A case series of infectious complications in medical tourists requiring hospital admission or outpatient home parenteral therapy

BACKGROUND

Travelling for medical care is increasing, and this medical tourism (MT) may have complications, notably infectious diseases (ID). We sought to identify MT-related infections (MTRIs) in a large Canadian health region and estimate resulting costs.

METHODS

Retrospective and prospective capture of post-MT cases requiring hospital admission or outpatient parenteral antimicrobial therapy was completed by canvassing ID physicians practising in Calgary, Alberta, from January 2017 to July 2019. Cost estimates for management were made with the Canadian Institute for Health Information's (CIHI's) patient cost estimator database tool applied to estimated rates of Canadians engaging in MT from a 2017 Fraser Institute report.

RESULTS

We identified 12 cases of MT-related infectious syndromes. Eight had microbial etiologies identified. MTs were young (mean 40.3 [SD 12.2] y) and female (n = 11) and pursued surgical treatment (n = 11). Destination countries and surgical procedures varied but were largely cosmetic (n = 5) and orthopaedic (n = 3). Duration to organism identification (mean 5.3 wk) and treatment courses (mean 19 wk) appeared lengthy. CIHI cost estimates for management of relevant infectious complications of our cases ranged from $6,288 to $20,741, with total cost for cases with matching codes (n = 8) totalling $94,290.

CONCLUSIONS

In our series of MTRIs, etiologic organisms often found in Canadian-performed post-procedural infections were identified, and prolonged treatment durations were noted. Young women pursuing cosmetic surgery may be a population to target with public health measures to reduce the incidence of MTRIs and burden of disease.

Idiopathic granulomatous mastitis: a mimicking disease in a pregnant woman: a case report

Background

Idiopathic granulomatous mastitis is a rare, benign, inflammatory chronic condition of unclear etiology.

This case is reported because it illustrates how idiopathic granulomatous mastitis can mimic other diseases, making it difficult to associate the presenting symptoms and the correct diagnosis; This disease is a challenge for clinicians to diagnose, manage and avoid iatrogenic complications, and requires consultation with experts in several specialties.

Case presentation

The patient was 30 years old, South-American, eleven weeks pregnant, and with an apparent infectious mastitis. She presented with progressive worsening of her breast symptoms and multiple negative laboratory tests. She suffered different side effects from several prescribed treatments and endured a prolonged recovery. The article emphasizes the need for ruling out common pathologies to arrive at the correct diagnosis such as bacterial and fungal infections; granulomatous conditions like tuberculosis and sarcoidosis; and inflammatory breast carcinoma. It also describes frequently used pharmacological and supplementary forms of treatment for patients with this condition.

Conclusion

Idiopathic granulomatous mastitis is a rare unusual condition of unknown etiology. Pathological confirmation is required for its diagnosis and optimal management is still unclear. The presentation and management of this case is intended to advance its awareness to physicians from different specialties.

Physician adoption of an information system in an integrated health region

We describe the strategies used to engage organizational and physician leadership through design, preparation, and support to achieve an inpatient Computerized Physician Order Entry (CPOE) rate over 70% by 1,700 physicians.

Is anybody managing the store? National trends in hospital performance

Nine standardized measures compiled from Medicare data show trends in the safety, quality, financial management, and efficiency for more than 2,500 community hospitals over five years ending in 2003. Although much public attention has been given to hospital performance, along with exhortations to improve, few measures show substantial positive trends, either in variance reduction or overall improvement. The authors conclude that environmental forces are not stimulating improvement and that the overall picture is one of randomness rather than management.

Practising physician's knowledge and patterns of practice regarding the asplenic state: the need for improved education and a practical checklist

OBJECTIVE

To examine physicians' knowledge and actions regarding the asplenic state and to develop a practical checklist to aid in the systematic education and management of asplenic patients.

DESIGN

A prospective cohort survey utilizing an experienced nurse practitioner and a survey questionnaire with on-site interviews.

SETTING

The Okanagan Valley, British Columbia.

SUBJECTS

A cohort of 122 physicians serving a population base of 350,000.

MAIN OUTCOME MEASURES

Beliefs and practices relating to vaccination and precautions necessary for adult and pediatric splenectomized patients.

PRINCIPAL RESULTS

The majority of physicians appeared to be knowledgeable about potential conditions affecting splenic function, except in the case of severe liver disease with portal hypertension and collagen vascular disease. There appeared to be good understanding on the part of most physicians of the risks associated with various infectious diseases and the asplenic state, except in the case of Capnocytophaga canimorsus infection linked to dog bites and the increased susceptibility of asplenic patients to intraerythrocytic parasites. Although a majority of physicians were cognizant of the need for pneumococcal vaccination and other immunizations in adults, there was marked uncertainty in relation to the need and the appropriate time interval for revaccination. In the case of children there appeared to be uncertainty regarding the role of antibiotic prophylaxis. There were discrepancies between physicians' expressed attitudes and the actions actually taken for asplenic patients in individual practices.

CONCLUSIONS

Further education is required concerning the management of asplenic patients. The systematic use of a practical checklist may facilitate this process.

Pneumococcal vaccine administration associated with splenectomy: the need for improved education, documentation, and the use of a practical checklist

An audit was performed of the documentation of pneumococcal vaccination in splenectomy patients in three major hospitals involving a geographical population base of 350,000 patients in British Columbia, Canada. Overall, 111 of the 164 hospitalized splenectomy patients (68%) had received pneumococcal vaccination. Of elective splenectomy cases, only 11 of 55 (20%) had been vaccinated prior to surgery, as is currently recommended. One hundred fifty-five patients (95%) had splenectomy status mentioned in the discharge summary. However, only 35 (21%) had mention of vaccination status, 10 (6%) mention of the need for future revaccination, and only 8 (5%) notation of the possibility of future infectious risks. The rate of pneumococcal vaccination was as satisfactory as any reported in the literature to date. However, there is need for improved education in relation to the timing of vaccination and discharge summary documentation. A checklist for potential splenectomy patients may aid in improving this situation as may geographically based splenectomy registries.

Accurate and differential quantitation of HIV-1 tat, rev and nef mRNAs by competitive PCR

An accurate method is described for measuring the relative abundance of HIV-1 regulatory mRNAs directly in clinical specimens. Specimen RNA is reverse transcribed and coamplified with a common competitor containing tat, rev and nef internal standards using fluorescent primers and a competitive polymerase chain reaction. After amplification, individual products are separated and analyzed on a fluorescent DNA sequencer. Using this approach, it was possible to measure reproducibly two-fold differences in the relative abundance of mRNAs with coding potential for tat, rev and nef from as little as 0.2 ng of total RNA extracted from peripheral blood mononuclear cells of HIV-1 infected persons. The ratio method eliminates the need to account for variability in RNA recovery during sample processing and provides a powerful tool for measuring the differential expression of HIV-1 regulatory genes in vivo.