The Enneagram and its application in medical education.

Personality testing has become increasingly popular in healthcare with multiple modalities and implementations. Although personality testing has been utilized to inform various facets of graduate medical education, little is known about how the Enneagram can be utilized throughout postgraduate training. This narrative review explores the use of personality testing in graduate medical education, how personality testing has been used in the workplace, what research is available showing its use in medical residencies, and the need for additional studies on the Enneagram's use in these areas. We conclude the Enneagram may serve as a valuable tool that can be used in postgraduate medical education to improve learning, interpersonal relationships, and teaming.

Characteristics of Native Americans with HIV and implications for care.

Limited data have been published about HIV infections and response to antiretroviral therapy in the Native American population. We reviewed baseline characteristics of 112 Native American patients to determine if there were any shared characteristics that would dictate the best treatment for this population. Metabolic diseases and psychiatric disorders were common findings among our patients. Native American patients should be monitored and screened as appropriate for comorbid conditions, and these disease states should be considered when choosing an antiretroviral regimen.

Disseminated Kaposi's sarcoma without cutaneous involvement.

Kaposi's sarcoma (KS) is a low-grade vascular tumor caused by infection with human herpesvirus 8. Prior to the AIDS epidemic, KS was rare in the United States. With the advent of highly active antiretroviral therapy, KS has become far less common, now occurring at a rate of about 6 cases per million people each year. It is still seen most commonly in those infected with HIV, and cutaneous manifestations represent the most common presentation. In this case, we describe a patient with disseminated AIDS-associated KS lacking cutaneous manifestations.

Conjugal amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a disease characterized by progressive degeneration of motor neurons in the motor cortex, brainstem, and spinal cord. The incidence of sporadic ALS is 1.5 to 2.7 in 100,000, and the prevalence is 5.2 to 6.0 in 100,000. Conjugal ALS is even rarer than sporadic ALS. We report a case of conjugal ALS encountered in our outpatient neurology clinic.

Primary hyperparathyroidism and pregnancy.

Primary hyperparathyroidism is the third most common endocrine disorder after diabetes and thyroid disease, and women are affected twice as often as men. Hyperparathyroidism in pregnancy was first reported in 1931. Maternal complications in patients with hyperparathyroidism can be as high as 67%. We present a case of a pregnant patient with chronic hypertension that was exacerbated throughout the course of her pregnancy with a concomitant diagnosis of primary hyperparathyroidism and its sequelae for both the mother and fetus.

Clostridium difficile-associated diarrhea in a tertiary care medical center.

This retrospective, case-control study aimed to identify variables associated with the incidence of Clostridium difficile-associated diarrhea (CDAD) in acute care facilities and to specifically identify the relationship of fluoroquinolones and acid suppressive agents in the development of CDAD. Seventy-one symptomatic patients positive for C. difficile toxin A or B hospitalized for at least 72 hours were compared with 142 control patients hospitalized for at least 72 hours who were not positive for C. difficile toxin A or B. Two controls were matched to one case patient for age within 5 years, unit of admission, and date of admission. The mean ages for cases and controls were 63.5 and 62.7 years, respectively. After adjusting for two confounding variables-hospital stay within 3 months and Charlson Comorbidity Index-conditional multiple logistic regression identified six risk factors for development of CDAD: gastrointestinal procedures within 60 days (odds ratio [OR] 9.1, P < 0.013), levofloxacin exposure (OR 8.2, P < 0.033), moxifloxacin exposure (OR 4.1, P < 0.026), imipenem exposure (OR 14.9, P < 0.014), laxative use (OR 20.2, P < 0.0001), and immunosuppressive use (OR 20.7, P < 0.034). The risk of CDAD after exposure to levofloxacin or moxifloxacin was not significantly different. Acid suppressive therapy was not a risk factor for CDAD development.

Hemolytic uremic syndrome caused by Shiga toxin-producing Escherichia coli 0111.

Shiga toxin-producing Escherichia coli (STEC) was first discovered in 1977 and since has caused serious complications including the life-threatening condition of hemolytic uremic syndrome (HUS). While HUS is most common in children, adults and especially elderly patients experience a higher incidence of death and disability. Because the majority of HUS cases have been described in children, pediatric treatment options have been used to treat adult and elderly patients with HUS. More research regarding the treatment, risk factors, and prognosis of HUS in adults needs to be performed to ensure that optimal care is provided. The authors present a case series of 5 adults with HUS who were part of the largest outbreak of E coli 0111 reported in the United States. To date, there are no published cases of HUS secondary to E coli 0111 in adults. The authors also include a literature review of HUS secondary to STEC.

Insulin glargine and cancer risk: an opinion statement of the Endocrine and Metabolism Practice and Research Network of the American College of Clinical Pharmacy.

Diabetes mellitus has reached epidemic proportions worldwide, eliciting extensive research on both the disease process and its treatment. Regardless of diabetes type, the progressive nature of the disease makes insulin the long-term mainstay of diabetes management. Recently, the insulin analog glargine was reported in several epidemiologic studies to be associated with an increased risk of cancer. Inconsistent study results and media attention have caused much angst and concern to health care professionals and the general population. A clear understanding of the current evidence is needed to adequately develop a patient-oriented risk:benefit assessment. Members of the Endocrine and Metabolism Practice and Research Network of the American College of Clinical Pharmacy evaluated available evidence to provide guidance and discussion on the risk of cancer with insulin glargine use. We believe the current link between insulin glargine and cancer is tenuous but merits further evaluation. An independent analysis of all available glargine clinical trial data should be performed, and a vigorous postmarketing safety study of glargine should be conducted. Until more substantial data are available, however, neither the choice of initial insulin therapy nor insulin maintenance regimens should be influenced by the current information linking insulin glargine to cancer.

Is statin therapy safe in patients with HIV/hepatitis C coinfection?

Statins are effective therapy for hypercholesterolemia and are commonly indicated in patients with HIV and hepatitis C virus infections. Unfortunately, in patients coinfected with these viruses, the safety of statins has not been conclusively evaluated. We retrospectively evaluated five coinfected patients in our outpatient clinic who received statin therapy. Although the sample size was small, we found that statins were safe in this population and recommend that further evaluation with a prospective controlled trial be undertaken to definitively answer this safety issue.

Use of daptomycin in a pregnant patient with Staphylococcus aureus endocarditis.

OBJECTIVE: To report on 6 weeks of daptomycin treatment for tricuspid valve endocarditis caused by Staphylococcus aureus in a pregnant female in her second trimester. CASE SUMMARY: A 24-year-old, 14-week pregnant patient with no significant medical history, but with a history of intravenous drug abuse presented with tricuspid valve endocarditis caused by methicillin-sensitive S. aureus. After initial treatment with vancomycin, the patient continued to have fever and bacteremia and was initiated on daptomycin 6 mg/kg for 6 weeks of therapy. The treatment resulted in the resolution of the endocarditis, and no adverse sequelae were identified in the mother or baby. DISCUSSION: Infective endocarditis is a common infection encountered in the hospital setting and represents an increased cost burden to institutions due to prolonged lengths of treatment. Antimicrobial resistance, antimicrobial failure, inadequate attainment of effective drug concentrations, drug allergies, and adverse reactions may be factors that limit the use of commonly utilized antimicrobial agents. Therefore, newer therapies like daptomycin may need to be employed in these situations. Although daptomycin is pregnancy category B, limited case reports with neonatal outcomes are reported. CONCLUSIONS: This case provides further support for the safety of daptomycin in pregnancy with the dose of 6 mg/kg, the extended duration of therapy (6 weeks), and the primary exposure in the second trimester.

Novel treatment approach to combat an infection with Acinetobacter.

The antimicrobial resistance of gram-negative pathogens has become problematic. In some cases related to Pseudomonas spp. and Acinetobacter spp., no antimicrobials on the market can be utilized at standard doses. We report a case of resistant Acinetobacter infection in a patient in the intensive care unit. In this scenario, we successfully treated the infection with doripenem at a higher dose of 1 g with a 4-hour infusion time along with the combination of tigecycline and colistin.

Combination drug products: an indication for medication reconciliation and pharmacist counseling.

OBJECTIVE: To describe a case of drug-induced rhabdomyolysis that occurred because of an inadvertent duplication in statin therapy. SETTING: Tertiary care academic teaching hospital in Oklahoma, December 2005. PATIENT PRESENTATION: A 45-year-old white man received the combination therapy simvastatin 80 mg/ezetimibe 10 mg (Vytorin-Merck/Schering-Plough) daily after a coronary artery bypass graft (CABG) procedure. This patient was also receiving simvastatin 80 mg daily and cyclosporine 150 mg twice daily, which had been prescribed before CABG. The use of two simvastatin products prescribed at high doses subsequently led to rhabdomyolysis and renal failure. RESULTS: Statin therapy was discontinued at admission, and the patient was aggressively hydrated with 0.45% sodium chloride injection containing 50 mEq of sodium bicarbonate per liter at a rate of 250 mL/hour to alkalinize his urine. Hydration therapy alone decreased the patient's serum creatine kinase level to 910 units/L by day 7, but his serum creatinine remained elevated at 2.7 mg/dL. To manage rhabdomyolysis during hospitalization, the patient received a total of 6.7 liters of 0.45% sodium chloride injection with 50 mEq of sodium bicarbonate per liter. The patient was discharged 7 days after admission to a rehabilitation facility for continued strengthening of muscle tissue. CONCLUSION: The increased use of combination drug products poses an increased risk of therapeutic duplication in patients. The medication reconciliation process and proper counseling by pharmacists is necessary to avoid these potentially harmful errors.

Teriparatide in the treatment of osteoporosis.

PURPOSE: The efficacy, safety, and cost of teriparatide in the treatment of osteoporosis are reviewed. SUMMARY: Osteoporosis is a leading cause of fractures in women and men but is underdiagnosed and undertreated. Antiresorptive therapies (calcitonin, estrogen, bisphosphonates, and selective estrogen-receptor modulators) have historically been used to treat this condition. Teriparatide (recombinant human parathyroid hormone) is an anabolic agent labeled for use in postmenopausal women and men with osteoporosis who are at high risk for fractures. Clinical trials indicate that teriparatide increases predominantly trabecular bone in the lumbar spine and femoral neck; it has less significant effects at cortical sites. The combination of teriparatide with antiresorptive agents is not more effective than teriparatide monotherapy. The most common adverse effects associated with teriparatide include injection-site pain, nausea, headaches, leg cramps, and dizziness. After a maximum of two years of teriparatide therapy, the drug should be discontinued and antiresorptive therapy begun to maintain bone mineral density. Teriparatide is expensive but may be cost-effective in selected patients. CONCLUSION: Teriparatide offers a therapeutic option for patients at high risk of an osteoporotic fracture and for patients who are intolerant of or unresponsive to antiresorptive therapy.

Using team-based learning in an endocrine module taught across two campuses.

OBJECTIVES: To implement a team-based learning (TBL) format in an endocrine module to promote students' active learning in a course delivered to 2 campuses. METHODS: Course lectures were transformed into 13 TBL sessions consisting of content pre-assignments (self-directed learning), in-class readiness assurance tests (accountability), and team problem solving of patient cases and faculty-led class discussion (knowledge application). Student performance was evaluated through multiple assessments during the TBL sessions and on unit examinations. Students evaluated each individual TBL session and the course as a whole. RESULTS: Course grades were higher using the TBL method compared to the traditional lecture-based method that was used previously. Individual readiness assurance tests and team contribution scores significantly predicted overall course grades (p<0.001). Students accepted the change in course format as indicated by course evaluation results. CONCLUSIONS: TBL is an effective active-learning, instructional strategy for courses with large student-to-faculty ratios and distance education environments.

Metabolic effects of a conversion from rosiglitazone to pioglitazone in Native American patients with type 2 diabetes.

In this retrospective electronic chart review, we evaluated the metabolic changes that occurred in Native American patients with type 2 diabetes who were treated with rosiglitazone and then converted to pioglitazone with no other changes in medication regimens for diabetes or dyslipidemia. Thirty-four patients were included in the analysis. After the conversion from rosiglitazone to pioglitazone, significant decreases in the levels of total cholesterol (10.1%), low-density lipoprotein cholesterol (11.7%), and triglycerides (15.3%) were seen. No significant changes occurred in weight, body mass index, fasting glucose, hemoglobin A(1c), high-densitylipoprotein cholesterol, blood pressure, or liver function tests. Significantly more patients achieved low-density lipoprotein cholesterol and triglyceride target goals when taking pioglitazone than when taking rosiglitazone. No drug discontinuations or adverse effects were reported among the evaluable population. These results are consistent with results of other studies evaluating these two drug therapies.

Gelatinous bone marrow in an HIV-positive patient.

Gelatinous bone marrow transformation has been identified in patients with anorexia, malignancy, malabsorption, and HIV/AIDS. This represents a deposition of gelatinous material within the bone marrow, along with atrophy. We report the case of an HIV-seropositive man who presented with low back pain related to his gelatinous bone marrow changes.

Two-year changes in bone mineral density and T scores in patients treated at a pharmacist-run teriparatide clinic.

STUDY OBJECTIVES: To determine changes in bone mineral density (BMD) and T scores of patients after 2 years of teriparatide therapy, and to determine the number of fractures that occurred during therapy. DESIGN: Prospective, observational study. SETTING: Pharmacist-run teriparatide clinic in a private-practice endocrinology group. PATIENTS: Sixty patients with osteoporosis who experienced fractures or adverse events while receiving antiresorptive therapy and were referred by the endocrinologists to the clinic between January 1, 2002, and January 1, 2004. INTERVENTION: After a 1-hour counseling and training session with a clinical pharmacist, patients self-administered subcutaneous teriparatide 20 microg/day for the next 2 years. MEASUREMENTS AND MAIN RESULTS: Primary outcome measures were dual x-ray absorptiometry-determined BMDs and T scores for the total hip, spine, and wrist at baseline and at 1 and 2 years. Patients' BMDs for the hip significantly increased by 3.5% at 1 year and by 3.9% at 2 years. In addition, BMD for the spine significantly increased by 7.2% at 1 year and 10.9% at 2 years. In 56 (93%) patients, BMD for the spine increased after 2 years of treatment. For the wrist, BMD decreased by 0.75% at 1 year and by 2.4% at 2 years, but the change was only significant at 2 years (p=0.011). At both 1 and 2 years, T scores for the total hip and spine significantly improved from baseline (p< or =0.019), whereas T scores for the wrist significantly declined after 2 years of therapy (p<0.003). No new fractures were documented in any of the patients. CONCLUSION: In patients with osteoporosis, the use of teriparatide in a pharmacist-run clinic significantly increased BMD at the total hip and spinal sites and significantly decreased BMD in the wrist.

Cytomegalovirus encephalitis in an HIV-seropositive person.

Cytomegalovirus (CMV) infection is common in persons with HIV/AIDS. It can affect the eye, lung, liver, GI tract, and nervous system. It is also a common cause of blindness in persons infected with HIV. We report a case of CMV encephalitis in a person in whom AIDS was recently diagnosed who did not have CMV retinitis on ophthalmological examination.