Comparison of 3 Surveillance Methods to Detect Potential Controlled Substance Diversion in an Academic Medical Center.

Objectives: To compare 3 methods of detecting potential diversion of controlled substances (CS) by health care personnel from inpatient units in a large, academic medical center. Methods: Three different reports were retrospectively analyzed and evaluated to determine which employees are "high-risk" for diversion over a 30-day period using defined criteria. Reports were derived from automated dispensing machines (ADMs), purchased third-party software (TPS), and the electronic health record (EHR). The primary outcome was the percentage of employees in each report who were deemed to be high-risk for CS diversion (positive predictive value [PPV]). Secondary outcomes included the number of false positives and description of high-risk users on each report. Descriptive statistics were used to analyze differences between methods. Results: The PPV was highly variable between reports. The PPVs among the ADM, TPS, and EHR reports were 3.28%, 6.82%, and 23.88%, respectively. False positives were high among all reports (96.72%, 93.18%, and 76.12% for the ADM, TPS, and EHR reports, respectively). Conclusions: A report from the EHR has the highest PPV to detect high-risk employees who may be diverting CS. However, false positives were high for all reports, indicating that significant improvements are needed in the development of accurate and reliable software to detect potential and actual CS diversion.

Evolving Pharmacist Productivity Models.

Leaders in health-system pharmacy are challenged to minimize costs, maximize revenue, and maintain or improve quality while simultaneously expanding services. Strong command of productivity and workload measurement is necessary to achieve these goals. This article reviews foundational pharmacy productivity concepts and key terminology, reviews historical pharmacy productivity models and their limitations, and considers new and evolving pharmacist productivity models.

Development of an inpatient operational pharmacy productivity model.

PURPOSE: An innovative model for measuring the operational productivity of medication order management in inpatient settings is described. METHODS: Order verification within a computerized prescriber order-entry system was chosen as the pharmacy workload driver. To account for inherent variability in the tasks involved in processing different types of orders, pharmaceutical products were grouped by class, and each class was assigned a time standard, or "medication complexity weight" reflecting the intensity of pharmacist and technician activities (verification of drug indication, verification of appropriate dosing, adverse-event prevention and monitoring, medication preparation, product checking, product delivery, returns processing, nurse/provider education, and problem-order resolution). The resulting "weighted verifications" (WV) model allows productivity monitoring by job function (pharmacist versus technician) to guide hiring and staffing decisions. A 9-month historical sample of verified medication orders was analyzed using the WV model, and the calculations were compared with values derived from two established models­one based on the Case Mix Index (CMI) and the other based on the proprietary Pharmacy Intensity Score (PIS). RESULTS: Evaluation of Pearson correlation coefficients indicated that values calculated using the WV model were highly correlated with those derived from the CMI-and PIS-based models (r = 0.845 and 0.886, respectively). Relative to the comparator models, the WV model offered the advantage of less period-to-period variability. CONCLUSION: The WV model yielded productivity data that correlated closely with values calculated using two validated workload management models. The model may be used as an alternative measure of pharmacy operational productivity.

Association of the presence of bone bars on radiographs and hip fracture in postmenopausal Caucasian women.

AIM: To determine whether the presence of bone bars (BB) identified on anteroposterior hip radiographs are more prevalent in patients that have had a hip fracture as compared to patients without a fracture. MATERIALS AND METHODS: Ninety-two Caucasian women with a unilateral proximal femur fracture were retrospectively evaluated and randomly selected using radiology database records to comprise the investigational group. Ninety-eight age-matched Caucasian women without hip fracture were selected as a control group. Anteroposterior hip radiographs were evaluated for the presence of BBs by two musculoskeletal radiologists. Chi-square tests were used to assess whether fractures were more prevalent in patients with BB than those without BB. RESULTS: The patient population was comprised Caucasian women with a mean age of 79.8 ± 6.4 years in the control group and 79.9 ± 6.6 years in the investigational group. Regardless of the reader, BB were identified in a significantly higher percentage of women with a fracture (75 versus 39%, p < 0.001 or 53 versus 38%, p = 0.041) as compared to those without a fracture. CONCLUSION: BB are associated with hip fracture. Their presence is a trigger for requesting a dual-energy x-ray absorptiometry (DXA) examination to confirm or refute a diagnosis of low bone mineral density (BMD) and a subsequent increased risk of fracture.

Pathological fractures of the proximal humerus treated with a proximal humeral locking plate and bone cement.

Bone loss secondary to primary or metastatic lesions of the proximal humerus remains a challenging surgical problem. Options include preservation of the joint with stabilisation using internal fixation or resection of the tumour with prosthetic replacement. Resection of the proximal humerus often includes the greater tuberosity and adjacent diaphysis, which may result in poor function secondary to loss of the rotator cuff and/or deltoid function. Preservation of the joint with internal fixation may reduce the time in hospital and peri-operative morbidity compared with joint replacement, and result in a better functional outcome. We included 32 patients with pathological fractures of the proximal humerus in this study. Functional and radiological assessments were performed. At a mean follow-up of 17.6 months (8 to 61) there was no radiological evidence of failure of fixation. The mean revised musculoskeletal Tumour Society functional score was 94.6% (86% to 99%). There was recurrent tumour requiring further surgery in four patients (12.5%). Of the 22 patients who were employed prior to presentation all returned to work without restrictions. The use of a locking plate combined with augmentation with cement extends the indications for salvage of the proximal humerus with good function in patients with pathological and impending pathological fractures.

Ultrasound of target joints for the evaluation of possible inflammatory arthropathy: associated clinical factors and diagnostic accuracy.

OBJECTIVE: To examine the clinical features associated with an ultrasound (US) diagnosis of synovitis and/or erosions in patients suspected of inflammatory arthritis, and the factors associated with this evolution in patients with a normal initial US. PATIENTS AND METHODS: Cross-sectional: the records of 144 patients who underwent US for suspected inflammatory arthropathy were categorized into synovitis and/or erosions present or not. Longitudinal: of 58 patients without synovitis and/or erosions, 30 could be located and 19 agreed to be studied (two were asymptomatic and refused, nine could not be reached). ANALYSES: univariable descriptive analyses were performed. Age, gender, variables significant (p<0.05) in the univariable analyses, and those clinically relevant were examined by logistic regression for the cross-sectional study. The metric properties of US compared to overall clinical assessment were also examined. RESULTS: Age, gender, ethnicity and symptoms' duration were comparable in patients with and without synovitis and/or erosions. Wrist swelling (history) and the number of swollen wrist/hand joints were associated with synovitis and/or erosions by US; morning stiffness, sicca symptoms and low back pain were negatively associated with synovitis and/or erosions. Four patients evolved into an inflammatory arthropathy but no features distinguished them from those who did not evolve into an inflammatory arthropathy. The sensitivity, specificity, and overall accuracy of US, compared to the clinical assessment were 98.9%, 94.1% and 98.1%, respectively. CONCLUSIONS: US is an adequate tool for the assessment of inflammatory arthropathy; however, patients with a single negative US at initial clinical presentation still need to be followed for the eventual development of an overt arthropathy.

Synchronous bifocal alveolar rhabdomyosarcoma: a case report.

We report a case of bifocal rhabdomyosarcoma involving the hand and thigh in an 11-year-old female. We highlight the importance of a thorough clinical examination and an aggressive surgical approach in which each lesion is treated as a separate primary.

Deep-vein thrombosis in high-energy skeletal trauma despite thromboprophylaxis.

We report the incidence and location of deep-vein thrombosis in 312 patients who had sustained high-energy, skeletal trauma. They were investigated using magnetic resonance venography and Duplex ultrasound. Despite thromboprophylaxis, 36 (11.5%) developed venous thromboembolic disease with an incidence of 10% in those with non-pelvic trauma and 12.2% in the group with pelvic trauma. Of patients who developed deep-vein thrombosis, 13 of 27 in the pelvic group (48%) and only one of nine in the non-pelvic group (11%) had a definite pelvic deep-vein thrombosis. When compared with magnetic resonance venography, ultrasound had a false-negative rate of 77% in diagnosing pelvic deep-vein thrombosis. Its value in the pelvis was limited, although it was more accurate than magnetic resonance venography in diagnosing clots in the lower limbs. Additional screening may be needed to detect pelvic deep-vein thrombosis in patients with pelvic or acetabular fractures.

Incidence of hip osteonecrosis among renal transplantation recipients: a prospective study.

AIM: To investigate whether a lessened glucocorticoid cumulative dose would lead to a decreased incidence of femoral head osteonecrosis. METHODS: Newly transplanted in-patients (n = 49) underwent hip radiographs and magnetic resonance imaging (MRI) a mean of 17.0+/-4.3 (range 8-29) days after renal transplantation. For the 48 patients without evidence of prevalent osteonecrosis, imaging at a mean of 5.9+/-0.8 (range 4.8-8.7) months after renal transplantation was graded for presence/absence of femoral head osteonecrosis by two blinded radiologists. Sociodemographic and disease characteristics of patients were compared to identify potential associations with incident osteonecrosis. RESULTS: At 6-month follow-up, only two patients (4%) had osteonecrosis of the femoral head (three hips). The two primary radiologists had excellent agreement between osteonecrosis diagnosis (kappa coefficient=0.78). Both cases of a definite MRI diagnosis of osteonecrosis occurred in patients who were in the highest tertile of glucocorticoid dosage. CONCLUSION: Osteonecrosis was uncommon among a prospective cohort of renal transplant recipients within 6 months after engraftment.

Mechanical prophylaxis against deep-vein thrombosis after pelvic and acetabular fractures.

BACKGROUND: Deep-vein thrombosis is a common complication following pelvic and acetabular fractures. The hypothesis of this study was that pulsatile mechanical compression is superior to standard sequential mechanical compression for decreasing the prevalence of deep-vein thrombosis in patients with pelvic or acetabular fracture. METHODS: A prospective, randomized, blinded study of two methods of mechanical prophylaxis against deep-vein thrombosis was conducted. One hundred and seven patients were randomized into either Group A (fifty-four patients), in which a thigh-calf low-pressure sequential-compression device was used, or Group B (fifty-three patients), in which a calf-foot high-pressure pulsatile-compression pump was used. All patients underwent duplex ultrasonography and magnetic resonance venography. The two groups were comparable with regard to demographics, fracture type, fracture treatment, time from the injury to the prophylaxis, and patient compliance. RESULTS: Deep-vein thrombosis developed in ten patients (19%) in Group A, with seven (13%) having a large or occlusive clot and one (2%) having a documented pulmonary embolism. Deep-vein thrombosis developed in five patients (9%) in Group B, with two (4%) having a large or occlusive clot and none having a documented pulmonary embolism. Nine of the nineteen detected thromboses were in the deep pelvic veins. The difference in the prevalence of large or occlusive clots between the two groups demonstrated a trend but, with the numbers available, was not significant (p = 0.16). Increased patient age and the time elapsed from the injury to the surgery were found to be associated with higher rates of thrombosis. CONCLUSIONS: Pulsatile compression was associated with fewer deep-vein thromboses than was standard compression, with the difference representing a trend but not reaching significance with the number of patients studied.

Hip pain as the presenting manifestation of acute gouty sacroiliitis.

Gout can present in a variety of less typical forms. We describe a case of an elderly woman presenting with hip and lower extremity pain. It remained undiagnosed for several days but proved to be secondary to gouty involvement of the right sacroiliac (SI) joint. Monosodium urate crystals were identified in computed tomographic guided aspiration of the SI joint. The importance of obtaining a good history and performing a complete physical examination if the diagnosis of sacroiliitis (or any other musculoskeletal disorder) is to be made, its cause defined, and proper treatment instituted is emphasized.

Focal posttransplantation lymphoproliferative disorder at the renal allograft hilum.

OBJECTIVE: This report describes the imaging characteristics of focal posttransplantation lymphoproliferative disorder. CONCLUSION: Posttransplantation lymphoproliferative disorder may be limited to the allograft. A focal complex mass in the renal allograft hilum surrounding the main renal blood vessels is a common finding and can be visualized with sonography. MR imaging can help increase diagnostic confidence.

Postransplant lymphoproliferative disorder localized near the allograft in renal transplantation.

BACKGROUND: Posttransplant lymphoproliferative disorder (PTLD), a complication of immunosuppression, develops in approximately 1% of renal allograft recipients. Typically, PTLD is a proliferation of B-cells associated with Epstein-Barr virus (EBV) infection; it is said to be most often a systemic disease. Involvement occasionally is localized near the allograft. METHODS: This is a retrospective analysis of all cases of PTLD in recipients of 1474 renal transplants performed at University of Alabama at Birmingham between 1993 and 1997. RESULTS: Of 14 patients developing PTLD, 10 had disease localized near the allograft. The mean interval from transplantation to diagnosis was 221 +/- 70 days. All patients presented with renal dysfunction; an ultrasound examination revealed a hilar mass, with hydronephrosis in five and stenosis of renal vessels in eight. No patient had lymphadenopathy, according to computerized tomographic or magnetic resonance imaging findings. After reduction of immunosuppressive therapy, seven required a nephrectomy because of rejection, progressive dysfunction, or mass enlargement. Tissue recovered in four patients was consistent with PTLD; the tumors in the remaining three patients were unresectable and regressed. One patient died 1 month after a nephrectomy, and another died 4 years after surgery; neither had evidence of PTLD when they died. Three patients retain functional grafts without clinical or radiographical evidence of progression. All patients with disseminated disease died. CONCLUSIONS: In a large cohort of renal allograft recipients, PTLD affected 1%. Disease localized near the allograft was the most common variant. For most patients with localized disease, the outcome was graft loss, and the mortality was low. Localized PTLD should be considered in the differential diagnosis of allograft dysfunction in the 1st posttransplant year.

Osteosarcoma in a patient with McCune-Albright syndrome and Mazabraud's syndrome.

Sarcomas infrequently develop in osseous sites of fibrous dysplasia. We report a patient with Mazabraud's syndrome (polyostotic fibrous dysplasia and soft tissue myxomas) complicated by the development of osteogenic sarcoma in a bone affected by fibrous dysplasia. This is the third case of osteosarcoma within the small population of reported patients with Mazabraud's syndrome. There may be an increased incidence of malignant transformation in these individuals' dysplastic bones above that associated with patients suffering from fibrous dysplasia alone.

Doppler sonographic enhancement of hepatic hemangiomas and hepatocellular carcinomas after perflenapent emulsion: preliminary study.

Ultrasonographic microbubble contrast agents improve Doppler signals by increasing blood backscatter. We retrospectively reviewed our experience with perflenapent (EchoGen), an emulsion of liquid dodecafluoropentane, in the evaluation of 13 patients with focal hepatic lesions (10 hemangiomas and six hepatocellular carcinomas). Perflenapent improved the detection of color Doppler flow signals within the lesions. The hemangiomas showed peripheral nonpulsatile signals and the hepatocellular carcinomas showed more diffuse enhancement with both arterial and venous type signals. This preliminary study suggests that perflenapent administration may aid in the sonographic differentiation of these focal lesions.