Permanent pacemaker use after cardiac transplantation: completing the audit cycle.

OBJECTIVE: To determine the effects of delaying permanent pacemaker implantation in cardiac transplant recipients from less than tree weeks to three weeks or more post transplantation-a change prompted by an earlier audit. DESIGN: Retrospective review of resting 12 lead electrocardiograms and prospective 24 hour ambulatory electrocardiograms. Comparison of pacemaker usage before (period 1) and after (period 2) the policy change in November 1990. SETTING: Outpatient department, supra-regional cardiopulmonary transplant unit. PATIENTS: All 30 consecutive orthotopic cardiac transplant recipients who received a permanent pacemaker within one month of transplantation between May 1985 and August 1995. MAIN OUTCOME MEASURES: Presence of pacing on the 12 lead electrocardiogram and during 24 hour ambulatory electro-cardiogram monitoring (pacemaker programmed to 50 beats per minute). RESULTS: 16/152 (10.5%) cardiac transplant recipients received permanent pacemakers in period 1 compared with 14/180 (7.8%) in period 2 (P = NS). Evidence of pacing was seen on 12 lead electrocardiograms at three months in 37.5% recipients in period 1 compared with 78.6% in period 2 (P = 0.03). At six months pacemaker usage had declined to 18.8% in period 1 and 35.7% in period 2 and at three years to 13.3% in period 1 and 40% in period 2 (P = NS for both). 21% patients in period 1 paced on ambulatory 24 hour monitoring compared with 38.5% in period 2 (P = NS). CONCLUSIONS: Delaying permanent pacemaker implantation to three weeks or more after cardiac transplantation reduced the proportion of permanent pacemaker implantations, slightly but not significantly. There was a significant increase in permanent pacemaker usage at three months post transplantation with trends towards increased usage at later times, suggesting more appropriate selection of patients for permanent pacing.     

Analysis of Hospitalizations for COPD Exacerbation: Opportunities for Improving Care

ABSTRACT

Background: Little is known about the actual treatment of patients with chronic obstructive pulmonary disease (COPD), either in the inpatient or outpatient settings. We hypothesized that there are substantial opportunities for improvement in adherence with current guidelines and recommendations. Methods: We reviewed the medical records of all patients hospitalized with acute exacerbation of COPD between January 2005 and December 2006 at 5 New York City hospitals. Results: There were 1285 unique patients with 1653 hospitalizations. Of these 1653, 83% were for patients with a prior history of COPD and 368 (22%) represented repeat admissions during our study period. The majority were treated during their hospitalization with a combination of systemic steroids (85%), bronchodilators (94%) and antibiotics (80%). There were 59 deaths (3.6%). Smoking cessation counseling was offered to 48% of active smokers. Influenza and pneumococcal vaccines were administered to half of eligible patients. On discharge, only 46.0% were prescribed maintenance bronchodilators and 24% were not prescribed any inhaled therapy. Even in the 226 unique patients (17.6%) readmitted at least once during course of the study, on discharge only 44.7% were prescribed maintenance bronchodilators and 23% were not prescribed any regular inhaled therapy. Conclusions: Patients hospitalized with acute exacerbation of COPD generally receive adequate hospital care, but there may be opportunities to improve care pharmacologically and with smoking cessation counseling and vaccination during and after hospitalization.     

Survey of H2-antagonist usage in acute upper gastrointestinal hemorrhage

H2-antagonists are frequently used in the management of upper gastrointestinal (UGI) hemorrhage despite their lack of proven efficacy. In order to determine the pattern of H2-antagonist usage for this indication, we retrospectively reviewed the charts of 137 patients admitted with acute UGI bleeding over a 1-year period at two teaching hospitals in West Texas. An H2-antagonist was ordered in 89% of patients (77%) intravenous, 12% oral). It was administered within 2 h of admission in 25% of these patients, within 4 h in 54%, and within 8 h in 78%. An H2-antagonist was ordered among the initial six orders in 49% and among the initial 10 orders in 77% of patients. Considering orders for specific therapies, an H2-antagonist was in the initial three orders in 60% of patients and among the initial six orders in 97%. Of the patients who were prescribed an H2-antagonist and who also had upper endoscopy, the drug was ordered prior to endoscopy in 86%. This review of H2-antagonist usage in the management of acute UGI bleeding has identified a prescribing pattern of writing for these drugs early in the sequence of order writing, with the drugs being given early in the course of hospitalization.     

Acute myocardial infarction associated with high dose intravenous immunoglobulin infusion for autoimmune disorders. A study of four cases

OBJECTIVE: To report on four patients with autoimmune disorders who developed acute myocardial infarction (MI) during or soon after treatment with high dose intravenous immunoglobulins (IVIG) and to determine the clinical profile of patients prone to this complication. METHODS: The clinical history of the four patients is reported with details concerning age, sex, indication for IVIG treatment, risk factors, timing of the MI and outcome. The relevant medical literature has been reviewed. RESULTS: The patients, three men and one woman, aged 42-67, received IVIG treatment for different autoimmune disorders. All had a history of atherosclerosis or previous risk factors such as hypertension, stroke, hyperlipidaemia and obesity. Two of the patients suffered a MI after the first infusion of IVIG while the others-after the 5th and 15th pulses. MI occurred during the infusion in two patients and after a few days in the others. All the patients recovered from the acute event. These observations are in concert with sporadic cases of IVIG related thrombosis reported in the medical literature. CONCLUSION: In patients with vascular risk factors such as old age, hypertension, history of stroke or coronary artery disease, the possibility of IVIG related vascular complications should be considered and IVIG prescribed with a cautious reweighted risk/benefit consideration.     

Patients' perceptions of blood transfusion risks in Karachi, Pakistan.

OBJECTIVE: To evaluate the understanding of and attitudes toward risks of blood transfusions among transfusion recipients in Karachi. METHODS: One hundred forty-one transfusion recipients from 13 major Karachi hospitals were interviewed. Indications for transfusion were obtained by reviewing the patients' medical records. RESULTS: The most common indications for transfusion were surgical complications (n = 77, 55%), anemia (n = 34, 24%), and generalized weakness (n = 15, 11%). Most recipients (n = 103, 80%) had never heard of viral hepatitis, and 44 (31%) had never heard of acquired immunodeficiency syndrome (AIDS). Ninety-four recipients (66%) believed that generalized weakness was a valid indication for blood transfusion. Sixty-nine recipients (49%) were not willing to pay an increased price for blood that was screened for blood-borne pathogens. CONCLUSIONS: Blood recipients in Karachi are unaware of the risks of transfusions, and the reasons given by the ordering physician for many of the transfusions were not consistent with international guidelines. Steps to educate the public about the risks of transfusions and practitioners about the indications for transfusion could prevent blood-borne virus transmission in Karachi.     

Pharmacological profile of survivors of acute myocardial infarction at Turkish academic hospitals

AIM: The purpose of this study was to document treatment profiles in 850 patients surviving acute myocardial infarction at 17 academic hospitals in Turkey. METHODS AND RESULTS: Pharmacological management data of acute myocardial infarction survivors were collected and divided into three categories: drugs which patients received before hospitalization, during the hospitalization, and at hospital discharge. Data regarding medical history, complications during hospitalization, MI extent (Q wave or non-Q wave), infarct location and diagnostic and revascularization procedures were also recorded. This study is based on the 850 patients who met the diagnostic criteria for initial acute MI in the period examined. Among 850 patients with myocardial infarction enrolled 408 (48%) received thrombolytic therapy. The median time interval from symptom onset to initiation of thrombolytic therapy was 196 min. The most commonly used thrombolytic agent was streptokinase (93%). Thrombolytic recipients were younger, and presented sooner after onset of symptoms. Among patients receiving thrombolytic therapy, concomitant pharmacotherapy included aspirin (95%), intravenous heparin (93%), intravenous nitroglycerin (91%), oral beta-blockers (44%), calcium channel antagonists (13%), and angiotensin converting enzyme inhibitors (41%). The lipid lowering therapy was only used in 4% of all patients, and was given to 18% of patients with hyperlipidemia. CONCLUSION: Current usage rates of thrombolytic therapy in Turkey are lower than expected, but when compared with previous reports it increased. Although adjunctive treatment with intravenous heparin and intravenous nitroglycerin is usually used, beta-blockers appear to be underused and calcium channel blockers appear to be overused. The lipid reducing therapies were infrequently prescribed.     

Results and long-term followup of intravenous immunoglobulin infusions in chronic, refractory polymyositis: an open study with thirty-five adult patients

OBJECTIVE: Polymyositis is a rare inflammatory muscular disease of unknown cause. Corticosteroids and immunosuppressive drugs are the first choice of therapy but are not always effective and may cause serious side effects. Many studies have shown that polyvalent intravenous immunoglobulin (IVIG) may be of interest for the treatment of dermatomyositis. We carried out an open, prospective study to evaluate the efficacy of IVIG in subjects with polymyositis that was refractory to traditional treatments, and we evaluated the benefits of this therapy over a long-term period of followup. METHODS: Thirty-five adult white patients (20 female, 15 male, mean age 43.5 years [SD 16.8]) with chronic, refractory polymyositis were treated with high doses of IVIG, after the patients had received the following traditional treatments: prednisone (n = 35), methotrexate (n = 24), azathioprine (n = 13), cyclophosphamide (n = 4), cyclosporine (n = 7), chlorambucil (n = 1), plasmapheresis (n = 8), lymphopheresis (n = 1), and total body irradiation (n = 1). There had been no changes in the patients' treatment in the 2 months before the initiation of IVIG therapy, and doses were not increased during IVIG treatment. We used preparations of polyvalent human IVIG with increased concentrations of intact IgG. The patients received 1 gm/kg/day for 2 consecutive days per month. The mean course of treatment was 4-6 months. The clinical assessment involved the evaluation of proximal muscle power, muscle disability scale score, and esophageal disorders. The biochemical evaluations carried out before each treatment period were compared by Student's t-test and nonparametric Wilcoxon test. Results were considered to be significant at P = 0.05. RESULTS: In the short-term, significant clinical improvement was noted in 25 of the 35 patients (71.4%). Mean muscle power was estimated before and after IVIG therapy and was found to be significantly improved (P < 0.01). All patients had a significant biochemical response. Mean creatine kinase levels during IVIG therapy decreased significantly before the fourth IVIG perfusion (P < 0.01). Side effects, usually minor, were noted in 6 patients. This benefit allowed the initial prednisone dose to be reduced by >50% in all patients. The mean (+/- SD) followup time for the 25 patients who responded favorably to IVIG treatment was 51.4 +/- 13.1 months. Twelve of these 25 patients remained in full remission following their initial course of IVIG, resulting in complete stoppage of medication in 5 patients or low doses of steroids in 7 patients. The condition of 6 patients remained improved and no other drugs were prescribed, but the patients remained dependent on IVIG infusions. Seven of the 25 patients who responded well to IVIG treatment relapsed at an average of 17.1 months (range 4-23 months) after the discontinuation of IVIG. CONCLUSION: IVIG is an interesting therapy for the treatment of polymyositis, with results showing that the condition of approximately 70% of the patients tested improved. After the discontinuation of the IVIG therapy, the efficacy remained stable in 50% of the patients, with a followup of over 3 years.     

Risk factors for symptomatic hypocalcaemia complicating treatment with zoledronic acid

Background: The bisphosphonate zoledronic acid is commonly prescribed to prevent skeletal complications in patients with multiple myeloma or metastatic cancer. Although symptomatic hypocalcaemia is a potential risk of treatment, it has been thought to be uncommon. Aims: After seeing several episodes of symptomatic hypocalcaemia following zoledronic acid administration, we undertook a review to determine the incidence of this complication in our population and to attempt to identify risk factors. Methods: We reviewed the records of all patients receiving zoledronic acid in two teaching hospitals over a 2‐year period. Findings collected included the indication for treatment, whether dosing was adjusted for creatinine clearance, coadministered medications, serum chemistries and clinical course. Results: Of 120 patients who received a total of 546 zoledronic acid infusions, hypocalcaemia developed related to 55 infusions (10%) in 42 patients (35%). Symptomatic hypocalcaemia requiring i.v. supplementation occurred in 10 patients (8%), in spite of appropriate dose adjustment for creatinine clearance and despite prophylactic administration of oral calcium and vitamin D. More patients who became hypocalcaemic developed impairment of creatinine clearance during zoledronic acid treatment than in the group that remained normocalcaemic. Hypomagnesaemia was found in all patients who developed hypocalcaemia who had serum magnesium measured. Conclusions: Hypocalcaemia was common in our patient group following zoledronic acid treatment. Because of the prolonged elimination half‐life of this agent (146 h), renal impairment occurring during a number of days after administration may increase risk. Hypomagnesaemia may further increase risk by blunting compensatory increase in parathyroid hormone secretion.     

Respiratory syncytial virus upper respiratory tract illnesses in adult blood and marrow transplant recipients: combination therapy with aerosolized ribavirin and intravenous immunoglobulin

Respiratory syncytial virus (RSV) is an important cause of serious respiratory illness in blood and marrow transplant (BMT) recipients. In some subsets of these immunocompromised patients, RSV upper respiratory illnesses frequently progress to fatal viral pneumonia. The frequency of progression to pneumonia is higher during the pre-engraftment than during the post-engraftment period. Once pneumonia develops, the overall mortality is 60-80%, regardless of the treatment strategy. We performed a pilot trial of therapy of RSV upper respiratory illnesses using aerosolized ribavirin and IVIG (500 mg/kg every other day), with the goal of preventing progression to pneumonia and death. Two dosages of ribavirin were used: a conventional regimen (6 g/day at 20 mg/ml for 18 h/day) and a high-dose short-duration regimen (6 g/day at 60 mg/ml for 2 h every 8 h). Fourteen patients were treated for a mean of 13 days (range: 7-23 days). In 10 (71%) patients, the upper respiratory illness resolved. The other four (29%) patients, three of whom were in the pre-engraftment period, developed pneumonia, which was fatal in two. The most common adverse effect was psychological distress at being isolated within a scavenging tent. In conclusion, prompt therapy of RSV upper respiratory illnesses in BMT recipients with a combination of aerosolized ribavirin and IVIG was a safe and promising approach to prevent progression to pneumonia and death.     

Recipients of hip replacement for arthritis are less likely to be Hispanic, independent of access to health care and socioeconomic status

OBJECTIVE: To compare the proportion of Hispanics among recipients of hip replacements for primary articular disorders, recipients of knee replacements for the same reason, and persons hospitalized for other reasons. METHODS: Twelve of the 17 accredited hospitals in Bexar County, Texas, in which hip or knee replacement surgery is performed permitted us to review their medical records. From 1993 through 1995, 3,100 elective, non-fracture-related, hip or knee replacements were performed. These individuals were matched by age, sex, hospital, and month of admission with 4,604 persons hospitalized for other reasons. Age, sex, ethnic background, type of medical insurance, median household income by zip code of residence, joint replaced, and surgical diagnosis were abstracted from the medical records. The validity of variables abstracted from the medical records was tested by comparison with self-report data in 115 patients interviewed prior to elective hip or knee replacement surgery. RESULTS: During the study period, 2,275 subjects had a total knee replacement and 825 had a total hip replacement. Recipients of hip replacements were significantly less likely to be Hispanic than were recipients of knee replacements (19.5% versus 29.9%; odds ratio [OR] 0.57, 95% confidence interval [95% CI] 0.46-0.71; P < or = 0.001) or persons hospitalized for other reasons (29.4% Hispanic; OR 0.67, 95% CI 0.55-0.81). The under-representation of Hispanics was more pronounced among persons undergoing hip replacement for osteoarthritis compared with recipients of knee replacements for the same disease (OR 0.48, 95% CI 0.37-0.62). This pattern persisted after adjusting for age, sex, type of medical insurance, and median household income by the zip code of residence. Concordance between medical records and self-report data on ethnic background was high (kappa = 0.93). CONCLUSION: Recipients of hip replacement are less likely to be Hispanic than are other hospitalized persons with a similar level of access to care. The reasons for this under-representation probably involve factors in addition to lack of access to health care and low socioeconomic status. Further research is needed to understand the nature of such factors.     

Public Health Laboratory Service surveillance of prophylaxis by specific hepatitis B immunoglobulin in England and Wales during the period 1975-1987

Surveillance of specific hepatitis B prophylaxis given after accidental or sexual exposure was continued throughout the period 1975-1987 by keeping records of exposures and ascertaining acute attacks of hepatitis B by postal enquiry. Acute hepatitis B developed in 53 (0.6%) of 9370 recipients of prophylaxis; the highest rate (3.7%) was among 564 sexually exposed, 0.9% among 2056 accidentally inoculated and 0.2% among 5747 persons who had other skin or minor exposures affecting the mucous membranes. There were no cases among 1003 recipients whose exposures did not meet the criteria for prophylaxis. None of the 53 patients died and only one of the 44, for whom sickness records were completed, reported a severe attack. Comparisons of six attacks among 623 who had inoculation injuries with material tested for hepatitis 'e' antigen and antibody gave no indication of better protection by early prophylaxis or by a two-dose schedule.     

Mechanical ventilation in children with severe asthma

Hospital admissions for childhood asthma have increased during the past few decades. The aim of this study was to describe the need for mechanical ventilation for severe asthma exacerbation in children in Finland from 1976 to 1995. We reviewed medical records and collected data retrospectively from all 5 university hospitals in Finland, thus covering the entire population of about 5 million. The endpoints selected were the number of admissions and readmissions leading to mechanical ventilation, duration of stay in the hospital, and mortality. Moreover, asthma medications prescribed prior to admission and administered in the intensive care unit (ICU), as well as the etiology of the exacerbation associated with mechanical ventilation were examined. Mechanical ventilation was required in 66 ICU admissions (59 patients). This constituted approximately 10% of all 632 admissions for acute asthma to an ICU. The number of admissions decreased from 1976 to 1995: 41 admissions between 1976 and 1985 vs. 25 admissions during the next 10-year period. The mean age at admission to the ICU was 3.6 years, and 46% of the patients were boys. Prior to the index admission, 70% of the patients had used asthma medication such as oral bronchodilator (50%), inhaled bronchodilator (20%), theophylline (38%), inhaled glucocorticoid (18%), oral glucocorticoid (5%), and cromoglycate (7%). Respiratory infection was by far the most common cause of all the exacerbations (61%), followed by food allergy (8%) and gastroesophageal reflux (3%). In 28% of cases the cause of the severe asthma exacerbation could not be identified. In the mechanically ventilated patients readmissions occurred 38 times between 1976 and 1985 vs. 5 times between 1986 and 1995. Five of the patients who received mechanical ventilation died, and in 3 of these patients asthma was the event causing death. In conclusion, there has been decrease in the number of first and repeat ICU admission for asthma requiring mechanical ventilation between 1970 and 1995. This trend occurred despite a simultaneous 5% yearly increase in hospital admissions for childhood asthma during these 2 decades.     

Subcutaneous immunoglobulin in allogeneic hematopoietic cell transplant patients: A prospective study of feasibility,safety, and healthcare resource use

BackgroundWe evaluated feasibility, safety, and total resource use of subcutaneous immunoglobulin (SCIG) in a pilot study of patients who underwent allogeneic hematopoietic cell transplant (HCT) over a 6-month period.MethodsA total of 20 eligible patients were treated with SCIG at 0.1 g/kg/week for up to 6 months. Patients were matched to 20 concurrent intravenous immunoglobulin (IVIG) controls. Clinical outcomes measured included adverse reactions, healthcare resource use, patient satisfaction, and quality of life (QOL). (ClinicalTrials.gov Identifier: NCT03401268.)ResultsGroups were comparable in terms of age, weight, sex, transplant indication, donor type, and conditioning intensity. All 20 IVIG patients completed 6 consecutive months of therapy compared with 13/20 (65%) SCIG patients. There were no adverse reactions in IVIG patients, compared with six (30%) SCIG patients. All adverse reactions in SCIG patients were grade I, transient, and required no medical intervention. Median overall cost per patient was lower with SCIG than with IVIG ($9,756 vs. $13,780, p = .046). Among patients who completed 6 months of SCIG, median preference and satisfaction scores were 100%. Over the 6-month period, QOL scores remained stable in SCIG patients.ConclusionsIn a subgroup of patients, SCIG was associated with high patient satisfaction and a reduction in total healthcare costs compared with IVIG in a cohort of HCT patients.     

Beta blocker prescribing differences in patients with and without diabetes following a first myocardial infarction.

AIMS: To document the prescribed usage of beta blockers in patients with and without diabetes mellitus discharged from hospital following a first myocardial infarction. METHODS: All patients with diabetes and a group of patients matched for age and sex without diabetes, admitted with a documented first myocardial infarction during the period 1995-1999 at the Royal Liverpool University Hospital, Liverpool, UK were audited. RESULTS: Data were available on 201 patients with diabetes and 199 patients without diabetes. No significant differences existed between the diabetic and non-diabetic groups for age and sex. Twenty-three per cent of patients with diabetes were prescribed a beta blocker compared to 52% of non-diabetic patients (P < 0.01). Patients with diabetes had a higher frequency of perceived contraindications than patients without diabetes (36 vs. 27%, P < 0.001). Thirty-five per cent of patients with diabetes and 18% of non-diabetic patients had no contraindication to the use of beta blocker but were not prescribed one (P < 0.001). CONCLUSIONS: Although beta blockers can provide useful benefits in patients with diabetes following a myocardial infarction, this study suggests that a significant proportion of patients with diabetes and without a contraindication to treatment are still not receiving beta blockers after myocardial infarction.     

The cost of treating immune thrombocytopenic purpura using intravenous Rh immune globulin versus intravenous immune globulin

Multiple factors, including efficacy, toxicity and cost, may influence the decision to treat immune thrombocytopenic purpura (ITP) with intravenous immune globulin (IVIG) or intravenous Rho (D) immune globulin (IV RhIG). We conducted a survey of 50 hospitals in 31 states to determine the costs for treating ITP using conventional doses for IVIG or IV RhIG, based on package insert recommendations. The average cost for a dose of IVIG ($2,771) was 71.7% ($1,157) more than that for a dose of IV RhIG ($1,614). In the absence of clearly defined differences in clinical outcomes when treating ITP with IVIG or IV RhIG, the difference in cost may be an important factor in selecting the treatment.     

One drug or two? Step‐down therapy after i.v. antibiotics for community‐acquired pneumonia

Background: The aim of the study was to describe the oral antibiotics prescribed as step‐down therapy for patients hospitalized for community‐acquired pneumonia (CAP). Methods: A comparative audit of patient records in a Sydney teaching hospital, a district referral hospital and a regional hospital was carried out. Patients older than 15 years admitted between 1 July 2004 and 31 December 2004 with a diagnosis of CAP were identified by diagnostic code. The medical records were reviewed for patient demographics, the specialty of the attending physician, comorbidities, adverse drug events, relevant microbiological results and the antibiotic therapy prescribed for the treatment of pneumonia. Cases were randomly selected from all pneumonia admissions, with approximately equal numbers from urban and regional hospitals. One hundred and ninety‐six admissions for CAP (in 193 patients) were included in this review. Patients were predominantly cared for by respiratory physicians (62%) and geriatricians (14%). Eighty‐nine per cent of patients received dual antibiotic therapy on admission. Results: For patients commenced on two antibiotics, 62% were prescribed two oral antibiotics after completing i.v. therapy, 27% were prescribed one oral agent and 11% were prescribed no step‐down therapy. Geographic location and the presence of a documented antibiotic allergy affected prescribing practice. Neither the specialty of the attending medical officer nor the identification of a likely pathogen affected prescribing practice. Conclusion: Although most of the patients with CAP were initially prescribed two antibiotics, there was considerable variability in whether one, two or no oral agents were prescribed as step‐down therapy.