Gabapentin-Induced Bullous Pemphigoid.

Bullous pemphigoid is an autoimmune blistering dermatosis with separation of the epidermis from the dermis. This disease process is common among elderly patients and manifests with subepidermal vesicles and tense bullae. Patients with bullous pemphigoid are more likely to have also received a previous diagnosis of a neurologic disorder. Gabapentin is an antiepileptic that is used to manage neuropathic pain. The authors describe, to their knowledge, the first report of gabapentin-induced bullous pemphigoid in an elderly man with no history of rashes or reactions to other medications.

Acute renal infarction associated with homozygous methylenetetrahydrofolate reductase mutation C677T and IgA beta-2-glycoprotein antibodies.

Arterial thrombosis of the kidney(s) is a rare clinical entity usually presenting as a result of cardioembolic disease, though rare inherited hypercoagulable states have also been implicated. Within this context, both hyperhomocysteinemia triggered by a mutated methylenetetrahydrofolate reductase (MTHFR) gene product and the presence of antiphospholipid antibodies have been separately associated with arterial thrombotic events, including renal artery embolism. We present a case of combined homozygous MTHFR C677T mutation and IgA beta-2-glycoprotein antibody positivity resulting in acute renal infarction and previous silent myocardial infarction. An acute and otherwise unexplained thrombotic event of unusual location always warrants further investigation, which should include testing for hereditary thrombophilic disorders.

Feasibility of energy medicine in a community teaching hospital: an exploratory case series.

BACKGROUND: Energy medicine (EM) derives from the theory that a subtle biologic energy can be influenced for therapeutic effect. EM practitioners may be trained within a specific tradition or work solo. Few studies have investigated the feasibility of solo-practitioner EM in hospitals. OBJECTIVE: This study investigated the feasibility of EM as provided by a solo practitioner in inpatient and emergent settings. DESIGN: Feasibility study, including a prospective case series. SETTINGS: Inpatient units and emergency department. OUTCOME MEASURES: To investigate the feasibility of EM, acceptability, demand, implementation, and practicality were assessed. Short-term clinical changes were documented by treating physicians. PARTICIPANTS: Patients, employees, and family members were enrolled in the study only if study physicians expected no or slow improvement in specific symptoms. Those with secondary gains or who could not communicate perception of symptom change were excluded. RESULTS: EM was found to have acceptability and demand, and implementation was smooth because study procedures dovetailed with conventional clinical practice. Practicality was acceptable within the study but was low upon further application of EM because of cost of program administration. Twenty-four of 32 patients requested relief from pain. Of 50 reports of pain, 5 (10%) showed no improvement; 4 (8%), slight improvement; 3 (6%), moderate improvement; and 38 (76%), marked improvement. Twenty-one patients had issues other than pain. Of 29 non-pain-related problems, 3 (10%) showed no, 2 (7%) showed slight, 1 (4%) showed moderate, and 23 (79%) showed marked improvement. Changes during EM sessions were usually immediate. CONCLUSIONS: This study successfully implemented EM provided by a solo practitioner in inpatient and emergent hospital settings and found that acceptability and demand justified its presence. Most patients experienced marked, immediate improvement of symptoms associated with their chief complaint. Substantial practicality issues must be addressed to implement EM clinically in a hospital, however.

Underutilization of acetylsalicylic acid for acute coronary syndromes in the emergency department.

OBJECTIVE: Acetylsalicylic acid (ASA) is a simple and cost-effective treatment for acute coronary syndromes (ACS). Our objectives were to determine the frequency of ASA administration in the emergency department (ED) for patients with acute myocardial infarction or unstable angina, and to identify patient characteristics associated with its administration. METHODS: This is a retrospective chart review of patients discharged with a final diagnosis of ACS. Data on age, gender, mode of presentation, presence of chest pain at triage, administration of ASA or not in the ED, dosage and form of ASA received, timing of administration, presence of contraindications to ASA and use of regular ASA prior to ED presentation were recorded. RESULTS: Six hundred and one charts were analyzed. Five hundred and fifty patients (91.5%) received ASA. Only 444 (73.9%) of these 550 patients were administered the ASA appropriately, according to the American Heart Association / American College of Cardiology (AHA/ACC) guidelines. Univariate analysis showed that chart notes "Transport by ambulance," "Allergy to ASA" and "Gastrointestinal bleed" were associated with a lower probability of the patient being administered ASA. If a patient was noted as taking ASA regularly, it increased the chance of this patient being administered ASA in the ED. CONCLUSION: Although the study ED performed well, administering ASA to 91.5% of patients with ACS, only 73.9% of the patients who received ASA were administered the ASA appropriately, as recommended in the AHA/ACC guidelines. Educational strategies and system changes are necessary to increase the proportion of eligible ACS patients who receive appropriate ASA therapy.