Patterns and Predictors of Proton Pump Inhibitor Overuse among Academic and Non-Academic Hospitalists.

Intern Med. 2010;49(23):2561-8

Authors: Eid SM, Boueiz A, Paranji S, Mativo C, Ba RL, Abougergi MS

Objective In the hospital setting, several studies have reported proton pump inhibitor (PPI) overuse, a majority of which is continued after discharge. In addition to being expensive, PPIs are associated with an increased risk of infections, osteoporosis and serious drug interactions. We examined the trends and predictors of PPI guidelines non-compliance among academic and non- academic hospitalists in USA. Methods and Patients Oral PPI prescriptions initiated by 2 academic and 2 non-academic hospitalist groups were reviewed. Prescription indications were recorded when explicitly stated in the chart. Otherwise, qualified physicians reviewed the chart to make such determination. Indications were then compared to the published guidelines. Several variables were tested to determine independent predictors of initiation and post discharge continuation of guideline non-compliant prescriptions. Results Of the 400 PPI prescriptions 39% were guideline compliant. Academic hospitalists were significantly more compliant with PPI prescription guidelines (50 vs 29%). Gastrointestinal ulcer bleeding prophylaxis (GIP) for low risk patients was the most common indication for non-compliant prescriptions, while that of guideline compliant prescriptions was dyspepsia treatment. Independent predictors of the initiation of guideline non-compliant prescriptions were non-academic hospitalist group, PPI indication not documented in the chart, and GIP as part of the admission orderset. The latter was an independent predictor of those prescriptions continuation post-discharge (protective) in addition to non-academic hospitalists group. Conclusion Hospitalists overprescribe PPI to a level comparable to that of the non-hospitalist providers in the literature. Understanding the determinants of increased compliance among academic groups is instrumental to design interventions aimed at increasing PPI prescription compliance.

PMID: 21139293 [PubMed - in process]

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Influence of human T lymphotropic virus type I infection on the etiology of community-acquired pneumonia.

Intern Med. 2009;48(12):959-65

Authors: Atsumi E, Yara S, Higa F, Hirata T, Haranaga S, Tateyama M, Fujita J

BACKGROUND: Human T lymphotropic virus type I (HTLV-I), the cause of human T cell leukemia, is associated with a high incidence of several other infectious diseases. However, the relationship between pulmonary infections and HTLV-I infection is still unclear. OBJECTIVE: A large-scale retrospective study was conducted on hospital inpatients to evaluate the relationship between community-acquired pneumonia (CAP) and HTLV-I infection. METHODS: The present study included 4,666 hospitalized patients during 1991-2007. Three hundred and thirteen of them were diagnosed as CAP. The presence of serum HTLV-I antibody was determined in all patients on admission. Prevalence of HTLV-I infection was analyzed between CAP patients and all inpatients. We also compared HTLV-I-positive CAP patients and HTLV-I-negative CAP patients for severity and manifestation of pneumonia. RESULTS: The prevalence of HTLV-I was higher in CAP patients than in all inpatients (18.9%: 13.7%, p=0.011). The rates of renal diseases and collagen vascular disorders were higher in the HTLV-I-positive CAP patients than in the HTLV-I-negative CAP patients. Multivariate analysis revealed that HTLV-I infection, gender, COPD and collagen vascular disorders were all independent risk factors for CAP. The severity indices of CAP, the PORT score and the CURB-65 score, were higher in the HTLV-I-positive patients than in the HTLV-I-negative patients. CONCLUSION: This study demonstrates that HTLV-I infection might be an independent risk factor for CAP and that HTLV-I-infected patients tend to demonstrate a relatively severe form of pneumonia.

PMID: 19525581 [PubMed - indexed for MEDLINE]

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Identifying low-risk patients for bacterial meningitis in adult patients with acute meningitis.

Intern Med. 2009;48(7):537-43

Authors: Tokuda Y, Koizumi M, Stein GH, Birrer RB

OBJECTIVE: To derive and validate a clinical prediction model with high sensitivity for differentiating aseptic meningitis (AM) patients from bacterial meningitis (BM) patients. METHODS: We developed the model using the derivation cohort in a community rural hospital in Okinawa and assessed its performance using the validation cohort in a metropolitan urban hospital in Tokyo. There were 66 (39.5%) and 5 (17.9%) adult patients with BM among the derivation (n=167) and the validation cohort (n=28), respectively. Recursive partitioning analysis was used to determine the important classification variables and to develop a sensitive model to safely exclude BM. RESULTS: The model produced high- and low-risk groups based on the following: 1) Gram stain, 2) CSF neutrophil percent < or =15%, 3) CSF neutrophil count < or =150 cells/mm(3), and, 4) mental status change. Among the derivation cohort, there were 65 patients with BM in the high-risk group (n=76), while only one patient with BM was noted (sensitivity, 99%) in the low-risk group (n=91). Among the validation cohort, there were 5 patients with BM in the high-risk group (n=7), while no patient was classified with BM (sensitivity, 100%) in the low-risk group (n=21). CONCLUSION: This simple and sensitive model might be useful to safely identify low-risk patients for BM who would not require antibiotic treatment.

PMID: 19336955 [PubMed - indexed for MEDLINE]

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Treatment of hyponatremia.

Intern Med. 2008;47(10):885-91

Authors: Gross P

Hyponatremia is an electrolyte disorder that is defined by a serum sodium concentration of less than 136 mmol/L. Hyponatremia occurs at a high incidence. It is commonly associated with mild to moderate mental impairment. Hypoosmolar hyponatremia occurs in the setting of plasma volume deficiency (“hypovolemia”, e. g. after gastrointestinal fluid loss), liver cirrhosis and cardiac failure (“hypervolemic” hyponatremia) and syndrome of inappropriate antidiuretic hormone secretion (“euvolemic” hyponatremia). Excessive antidiuretic hormone and continued fluid intake are the pathogenetic causes of these hyponatremias. Whereas hypovolemic hyponatremia is best corrected by isotonic saline, conventional proposals for euvolemic and hypervolemic hyponatremia consist of the following: fluid restriction, lithium carbonate, demeclocycline, urea and loop diuretic. None of these nonspecific treatments is entirely satisfactory. Recently a new class of pharmacological agents -orally available vasopressin antagonists, collectively called vaptans- have been described. A number of clinical trials using vaptans have been performed already. They showed vaptans to be effective, specific and safe in the treatment of euvolemic and hypervolemic hyponatremia.

PMID: 18480571 [PubMed - indexed for MEDLINE]

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Clinical and radiological features of Pneumocystis pneumonia in patients with rheumatoid arthritis, in comparison with methotrexate pneumonitis and Pneumocystis pneumonia in acquired immunodeficiency syndrome: a multicenter study.

Intern Med. 2008;47(10):915-23

Authors: Tokuda H, Sakai F, Yamada H, Johkoh T, Imamura A, Dohi M, Hirakata M, Yamada T, Kamatani N, Kikuchi Y, Sugii S, Takeuchi T, Tateda K, Goto H

OBJECTIVE: To elucidate the clinical and radiological features of Pneumocystis pneumonia (PCP) in patients with rheumatoid arthritis (RA), compared with methotrexate (MTX) pneumonitis in RA and Pneumocystis pneumonia in acquired immunodeficiency syndrome (AIDS). SUBJECTS AND METHODS: Retrospective analysis of 14 PCP cases in RA (RA-PCP), 10 MTX pneumonitis cases in RA (MTX-P) and 11 PCP cases in AIDS (AIDS-PCP) from 9 centers in the Kanto area in the last 6 years. RESULTS: Compared with AIDS-PCP, both RA-PCP and MTX-P developed more rapidly, showing higher serum CRP and lower plasma beta-D-glucan levels, and more severe oxygenation impairment. In most of the RA-PCP cases, a high dose of corticosteroid was administered as adjunctive therapy, resulting in a favorable outcome. The mortality was 14% in RA-PCP, 0% in AIDS-PCP and 0% in MTX-P cases. In RA-PCP patients the CD4 cell count showed only mild suppression, not reaching the predisposing level for PCP in HIV infection, suggesting that there are risk factors for RA-PCP other than immunosuppression. Radiologic analysis revealed some characteristic patterns of each disease. In MTX-P, diffuse homogeneous ground glass opacity (GGO) with sharp demarcation by interlobular septa (type A GGO) was found in 70%, while in AIDS-PCP diffuse, homogeneous or nonhomogeneous GGO without interlobular septal boundaries (type B GGO) was predominant (91%). In RA-PCP, type A GGO was found in 6 cases and type B GGO in 5 cases, showing the complex nature of this disease. CONCLUSION: RA-PCP differed considerably from AIDS-PCP clinically and radiologically. Clinically it occurred without severe immunosuppression, and showed characteristic aspects, with more intense inflammation and less parasite burden. Radiologically it mimicked MTX-P in some cases sharing the conspicuous CT features of MTX-P, rendering the distinction of these two disorders difficult.

PMID: 18480575 [PubMed - indexed for MEDLINE]

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Clinical efficacy of the transdermal tulobuterol patch in patients with chronic obstructive pulmonary disease: a comparison with slow-release theophylline.

Intern Med. 2008;47(6):503-9

Authors: Minami S, Kawayama T, Ichiki M, Nishiyama M, Sueyasu Y, Gohara R, Kinoshita M, Koga H, Iwanaga T, Aizawa H

BACKGROUND: There is insufficient evidence for the efficacy of a transdermal tulobuterol patch (TP), although combination therapy with bronchodilators is recommended for chronic obstructive pulmonary disease (COPD). OBJECTIVE: A randomized, controlled crossover study was conducted to evaluate the clinical efficacy and safety of the TP in 16 patients with COPD. Slow-release theophylline was used as a control drug. METHODS: Following a 2-week run-in period, patients were randomly allocated to two groups by the envelope method; they then received the TP and theophylline for 4 weeks each by the crossover method. Pulmonary function tests, peripheral blood examination, and electrocardiography were performed before and after each treatment period. Patients recorded in diaries their symptom scores, numbers of administrations of inhaled beta(2) agonists, and presence/absence of adverse reactions. RESULTS: Patients receiving TP exhibited significant improvement in the number and ease of sputum expectoration and in cough frequency score and wheezing severity score compared with baseline (p<0.05); the corresponding improvement in patients receiving theophylline was non-significant. Assessment of quality of life by the St. George's Hospital Respiratory Questionnaire revealed that treatment with TP was associated with significant improvement in symptoms, impact, and total scores compared with baseline (p<0.05); theophylline gave only a non-significant improvement in total score. Neither drug caused significant changes in the results of physiological examinations or in pulse or blood pressure. There was no difference in safety between the treatments. CONCLUSION: Treatment of COPD patients with TP is more effective than with theophylline.

PMID: 18344636 [PubMed - indexed for MEDLINE]

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