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.

A community continuity programme: volunteer faculty mentors and continuity learning.

BACKGROUND: Longitudinal generalist preceptorship experiences early in medical education can have beneficial effects on how students practise the art and science of medicine, regardless of their eventual career choices. DESCRIPTION: We evaluated the first 2 years of implementation of an integrated, regional campus-based, early clinical experience programme, the Community Continuity Program, at our new community-based medical school that is under the supervision of volunteer primary care faculty members acting as continuity mentors (CMs). Curricular components for years 1 and 2 consisted of three annual 1-week community-based experiences with CMs, extensive physical diagnosis practice, interprofessional learning activities, a multigenerational family care experience, a mandatory Community Health Research Project (CHRP) in year 1 and a mandatory Quality Improvement Project in year 2. EVALUATION: Outcome measures included student, faculty member and programme evaluations, student reflective narratives in portal-based e-journals, a Liaison Committee on Medical Education (LCME) self-study student survey and serial level-of-empathy surveys. RESULTS: Students found all elements of this integrated community experience programme beneficial and worthwhile, especially the CMs and the use of standardised and real-life patients. CMs noted effective and professional student-patient interactions. The number of reflective e-journal postings per student during year1 ranged from 14 to 81 (mean, 47). Serial empathy questionnaires administered over 2 years demonstrated preservation of student empathy, and students believed that the programme had a positive effect on their personal level of empathy. CONCLUSION: An integrative, longitudinal, community-based, early clinical experience programme driven by volunteer CMs provides patient-centered instruction for preclinical students in the clinical, social, behavioural, ethical and research foundations of medicine.

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.

The role of fluconazole in the treatment of Candida endocarditis: a meta-analysis.

The treatment of Candida infective endocarditis generally involves infected valve removal accompanied by antifungal therapy with amphotericin B or a lipid-based derivative, with or without flucytosine. While often used as chronic suppressive therapy in these patients, the precise role for fluconazole has not been established. We conducted a meta-analysis of 64 literature cases of Candida endocarditis whose management did not include valve replacement but who received fluconazole, alone or concurrently or in sequence with 1 or more other antifungal drugs.Forty-nine (77%) patients were cured (n = 44) or improved (n = 5), 4 relapsed (6%), and 11 failed (10 of whom died) (17%). Among 19 patients for whom fluconazole was administered as the sole antifungal therapy, 11 (58%) were cured or improved. In contrast, among 45 patients who received 1 or more other antifungal agents in addition to fluconazole, 38 (84%) were cured or improved (p = 0.02). Eighteen of 21 (86%) patients with native valve infection were cured or improved compared with 13 of 19 (68%) patients with prosthetic valve endocarditis (p = 0.13). The mean duration of successful fluconazole regimens was 134 days. Twenty of 21 (95%) patients who received fluconazole as chronic suppressive therapy for ≥6 months were cured. Prognosis was independent of Candida species or patient age. Among 23 historical controls managed with fluconazole-containing antifungal therapy plus valvular surgery, survival was 91%.In conclusion, fluconazole-containing, combination antifungal therapy, with or without concomitant valve replacement, and followed by prolonged, perhaps indefinite fluconazole suppression, is effective in patients with Candida endocarditis.

A regional model of interprofessional education.

This paper describes the innovative features of the first regional model of interprofessional education (IPE) in the US, developed by The Commonwealth Medical College, Scranton, PA, USA, as a new, independent, community-based medical school in northeastern Pennsylvania. Essential educational components include collaborative care seminars, interprofessional sessions, simulations, live web-based seminars and newly innovative virtual environment interactive exercises. All of these elements are being integrated into the curricula of 14 undergraduate and allied professional schools, and three graduate medical education programs located in the region. Activities incorporate simulation, standardized patients, student leadership, and faculty and student facilitation. As this new regional model of interprofessional education is fully implemented, its impact will be assessed using both quantitative and qualitative outcomes measurements. Appropriate ongoing modifications to the model will be made to ensure improvement and further applicability to collaborative learning.

Anatomy of a new U.S. medical school: The Commonwealth Medical College.

In response to the Association of American Medical Colleges' call for increases in medical school enrollment, several new MD-granting schools have opened in recent years. This article chronicles the development of one of these new schools, The Commonwealth Medical College (TCMC), a private, not-for-profit, independent medical college with a distributive model of education and regional campuses in Scranton, Wilkes-Barre, and Williamsport, Pennsylvania. TCMC is unique among new medical schools because it is not affiliated with a parent university. The authors outline the process of identifying a need for a new regional medical school in northeastern Pennsylvania, the financial planning process, the recruitment of faculty and staff, the educational and research missions of TCMC, and details of the infrastructure of the new school. TCMC's purpose is to increase the number of physicians in northeastern Pennsylvania, and in the next 20 years it is expected to add 425 practicing physicians to this part of the state. TCMC is characterized by autonomy, private and public support, assured resources in good supply, a relatively secure clinical base, strong cultural ties to the northeast, recruiting practices that reflect the dean's convictions, and strong support from its board of directors. TCMC has invested heavily in social and community medicine in its educational programs while still developing a strong research emphasis. Major challenges have centered on TCMC's lack of a parent university in areas of accreditation, infrastructure development, faculty recruitment, and graduate medical education programs. These challenges, as well as solutions and benefits, are discussed.

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.

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.

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.

Interprofessional education: a concept analysis.

Interprofessional education is broadly defined as a teaching and learning process that fosters collaborative work between two or more health care professions. Interprofessional education, as a proven, beneficial approach to collaborative learning that addresses the problems of fragmentation in health care delivery and separation among health care professionals, is frequently promulgated but not always successfully implemented. Furthermore, there are several different interpretations, overlapping terminologies, interchangeable terms, and a lack of uniformity of a definition for interprofessional education. This concept analysis determines the attributes and characteristics of interprofessional education, develops an operational definition that fits all health-related disciplines, defines common goals, and improves overall clarity, consensus, consistency, and understanding of interprofessional education among educators, professionals, and researchers. Through effective incorporation of interprofessional education into curricular and practice settings, optimal patient-centered outcomes can potentially result as effective and highly integrated teams facilitate and optimize collaborative patient care and safety.

Massive fluid requirements and an unusual BUN/creatinine ratio for pre-renal failure in patients with cholera.

BACKGROUND: Cholera is an important infectious cause of secretory diarrhea. The primary symptom of infection is the sudden onset of watery diarrhea with subsequent volume depletion causing renal insufficiency. The objective of this research is to study the level of dehydration at presentation and subsequent fluid management in patients with cholera. METHODS: This study was conducted on 191 patients of Cholera admitted at a tertiary care hospital in Karachi, Pakistan during the period of 5 years. Medical charts were evaluated retrospectively for initial hydration status, baseline lab investigations on admission and discharge and fluid therapy given to all the patients while their stay in the hospital and the data was analyzed on SPSS 15.0. RESULTS: Out of the 191 patients, 83(43%) were males and 108 (57%) were females with mean age of 42.3 years (SD+/-18.34). The average duration of symptoms was 3.75 days (SD+/-2.04). Of 191 patients, 175 (92.1%) presented with dehydration, 80 (42.3%) were given Ringer's Lactate (R/L) + Normal Saline (N/S), 45 (24%) patients were given R/L + N/S + Oral Rehydration Therapy (ORS), 27 (14.3%) of the patients were kept on R/L only and remaining were given various combinations of R/L, N/S, ORS and Dextrose Saline (D/S). On admission mean Blood Urea Nitrogen (BUN) was 24.54 (SD+/-16.6), mean creatinine was 2.47 (SD+/-2.35) and mean BUN/Creatinine ratio was 11.63 (SD+/-5.7). CONCLUSION: Aggressive fluid rehydration remains the cornerstone of management of cholera. Instead of presenting with a classical BUN/Creatinine ratio of >20:1, patients with pre-renal failure in cholera may present with a BUN/Creatinine ratio of <15:1.

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.

Preoperative antifungal therapy may improve survival in patients with Aspergillus brain abscess.

OBJECTIVE: The objective of this study was to determine if the preoperative use of antifungal therapy positively influences clinical outcome in patients with Aspergillus brain abscess. METHODS: We studied 25 patients with confirmed diagnosis of cerebral aspergillosis. We compared baseline characteristics and outcomes of patients treated with either amphotericin B or itraconazole either pre-operatively (n=11) or post-operatively (n=14) at a tertiary care hospital in Karachi. RESULTS: Twenty-five patients were included in the study. Cerebral aspergillosis was largely a disease of immune competent people (80%). Baseline clinical characteristics between the two treatment groups were comparable i.e., age (P>0.896), gender (P>0.999), coma at presentation (P>0.999), immunosuppression (P>0.623), number of abscesses (P>0.999) and interval between presentation and surgery (P>0.447). Overall mortality was 40%. The overall outcome was significantly better (P<0.001) in patients treated with antifungal therapy before surgery. All 11 patients who received antifungal therapy before surgery survived, but only preoperative itraconazole treatment was statistically associated with an improved survival compared to delayed treatment. CONCLUSION: Cerebral aspergillosis was largely a disease of immune competent people (80%). Overall mortality was 40%. The outcome was significantly better in patients treated with antifungal therapy (especially itraconazole) before surgery suggesting a possible beneficial effect of pre-surgical treatment with antifungal therapy.

Impact of prior antibiotic use in culture-negative endocarditis: review of 86 cases from southern Pakistan.

BACKGROUND: A large number of patients treated at our hospital for endocarditis have negative cultures. Taking into consideration the fact that many of these patients receive antibiotics prior to referral, we decided to study culture-negative endocarditis in Pakistan. METHODS: The medical records of all patients admitted to the Aga Khan University Hospital, Pakistan, for the period from 1988 to 2001, with an underlying diagnosis of infective endocarditis (IE) and negative cultures, were reviewed. RESULTS: Of the 159 patients diagnosed with IE by revised Duke criteria, 86 (54.1%) had persistent negative cultures. More than half of these patients (52%) had received antibiotics before being referred to our center. Patients with culture-negative endocarditis were less likely to be classified as definite endocarditis by revised Duke criteria (p<0.001, 95% CI 0.07-0.3) or to have large vegetations (p=0.021, 95% CI 0.05-0.5), and more likely to have a mitral valve prolapse (p=0.003, 95% CI 1.6-2.3). Definite endocarditis (p=0.042, 95% CI 1.02-7.4), heart failure (p=0.008, 95% CI 1.4-12.7), renal failure (p=0.017, 95% CI 1.16-40.7), embolism (p=0.019, 95% CI 1.2-38.8), and neurological complications (p=0.02, 95% CI 1.16-9.2) were associated with an increased mortality. CONCLUSION: Culture-negative endocarditis is very common among patients with IE in Pakistan. The presentation, laboratory findings, and complications are similar to those for culture-positive endocarditis. It is postulated that previous antibiotic treatment is the most common cause of culture-negative endocarditis in our hospital.

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.

Pulmonary resection combined with isoniazid- and rifampin-based drug therapy for patients with multidrug-resistant and extensively drug-resistant tuberculosis.

OBJECTIVE: To evaluate the clinical efficacy of pulmonary resection and postoperative use of a first-line drug regimen for patients with well-localized, cavitary pulmonary multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). METHODS: This was a prospective case study set in the National Masan Tuberculosis Hospital in Masan, Republic of Korea. From February 1998 to May 2004, 19 patients with well-localized, cavitary pulmonary MDR-TB or XDR-TB were enrolled and followed prospectively through April 2007. After radical surgical resection, patients were treated with anti-tuberculous therapy consisting of isoniazid (H), rifampin (R), ethambutol (E), pyrazinamide (Z), and streptomycin (S) (3HREZS/3HRES/6HRE). RESULTS: All recovered isolates of Mycobacterium tuberculosis were resistant to isoniazid and rifampin, and to a mean of 4.7 anti-tuberculous drugs (range 2-8 drugs). Seventeen patients had MDR-TB and two had XDR-TB. Surgical procedures included: lobectomy (14 patients), lobectomy plus segmentectomy or wedge resection (four patients), and pneumonectomy (one patient). The median time to postoperative sputum smear and culture conversion was 2 days (range 1-23 days). Fifteen (78.9%) subjects, including both with XDR-TB, had durable cures (mean follow-up period 53.2 months). One patient failed to convert her sputum and was successfully switched to second-line therapy. Another patient developed active disease again 68 months after cure, likely due to re-infection with a new M. tuberculosis strain. Two patients were lost to follow-up after hospital discharge. CONCLUSION: Resectional lung surgery combined with isoniazid- and rifampin-based anti-tuberculous chemotherapy can be an effective treatment strategy for patients with well-localized, cavitary pulmonary MDR-TB and XDR-TB.