A review of topical corrosive black salve

Black salve is a compound derived from various inert ingredients, but it can be transformed into a corrosive ointment by the addition of bloodroot (Sanguinaria canadensis) or zinc chloride. Black salve products have been advertised as a natural remedy for many ailments, ranging from bee stings to skin cancer. This article reviews the current literature surrounding this compound, which in its corrosive form can be dangerous for use without medical supervision. Patients should be educated about the lack of objective evidence supporting the clinical efficacy of black salve as a skin cancer treatment, as well as the possible cosmetic defects resulting from tissue necrosis secondary to the effects of bloodroot and zinc chloride.

Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections

Clostridium difficile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratified depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mild-to-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classification of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI.

A teledermatology care management protocol for tracking completion of teledermatology recommendations

In July 2009 we implemented a 3-year store-and-forward teledermatology project to provide dermatology care to veterans living in rural and underserved areas of the US Pacific Northwest. We also developed a follow-up protocol and tracking system. Information about all completed teledermatology consultations was entered into a database, and major procedures and select medications were tracked. In the first 21 months, 8202 dermatology conditions in 5232 veterans were treated and 3370 major procedures carried out. Ninety-five percent of conditions were associated with no more than two teledermatology consultations, and no condition required more than ten consultations. In total, 1454 conditions were reviewed for clinical pathological correlation, and in 310 (21%) there was a subsequent clinical pathological correlation conference, resulting in a change in final diagnosis for 93 conditions. The follow-up was important in ensuring high quality patient care.

Is primary prevention of Clostridium difficile infection possible with specific probiotics?

BACKGROUND

The efficacy of probiotics for the prevention of Clostridium difficile infection (CDI) is highly controversial, particularly with regard to the prevention of recurrent CDI. We hypothesize that primary prevention of CDI among patients receiving antibiotics might be a more achievable goal for probiotics than prevention in patients with previous CDI where the host flora is markedly altered.

METHODS

We conducted a literature search for randomized, placebo-controlled efficacy studies of probiotic use among adults receiving antibiotics, in which CDI was one of the outcomes measured. In addition, we conducted meta-analyses of probiotics that were included in more than one randomized trial.

RESULTS

Eleven studies were identified; most were seriously underpowered to determine the efficacy of probiotics in the prevention of CDI. Two showed significantly lower rates of CDI among the probiotic recipients. A meta-analysis of three studies that used the probiotic combination Lactobacillus acidophilus CL1285 and Lactobacillus casei LBC80R and a combined analysis of those studies with four studies that used Saccharomyces boulardii, showed lower CDI rates in recipients of probiotics compared with recipients of placebo (risk ratio=0.39; 95% confidence interval 0.19-0.79).

CONCLUSIONS

While potential flaws in study design were identified, a review of the available literature suggests that the primary prevention of CDI with specific probiotic agents may be achievable. Additional studies of sufficient size and with rigorous design are needed to confirm these findings.

Implementation of an education and skills programme in a teledermatology project for rural veterans

In July 2009 we implemented a store-and-forward teledermatology project to provide dermatology care to veterans living in underserved rural areas of the Pacific Northwest region of the US. We also developed an educational programme for rural primary care providers and imaging technicians. Participants were tested and their competencies were assessed at baseline and during a two-year project. Participation in a comprehensive education programme improved the knowledge of dermatology diagnosis and treatment care plans. All of the providers were performing dermatology procedures (e.g. biopsies, excisions, cauteries) after two years and more patients were being seen at their rural clinics than when the teledermatology project began (85% vs 39%). After two years, 71% of the providers and 56% of the imaging technicians had completed surgical training sessions and all passed their competency assessments. The educational component of the teledermatology project created teams of primary care health-care providers and imaging technicians with improved dermatology educational levels and new dermatology skills.

Alcohol consumption among urban, suburban, and rural Veterans Affairs outpatients

PURPOSE

United States rural residents tend toward poorer health than urban residents. Although alcohol use is associated with multiple medical conditions and can be reduced via brief primary care-based interventions, it is unknown whether alcohol consumption differs by rurality among primary care patients. We sought to describe alcohol consumption among urban, suburban, and rural Veterans Affairs (VA) outpatients.

METHODS

Outpatients from 7 VA facilities responded to mailed surveys that included the validated Alcohol Use Disorders Identification Test Consumption (AUDIT-C) screening questionnaire. The ZIP code approximation of the US Department of Agriculture's rural-urban commuting area (RUCA) codes classified participants into urban, suburban, and rural areas. For each area, adjusted logistic regression models estimated the prevalence of past-year abstinence among all participants and unhealthy alcohol use (AUDIT-C ≥ 3 for women and ≥ 4 for men) among drinkers.

FINDINGS

Among 33,883 outpatients, 14,967 (44%) reported abstinence. Among 18,916 drinkers, 8,524 (45%) screened positive for unhealthy alcohol use. The adjusted prevalence of abstinence was lowest in urban residents (43%, 95% CI 42%-43%) with significantly higher rates in both suburban and rural residents [45% (44%-46%) and 46% (45%-47%), respectively]. No significant differences were observed in the adjusted prevalence of unhealthy alcohol use among drinkers.

CONCLUSIONS

Abstinence is slightly more common among rural and suburban than urban VA outpatients, but unhealthy alcohol use does not vary by rurality. As the VA and other health systems implement evidence-based care for unhealthy alcohol use, more research is needed to identify whether preventive strategies targeted to high-risk areas are needed.

Department of Veterans Affairs compensation and medical care benefits accorded to veterans with major limb loss

Veterans injured in theaters of combat operations are eligible for benefits, including medical care and compensation. This article describes veterans with service-connected disability for major lower- and/or upper-limb loss resulting from combat-field-associated injuries sustained in the Vietnam war, Operation Desert Shield/Operation Desert Storm, and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF). Using the Department of Veterans Affairs (VA) Compensation and Pension Mini-Master file, we identified 2,690 veterans who in August 2007 received compensation for loss of one or more limbs. More than 97% sustained their injuries in Vietnam; most were young men who served in the U.S. Army or Marine Corps. All but 5% had at least 50% combined service-connected disability and nearly half had a 100% rating. In addition to limb loss, one of the most prevalent compensable conditions was posttraumatic stress disorder, present in 46% of OIF/OEF and 20% of Vietnam veterans. Of these veterans, 82% visited VA outpatient clinics in 2007, although only 4% were hospitalized. A special obligation exists to those who have sustained serious injuries related to combat; this responsibility extends for the life of the servicemember and beyond to his or her spouse and dependents.

Prosthetic cost projections for servicemembers with major limb loss from Vietnam and OIF/OEF

This study projects prosthetic- and assistive-device costs for veterans with limb loss from Vietnam and injured servicemembers returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) to inform the Department of Veterans Affairs (VA) for these veterans' future care. The 2005 Medicare prosthetic device component prices were applied to current prosthetic and assistive-device use obtained from a national survey of 581 veterans and servicemembers with major traumatic amputations. Projections were made for 5-year, 10-year, 20-year, and lifetime costs based on eight Markov models. Average 5-year projected costs for prosthetic and assistive-device replacement for the Vietnam group are lower than for the OIF/OEF cohort due in part to use of fewer and less technologically advanced prosthetic devices and higher frequency of prosthetic abandonment. By limb-loss level, for the Vietnam group and OIF/OEF cohort, 5-year projected unilateral upper limb average costs are $31,129 and $117,440, unilateral lower limb costs are $82,251 and $228,665, and multiple limb costs are $130,890 and $453,696, respectively. These figures provide the VA with a funding estimate for technologically advanced prosthetic and assistive devices within the framework of ongoing rehabilitation for veterans with traumatic limb loss from the Vietnam and OIF/OEF conflicts.

Multiple traumatic limb loss: a comparison of Vietnam veterans to OIF/OEF servicemembers

Multiple-limb loss due to war-theater injuries results in a unique group of servicemembers requiring intensive rehabilitation and diverse prosthetic devices. This article compares the Vietnam and the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) groups with war-theater-associated multiple-limb loss to document significant changes in health status, prosthetic-device use, and long-term prognosis. During 2007 and 2008, a national survey queried 73 Vietnam veterans and 61 OIF/OEF servicemembers sustaining multiple-limb loss. Average years since limb loss are 39 for Vietnam veterans and 3 for OIF/OEF servicemembers. Self-rated health status was excellent or very good in 38.9% of the Vietnam group and 60.7% of the OIF/OEF group (p = 0.01). More of the OIF/OEF group than the Vietnam group reported performing high-impact aerobic activities, 18% versus 3% (p = 0.005). The OIF/OEF group currently uses more diverse prosthetic-device types than the Vietnam group. Based on Vietnam veterans' 39-year experience, the long-term prognosis for OIF/OEF servicemembers with multiple-limb loss is an active, fulfilling life. The healthcare team caring for these patients should carefully address proper prosthesis fit and maintenance of good health and function.

Systematic review and meta-analysis of Saccharomyces boulardii in adult patients

This article reviews the evidence for efficacy and safety of Saccharomyces boulardii (S. boulardii) for various disease indications in adults based on the peer-reviewed, randomized clinical trials and pre-clinical studies from the published medical literature (Medline, Clinical Trial websites and meeting abstracts) between 1976 and 2009. For meta-analysis, only randomized, blinded controlled trials unrestricted by language were included. Pre-clinical studies, volunteer studies and uncontrolled studies were excluded from the review of efficacy and meta-analysis, but included in the systematic review. Of 31 randomized, placebo-controlled treatment arms in 27 trials (encompassing 5029 study patients), S. boulardii was found to be significantly efficacious and safe in 84% of those treatment arms. A meta-analysis found a significant therapeutic efficacy for S. boulardii in the prevention of antibiotic-associated diarrhea (AAD) (RR = 0.47, 95% CI: 0.35-0.63, P < 0.001). In adults, S. boulardii can be strongly recommended for the prevention of AAD and the traveler's diarrhea. Randomized trials also support the use of this yeast probiotic for prevention of enteral nutrition-related diarrhea and reduction of Helicobacter pylori treatment-related symptoms. S. boulardii shows promise for the prevention of C. difficile disease recurrences; treatment of irritable bowel syndrome, acute adult diarrhea, Crohn's disease, giardiasis, human immunodeficiency virus-related diarrhea; but more supporting evidence is recommended for these indications. The use of S. boulardii as a therapeutic probiotic is evidence-based for both efficacy and safety for several types of diarrhea.

Servicemembers and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: survey methods, participants, and summary findings

Care of veterans and servicemembers with major traumatic limb loss from combat theaters is one of the highest priorities of the Department of Veteran Affairs. We achieved a 62% response rate in our Survey for Prosthetic Use from 298 Vietnam war veterans and 283 servicemembers/veterans from Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) who sustained major traumatic limb loss. Participants reported their combat injuries; health status; quality of life; and prosthetic device use, function, rejection, and satisfaction. Despite the serious injuries experienced, health status was rated excellent, very good, or good by 70.7% of Vietnam war and 85.5% of OIF/OEF survey participants. However, many health issues persist for Vietnam war and OIF/OEF survey participants (respectively): phantom limb pain (72.2%/76.0%), chronic back pain (36.2%/42.1%), residual-limb pain (48.3%/62.9%), prosthesis-related skin problems (51.0%/58.0%), hearing loss (47.0%/47.0%), traumatic brain injury (3.4%/33.9%), depression (24.5%/24.0%), and posttraumatic stress disorder (37.6%/58.7%). Prosthetic devices are currently used by 78.2% of Vietnam war and 90.5% of OIF/OEF survey participants to improve function and mobility. On average, the annual rate for prosthetic device receipt is 10.7-fold higher for OIF/OEF than for Vietnam war survey participants. Findings from this cross-conflict survey identify many strengths in prosthetic rehabilitation for those with limb loss and several areas for future attention.

Evidence-based review of probiotics for antibiotic-associated diarrhea and Clostridium difficile infections

Probiotics are living microbes taken to confer a health benefit on the host. Although probiotics have a long history of use in Europe and Asia and have been on the U.S. market for over 14 years, there is still confusion about how to effectively use them. The use of probiotics for the prevention of antibiotic-associated diarrhea (AAD) and the treatment of Clostridium difficile infections (CDI) has been tested in randomized controlled clinical trials. This paper will review the evidence supporting probiotic therapy for these two diseases and also review the advantages and disadvantages of probiotics. The advantages of probiotic therapy include multiple mechanisms of action against pathogens, the ability to interact with the host's natural defense systems, survival to the target organ and a good risk to benefit ratio. Disadvantages of probiotics include lack of standardization for clinical trial designs, variations in regulatory standards, poor quality control for some products and infrequent serious adverse reactions. Overall, probiotics offer a promising strategy for the prevention and treatment for AAD and CDI.

Current guidelines for using angiotensin-converting enzyme inhibitors and angiotensin II-receptor antagonists in chronic kidney disease: is the evidence base relevant to older adults?

Angiotensin-converting enzyme inhibitors and angiotensin II-receptor antagonists are recommended for patients with chronic kidney disease because these drugs can slow disease progression. Older adults account for a large and growing number of patients with chronic kidney disease. The authors evaluated the relevance to adults older than 70 years of the evidence base for major U.S. practice guidelines for the use of these agents in chronic kidney disease. The authors first examined the representation of older adults in randomized trials that underpin these guidelines, then compared the characteristics of participants in these trials with those of a representative sample of older adults with chronic kidney disease in the general population. The authors found that current guidelines for the use of angiotensin-converting enzyme inhibitors and angiotensin II-receptor antagonists in chronic kidney disease are based on evidence with limited relevance to most persons older than 70 years with this condition.