Suboptimal prescribing in older inpatients and outpatients

Investigators searched Medline and HealthSTAR databases from January 1, 1985 through June 30, 1999 to identify articles on suboptimal prescribing in those age 65 years and older. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. The definitions for various types of suboptimal prescribing (polypharmacy, inappropriate, and underutilization) are numerous, and measurement varies from study to study. The literature suggests that suboptimal prescribing is common in older outpatients and inpatients. Moreover, there is significant morbidity and mortality associated with suboptimal prescribing for these older patients. Evidence from well-controlled studies suggests that multidisciplinary teams and clinical pharmacy interventions can modify suboptimal drug use in older people. Future research is necessary to measure and test other methods for tackling this major public health problem facing older people.     

门诊及住院患者支气管镜检查及治疗的诉求及安全性分析

<正>近年来,随着支气管介入技术的发展和推广应用,支气管镜检查及治疗已成为呼吸内科医师诊断疾病和解除患者病痛的一柄利器。它不但在气管异物的诊断及治疗中继续发挥着不可取代的作用,而且越来越多地被应用到各种肺脏疾病的诊治中。例如对肺脏小结节和毛玻璃影,采用介入性肺脏病学技术已成为确诊的主要临床诊断方法[1-6]。常规支     

Differences in skin flora between inpatients and chronically ill outpatients

BACKGROUND: Changes in skin flora have been reported among hospitalized and critically ill patients, but little is known about whether these changes are associated with hospitalization or with chronic, serious illness. The purpose of this survey was to compare skin flora of chronically ill outpatients and inpatients. METHODS: Aerobic skin flora of forearm and midsternum of 250 patients in an intensive care unit and 251 outpatients was sampled by contact plates. RESULTS: Mean colony-forming units were 160.6, forearm; 229. 4, sternum (P <.000). In logistic regression analysis, patients in the medical intensive care unit were significantly more likely to have high counts on the arm (odds ratio, 2.48; 95% confidence interval: 1.34-4.43; P =.004), and blacks were significantly more likely to have higher counts on the sternum when compared with other ethnic groups (odds ratio, 1.92; confidence interval: 1.18-3.11; P =. 009). No differences were noted between inpatients or outpatients in prevalence of methicillin-sensitive Staphylococcus aureus, but inpatients were more likely to carry methicillin-resistant Staphylococcus aureus (arm, P =.007; sternum, P =.02). Outpatients had a higher prevalence of micrococci and gram-negative bacteria at both skin sites (all P <.01) and yeast at the sternal site (P =.007). CONCLUSIONS: This comparison provides data to differentiate between effects of hospitalization and effects of chronic illness on skin flora.     

Epidemiology, etiology and pathophysiology of traveler's diarrhea

Traveler's diarrhea (TD) is the most frequent health problem in travelers to developing countries. Several personal and environmental risk factors are at the basis of TD acquisition and are discussed in this paper. TD is caused by a wide range of infectious organisms, ETEC and EAEC bacteria strains being the main enteropathogens incriminated in TD. Other causative bacteria are: Shigella spp., Campylobacter spp., Vibrio spp., Aeromonas spp., Salmonella spp., and Plesiomonas spp. Parasite species are also included: Cyclospora cayetanensis, Giardia lamblia, Cryptosporidium, Entamoeba histolytica, as well as viruses: rotavirus, adenovirus, Norwalk virus. Due to the great diversity of pathogens incriminated, several pathophysiological mechanisms have been described and some of them are still poorly understood. The clinical symptoms present are also quite variable, although inflammatory and non-inflammatory diarrhea have been established as a classical and basic classification of diarrhea.     

The prevalence and etiology of impotence in 101 male hypertensive outpatients

Erectile dysfunction and impotence has a high prevalence among male hypertensive patients. Whether this relates mainly to specific drug side effects or to primary pathogenic disorders is unknown. In the present study 101 male patients from our outpatient hypertension clinic answered detailed questionnaires about hypertension and sexual function. Patients with perceived impotence were offered a thorough penile evaluation and examination performed by specialists in the urology department. Twenty-seven (27%) men had impotence. The main cause of impotence was an arterial dysfunction (89%). The prevalence of impotence was related to the degree of secondary organ manifestation, reflected by World Health Organization (WHO) classification I-III (P = .01). Intermittent claudication (P = .001) and ischemic heart disease (P = .005) were the best determinants in this respect. Twelve impotent patients (44%) ascribed onset of impotence to drug initiation. A variety of drugs were incriminated in the occurrence of drug-induced impotence. In summary our results indicate that impotence in hypertensive men is caused mainly by penile arterial vascular changes, probably atherosclerosis. Drug-induced impotence could well be the result of blood pressure reduction itself and not specific drug side effects.     

Prospective studies on the etiology and treatment of pruritus ani

Seventy-five patients presented with the complaint of pruritus ani. The following prospective studies were employed to evaluate groups of these patients; (1) laboratory, including blood count, stool examination for ova and parasites, urinalysis, Sequential Multiple Analysis-12 serum studies, stoolpH, and skin scrapings for fungi; (2) Minnesota Multiphasic Personality Inventory; (3) anal manometry; (4) elimination of dietary factors, and (5) topical ointment application. Many patients were concerned that a cancer caused the symptom. Once reassured, they tolerated the pruritus. Forty-eight to 50 per cent of these patients had poorly formed stools or incomplete stool evacuation; thus, soiling was frequent. An underlying skin problem was found in six patients with psoriasis and in one with erythrasma. Patients tended to worsen the problem by application of many medications and overzealous cleaning. Minor surgical problems of the anus should be corrected before other managements are instituted. Idiopathic pruritus ani responds to anal cleanliness, dietary discretion with avoidance of specific items by some patients, bowel habit regulation, and a mild topical hydrocortisone cream. Read at the meeting of the American Society of Colon and Rectal Surgeons, Colorado Springs, Colorado, June 7 to 11, 1981. The opinions contained in this article are those of the authors. They are not necessarily the opinions of the United States Navy or of the Uniformed Services University of the Health Sciences.     

Advances in defining etiology and new therapeutic approaches in acute diarrhea

Defining etiology of acute diarrhea is critical to disease therapy and prevention. In this review we look at recent developments in etiologic agents of acute diarrhea and advances in therapy and prevention of the illness. Newly appreciated agents include enterotoxigenic Bacteroides fragilis, Klebsiella oxytoca and Laribacter hongkongensis. Atypical enteropathogenic E. coli (EPEC) strains lacking the gene for epithelial attachment appear to be more important as causes of diarrhea than traditional EPEC strains. Enterotoxigenic E. coli and enteroaggregative E. coli diarrhea known to be important abroad, have recently been shown to occur in the United States. Non-O157:H7 strains of Shiga toxin-producing E. coli are increasing and infrequently are being sought. There is currently a serious epidemic of nosocomial diarrhea due to a fluoroquinolone-resistant and more virulent and difficult to treat strain of C. difficile. Rotavirus vaccine development should lead to reduction of infant gastroenteritis mortality in infants living in developing regions. Noroviruses produce outbreaks of water- and food-borne disease but show broad genetic diversity. Reduced osmolarity oral rehydration treatment (ORT) and recombinant human lactoferrin/lysozyme plus rice-based ORT effectively treat acute diarrhea. Probiotics were shown to be effective in preventing antibiotic associated- and C. difficile-diarrhea. Rifaximin prevents and azithromycin effectively treats travelers' diarrhea.     

Malaria among adult inpatients in two Tanzanian referral hospitals: A prospective study

Most malaria research in sub-Saharan Africa has focused on children and pregnant women, but malaria among hospitalized adults in this region is poorly characterized. In this prospective study, we assessed the prevalence and clinical characteristics of malaria among the inpatient adults in two hospitals in Tanzania. We enrolled adults admitted with suspected malaria and performed routine thick blood smear (BS) and malaria rapid diagnostic tests (RDT). We also assessed malaria parasite clearance rates. We considered malaria status ‘confirmed’ or ‘excluded’ only in patients with two concordant tests. Malaria polymerase chain reaction (PCR) was performed in a subset of patients with discordant BS and RDT. After BS and RDT were performed on 579 adults with suspected malaria, malaria was excluded in 458/579 (79.1%) and confirmed in 16/579 (2.8%). One hundred and five out of 579 (18.1%) had discordant results. The prevalences of positive BS and positive RDT were 102/579 (17.6%) and 35/579 (6.0%), respectively, with only fair agreement (Kappa = 0.354, p < 0.0001). PCR results agreed with RDT in 35/35 (100%) of patients with a negative RDT but positive BS. PCR results also agreed with RDT in 9/13 (69.2%) of cases with a positive RDT but negative BS. Clinical correlates of malaria by multivariable analysis included subjective fever (OR 3.6 [1.0–12.3], p = 0.04), headache (OR 3.1 [1.2–8.0], p = 0.02) and vomiting (OR 2.7 [1.2–6.4], p = 0.02). Malaria parasite clearance was significantly delayed in the HIV-infected group. Our study demonstrated only fair agreement between RDT and BS malaria tests among Tanzanian adult inpatients with suspected malaria. PCR generally agreed with RDT results. HIV was associated with delayed parasite clearance in adults with malaria. We recommend the routine use of RDTs for malaria diagnosis among adults admitted to hospitals in sub-Saharan Africa.     

成人腹泻病人轮状病毒感染监测及分组分型研究

目的研究武汉市成人腹泻病人轮状病毒的感染状况及A组轮状病毒基因型的分布。方法收集2001—2002年度武汉市成人腹泻大便标本728份,用聚丙烯酰胺凝胶电泳进行轮状病毒检测,逆转录—聚合酶链反应进行A组轮状病毒基因型研究。结果和结论2001—2002年度武汉市成人腹泻病人A、B组轮状病毒检出率分别为7.83%和0.27%。A组轮状病毒以G3P[8]型为主。成人A组轮状病毒流行的季节和基因型别与婴幼儿的一致。     

Demographic and clinical characteristics of HIV-infected inpatients and outpatients at a Cambodian hospital

A retrospective cross-sectional survey of 299 HIV-infected inpatients and outpatients was conducted between March 1999 and June 2000 in Phnom Penh, Cambodia, to define patient demographics and risk factors for HIV-1 infection, and to compare whether symptoms and opportunistic infections (OIs) differ by gender and site of patient care. The population represented one third of HIV-infected patients regularly receiving care at the Sihanouk Hospital Center of HOPE. Over one quarter (26%) of the men were soldiers and 27% were farmers or laborers. Eighty-nine percent of the men had visited sex workers, 29% of men and women had unsafe injections in the past, and 18% of women reported a spouse who was HIV-positive. Eighty percent of patients presented with weight loss more than 10% from baseline. Seventy-two percent of patients were diagnosed with two or more concurrent OIs or conditions. Oral candidiasis (p = <0.001), abdominal lymphadenitis (p = 0.03), and two or more concurrent OIs (p = <0.001) were diagnosed more often among men than women. Multivariate logistic regression shows that patients who presented with weight loss more than 10% from baseline are more likely to have one or more OIs or conditions. The results of this survey suggest that the primary risk factor for HIV-infected men presenting to this care facility was visiting sex workers. The pattern of OIs and other HIV-associated conditions indicated that the majority of patients delayed seeking care at the hospital. HIV physicians in Cambodia should be aware of the likelihood for multiple OIs or conditions when patients present weight loss more than 10% from baseline.     

20-year old woman with diarrhea of unknown etiology

We report on a 20-year old woman who suffered from watery diarrhea. The results of the histology and the serology as well as clinical symptoms lead us to the diagnosis of sprue. Under specific gluten-free diet the diarrhea frequency was reduced. After a few weeks the patient returned to hospital again because of watery diarrhea. Histological examination of duodenal biopsy specimen showed a protracted infectious duodenitis and a secondary villous flattening of the small bowel. This diagnosis was a life-threatening illness that needed antibiotic treatment. These patients receive parenteral nutrition as long as the villous have not been recovered from the flattening. Additionally octreotid can be given to reduce the frequency of the diarrhea.     

Rotavirus in travelers' diarrhea: study of an adult student population in Mexico.

The role of rotavirus in adult diarrhea was evaluated in 165 students attending a Mexican university. Students were divided into three groups: newly arrived summer students from the United Sttes, regular students from the United States, and Mexican and Venezuelan students. Ninety-one students with diarrhea and 74 corresponding, matched, asymptomatic control students were included in the study. The frequency of rotavirus in stools was determined by electron microscopy with use of the pseudoreplica technique. Twenty-five percent of those who were ill and 12% of the controls had rotavirus in their stools. A significantly (P less than 0.05) greater number of newly arrived United States summer students with diarrhea had rotavirus in their stool than did matched controls (26% vs. 3%). There was no significant difference in rate of recovery of bacterial pathogens from rotavirus-positive and rotavirus-negative stools (52% vs. 53%) from students with diarrhea. Although significantly more rotavirus was identified from ill American summer students than from controls, the role of rotavirus as a cause of diarrhea in these students could not be established in all cases since bacterial pathogens were also commonly found in stool.     

Prevalence of rotavirus diarrhea among outpatients and hospitalized patients: a comparison

The prevalence of rotavirus diarrhea was compared in two settings, among children attending outpatient clinics and those hospitalized (inpatients) at Pune, India. A total of 489 and 628 fecal specimens were collected during October 1993 to September 1996 from outpatients and inpatients respectively. Overall occurrence of rotavirus diarrhea was more among hospitalized children. Using the stratification on the variable age, it is shown that age is indeed a confounding variable. The important finding of the study was, in < or = 6 months age group, it was observed that the occurrence of rotavirus diarrhea was more in the outpatients (30.26%) than among the inpatients (10.11%). Children of this age group are likely to be partially protected by maternal antibodies. The effect of seasonality and sex distribution did not differ in the two settings. It was found that G2 serotype was the major cause of diarrhea among the outpatients.