) followed by Streptococcus pneumoniae (16%). Ten percent of clinically diagnosed cases of meningitis had no causative microorganism recovered, and in 33% of patients with presumed pyogenic meningitis no specific bacterial pathogen could be identified. The peak occurrence of meningitis was in young children less than one year old. Most cases of meningococcal meningitis were seen among prison inmates and laborers, while viral meningitis occurred mainly in children and young adults attending school. The incidence rate of meningitis in Al-Ain ranged between 2.2/100,000 population in 2000 and 1/100,000 in 2005, with an overall downward trend by year. The incidence of Haemophilus influenzae type b decreased significantly after implementation of the national immunization program in 1999. CONCLUSIONS: Improved methods of bacterial detection including isolate serotyping must be made available in order to further reduce mortality and morbidity from meningitis.

Subcutaneously administered interferon-gamma for the treatment of multidrug-resistant pulmonary tuberculosis.

OBJECTIVE: We evaluated the clinical and laboratory effects of subcutaneously administered interferon-gamma (IFN-gamma) in the treatment of chronic and advanced multidrug-resistant tuberculosis (MDR-TB). DESIGN: Eight patients with sputum smear and culture persistently positive MDR-TB were subcutaneously administered 2 million international units of recombinant human IFN-gamma three times a week for 24 weeks (72 doses total) between December 2002 and May 2003. Subjects also received a customized drug regimen containing second- and third-line antituberculosis agents based upon drug susceptibility testing and previous treatment history. RESULTS: Body weight remained stable or slightly decreased in all subjects during the study period, and none displayed radiographic improvement on serial chest computed tomography scanning. Sputum smears and cultures remained positive for all patients, and there was no increase in the mean time to yield a positive culture (from 16.5+/-6.4 to 11.8+/-4.9 days). There was no enhancement of cell-mediated immune responses in terms of production of IFN-gamma or IL-10, or of composition of lymphocytes among peripheral blood mononuclear cells. In four patients, therapy was discontinued because of adverse reactions. CONCLUSION: In patients with chronic and advanced MDR-TB, subcutaneous IFN-gamma treatment did not result in improvement in clinical, radiologic, microbiologic, or immunologic parameters.

An algorithmic approach to intracranial mass lesions in HIV/AIDS.

We developed a diagnostic and therapeutic algorithm for intracranial mass lesions in patients with HIV/AIDS that obviates the need for neurosurgical intervention. The approach is based upon CD4(+) lymphocyte count, serum toxoplasma immunoglobulin G (IgG) serology, chest X-ray, routine lumbar puncture studies, cerebrospinal fluid (CSF) cytology, CSF adenosine deaminase or Mycobacterium tuberculosis polymerase chain reaction testing, single positron emission-computed tomography (SPECT) scanning for intracranial enhancing lesions, and limited therapeutic trials. Over a 12-month period involving 26 patients, we found that the algorithm correctly identified the aetiology of focal intracranial lesions in all 23 evaluable patients. Costs for SPECT scanning for the entire study cohort were more than offset by the savings achieved by reduced hospital stays for the four patients with lymphoma alone. An algorithmic approach can accurately identify the cause(s) of central nervous system (CNS) mass lesions in HIV-infected patients, and SPECT scanning can replace stereotactic brain biopsy in most cases where opportunistic malignancy is suspected.

Disciplinary action against physicians: who is likely to get disciplined?

PURPOSE: We sought to determine the characteristics of disciplined physicians at-large and the risk of disciplinary action over time and to report the type and frequency of complaints and the nature of disciplinary actions against allopathic physicians in Oklahoma. METHODS: Descriptive statistics, Kaplan-Meier analysis, and Cox proportional hazards modeling of publicly available data on physicians licensed by the Oklahoma Board of Medical Licensure and Supervision. RESULTS: Among 14,314 currently or previously licensed physicians, 396 (2.8%) had been disciplined. Using univariate proportional hazards analysis, men (P <0.04), non-whites (P < 0.001), non-board-certified physicians (P < 0.001), and those in family medicine (P < 0.001), psychiatry (P < 0.001), general practice (P < 0.001), obstetrics-gynecology (P < 0.03) and emergency medicine (P < 0.001) were found to be at greater risk of being disciplined than other medical specialty groups. Foreign medical graduates had a higher risk of disciplinary action compared to US medical graduates (P < 0.001), although this finding was not confirmed by multivariate analysis. Kaplan-Meier analysis revealed that the proportion of physicians disciplined increased with each successive 10-year interval since first licensure. Complaints against physicians originated most often from the general public (66%), other physicians (5%), and staff (4%), and the complaints most frequently involved issues related to quality of care (25%), medication/prescription violations (19%), incompetence (18%), and negligence (17%). CONCLUSION: To improve physician behavior and reduce the need for disciplinary action, medical schools and residency training programs must continue to emphasize both patient care and medical professionalism as critical core competencies.

Histoplasma endocarditis: clinical and mycologic features and outcomes.

OBJECTIVES: To define the salient clinical and microbiologic characteristics and outcome of infective endocarditis caused by Histoplasma capsulatum. METHODS: Case report and review of 43 literature cases. RESULTS: Infection involved both native (36 cases) and prosthetic (7) heart valves, had a high rate of systemic embolization (58%), and a more delayed diagnosis than bacterial endocarditis. Cardiac involvement generally occurred on mitral and/or aortic valves, and almost always in the setting of disseminated disease. Antemortem diagnosis was best made by serology (serum antibody titers or urinary antigen) or culture of blood (positive in <20% of cases), bone marrow, excised valves, and other non-blood specimens. Other diagnostic methods included histopathology and immunofluorescent staining of tissue samples. Untreated infection was uniformly fatal. Prolonged antifungal therapy with amphotericin B, without surgical intervention, appeared more effective than for Candida endocarditis. CONCLUSIONS: Histoplasma endocarditis is an infrequent but important cause of left-sided, blood culture-negative endocarditis. Its true prevalence may be underestimated because of the relative difficulty in making a precise microbiologic diagnosis. Amphotericin B therapy appears more effective than for Candida endocarditis, while the role for azole treatment and secondary prophylaxis remains uncertain. Indications for surgical valve replacement are similar to those for bacterial endocarditis.

Treatment options for hepatic cystic echinococcosis.

A number of surgical and non-surgical options exist to treat cystic echinococcosis of the liver. For decades, surgical excision via a conservative or radical approach was the recommended approach for hepatic hydatid cysts. The availability of chemotherapeutic agents with significant activity against Echinococcus granulosis has made it possible to undertake ultrasound- or computed tomography-guided transhepatic percutaneous drainage (termed puncture, aspiration, injection, and re-aspiration (PAIR)) of hydatid cysts. Pre- and post-intervention chemotherapy with albendazole or mebendazole offers the advantage of reducing the risk of disease recurrence and intraperitoneal seeding of infection that may develop via cyst rupture and spillage occurring spontaneously or during surgery or needle drainage. PAIR appears to have greater clinical efficacy (i.e. a higher incidence of cure), lower rates of major and minor complications, mortality, and disease recurrence, and fewer days of hospitalization compared to patients treated surgically. For patients who fail drug therapy alone, PAIR is a safe and effective procedure of choice for patients with hepatic echinococcosis, and perhaps other anatomic sites of infection such as lung, peritoneum, kidney, and other viscera. Surgery should be reserved for patients with hydatid cysts refractory to PAIR because of secondary bacterial infection or for those with difficult-to-manage cyst-biliary communication or obstruction.

Medical vs surgical management of spinal epidural abscess.

BACKGROUND: We compared the clinical features and outcomes of patients with spinal epidural abscess treated with prolonged parenteral antibiotics alone or combined with computed tomography-guided percutaneous needle aspiration drainage with those of patients undergoing surgical decompression. METHODS: A retrospective analysis of 57 cases of spinal epidural abscess treated at an academic teaching hospital during a 14-year period. RESULTS: The lumbar region was most frequently involved, and 46% of patients were immunocompromised. Staphylococcus aureus was the most frequently encountered pathogen. For 60 treatment courses, management included medical only (25 patients), medical plus computed tomography-guided percutaneous needle aspiration (7 patients), or surgical drainage approaches (28 patients). Prolonged use of parenteral antibiotics alone or combined with percutaneous needle drainage yielded clinical outcomes at least comparable with antibiotics plus surgical intervention, irrespective of patient age, presence of comorbid illness, disease onset, neurologic abnormality at time of presentation, or abscess size. CONCLUSION: Patients with spinal epidural abscess can be safely and effectively treated with conservative medical treatment without the need for surgery.

A university-sponsored home health nursing program in Karachi, Pakistan.

This article describes a university-sponsored home health nursing program in a large urban center in Pakistan and details the essential elements needed in implementing such a program in a developing country. Compared to in-hospital treatment, home healthcare reduced hospital stay from 12.8 days to 3.9 days, and resulted in a net savings of Pakistani rupees (PRs) 5,374,135 (USD 89,569). A cost-effective home treatment program in a resource-limited country can be successfully implemented by using the hospital pharmacy as the central point for the preparation and distribution of medications and specialty nursing services.

Percutaneous aspiration-injection-reaspiration drainage plus albendazole or mebendazole for hepatic cystic echinococcosis: a meta-analysis.

Using meta-analysis methodology, we compared the clinical outcomes for 769 patients with hepatic cystic echinococcosis treated with percutaneous aspiration-injection-reaspiration (PAIR) plus albendazole or mebendazole (group 1) with 952 era-matched historical control subjects undergoing surgical intervention (group 2). The rate of clinical and parasitologic cure (P<.0001) was greater in patients receiving PAIR plus chemotherapy. Disease recurrence (P<.0001), major complications (anaphylaxis, biliary fistula, cyst infection, liver/intra-abdominal abscess, and sepsis; P<.0001), minor complications (P<.0001), and death (P<.0824) occurred more frequently among surgical control subjects. Fever (P<.002) and minor allergic reactions subjects (P<.0001) were more common among PAIR-treated subjects. The mean durations of hospital stay were 2.4 days for group 1 and 15.0 days for group 2 (P<.001). Compared with surgery, PAIR plus chemotherapy is associated with greater clinical and parasitologic efficacy; lower rates of morbidity, mortality, and disease recurrence; and shorter hospital stays.

Crimean-Congo hemorrhagic fever: prevention and control limitations in a resource-poor country.

In autumn 2000, an outbreak of Crimean-Congo hemorrhagic fever (CCHF) occurred in Pakistan and involved nosocomial cases due to human-to-human transmission at a tertiary care hospital in Karachi. During a hospital-based investigation, 6 serologically confirmed cases (i.e., patients seropositive for CCHF antigen or anti-CCHF immunoglobulin M antibodies by means of a capture enzyme-linked immunosorbent assay [ELISA]) and 3 clinically confirmed cases (i.e., patients with negative ELISA for CCHF but with relevant epidemiologic exposures and compatible clinical disease) of CCHF were identified. The outbreak originated in rural Balochistan, a region of known CCHF endemicity where miniepidemics regularly occur, and subsequently spread to the urban centers of Quetta and Karachi. This outbreak demonstrated the capacities and weaknesses associated with a developing country's response to hemorrhagic fever epidemics. We describe aspects of disease prevention, control challenges, and political obstacles posed by illness associated with what we refer to as the "Asian Ebola virus."

Plasma cell pleocytosis in cerebrospinal fluid in patients with West Nile virus encephalitis.

We describe 4 patients with West Nile virus encephalitis who all displayed previously unreported plasma cell pleocytosis of the cerebrospinal fluid (CSF). Three patients recovered but had varying degrees of mild neurologic disability on discharge from the hospital, and 1 patient died. The finding of significant numbers of plasma cells in CSF may serve as a useful early diagnostic clue for West Nile virus encephalitis.

Varicella pneumonia in patients with HIV/AIDS.

OBJECTIVE: To determine the potential role of steroid therapy combined with early antiviral and supportive care in patients infected with human immunodeficiency virus (HIV) with varicella pneumonia. MATERIALS AND METHODS: A retrospective review was conducted of the incidence, clinical course, and outcome of varicella pneumonia in patients with HIV or acquired immunodeficiency syndrome (AIDS). RESULTS: Seven of 12 patients (58%) who were hospitalized with chickenpox developed clinically severe varicella pneumonia. All patients had advanced immunosuppression and all developed diffuse reticulonodular radiographic abnormalities, although two patients had normal chest radiographs on admission. All patients received antiviral therapy within 12 hours of hospital admission. The overall mortality rate was 43%. Six patients were treated with systemic corticosteroids in addition to antiviral agents, including all four of the survivors. CONCLUSIONS: Hospitalized patients with HIV or AIDS with chickenpox are at high risk for developing varicella pneumonia. There is a potentially high rate of death despite prompt initiation of appropriate antiviral therapy. Intensive care management and adjunctive use of systemic corticosteroids may improve outcome.

Infective endocarditis: a five-year experience at a tertiary care hospital in Pakistan.

OBJECTIVES: Infective endocarditis is common and data regarding its pattern and outcome from developing countries is sparse. We therefore examined the spectrum, demographics and clinical features of infective endocarditis and sought to determine the factors affecting its clinical outcome. PATIENTS AND METHODS: Over a five-year period at our university hospital in Karachi, Pakistan, we identified 66 patients with infective endocarditis and compared their clinicoepidemiologic features and outcomes to subjects in the West. RESULTS: The male:female ratio was 2:1; overall median age was 24 years (35.5 years for men and 13.5 years for women) (p < 0.001). Median duration of symptoms before presentation was 20.5 days. Major predisposing cardiac abnormalities included congenital (50%) and rheumatic (23%) lesions, and a history of heart surgery (17%). Causative organisms and valvular sites of infection were similar to those seen in developed countries. Blood culture-negative infective endocarditis was found in 48% of cases. Renal failure was more frequent among culture-positive patients (p = 0.055). Risk factors for mortality included neurologic (p = 0.003) and embolic (p = 0.02) complications, renal (p = 0.03) and left ventricular failure (p = 0.002), and a history of cardiac surgery (p = 0.026). Overall mortality was 27%. CONCLUSIONS: Patients with infective endocarditis in Pakistan exhibit significant differences compared to their counterparts in the West, including younger age at presentation, incidence of predisposing cardiac conditions, and gender differences reflecting sociocultural bias. Neurologic and embolic complications, renal failure and heart failure predict a worse outcome.