Assessment of Clinical Conditions Associated With Splenic Infarction in Adult Patients

This case series examines the clinical conditions associated with splenic infarction of adult patients between 2010 and 2015 from computed tomographic imaging scans.

Charity Care Characteristics and Expenditures Among US Tax-Exempt Hospitals in 2016

Objectives. To examine content of financial assistance polices (FAPs) among US tax-exempt hospitals and determine whether restrictive policies were associated with reduced charity care spending.Methods. Using hospital tax filings with the Internal Revenue Service in 2016 and FAPs obtained from hospital Web sites, we examined characteristics of FAPs and associated expenditures for charity care in a representative sample of 170 tax-exempt hospitals. We identified common eligibility requirements and used them to define restrictiveness of FAPs.Results. FAPs were characterized by various ways to exclude patients, a patchwork of coverage for typical health care services, and wide-ranging discounts. FAP expenditures were lowest among restrictive hospitals in states that expanded Medicaid as part of the Affordable Care Act and highest among nonrestrictive hospitals in nonexpansion states. FAP expenses did not differ by hospital restrictiveness alone.Conclusions. Standardizing common eligibility requirements among FAPs carries potential benefits with regard to optimizing charity care for community benefit and achieving at least some level of equity; however, further policy efforts must account for additional restrictions, charges, and exclusions to be effective.

A Clinical Overview of Off-label Use of Gabapentinoid Drugs

BACKGROUND

The gabapentinoid drugs gabapentin and pregabalin were originally developed as antiseizure drugs but now are prescribed mainly for treatment of pain. For gabapentin, the only pain-related indication approved by the US Food and Drug Administration (FDA) is postherpetic neuralgia. For pregabalin, FDA-approved indications related to pain are limited to postherpetic neuralgia, neuropathic pain associated with diabetic neuropathy or spinal cord injury, and fibromyalgia. Despite these limited indications, gabapentin and pregabalin are widely prescribed off-label for various other pain syndromes. Such use is growing, possibly because clinicians are searching increasingly for alternatives to opioids.

OBSERVATIONS

This report summarizes the limited published evidence to support off-label gabapentinoid uses, describes clinical cases in which off-label use is problematic, and notes how review articles and guidelines tend to overstate gabapentinoid effectiveness.

CONCLUSIONS

Clinicians who prescribe gabapentinoids off-label for pain should be aware of the limited evidence and should acknowledge to patients that potential benefits are uncertain for most off-label uses.

Iron Deficiency Anemia Associated With Acid-Modifying Medications: Two Cases and Literature Review

Iron deficiency anemia is often listed among potential adverse effects of gastric acid-suppressive medications, given that gastric acidity promotes intestinal absorption of nonheme iron. Additionally, the antacid calcium carbonate can inhibit iron absorption. However, there is little direct clinical evidence that proton-pump inhibitors, histamine-2 receptor antagonists, or calcium carbonate cause iron deficiency anemia. Most case reports have had substantial limitations (e.g., minimal follow-up and presence of other causes of iron deficiency), and retrospective cohort studies have lacked sufficient patient-specific detail to make strong causal inferences. We present 2 cases-both with detailed, prospective 10-year follow-up-in which combinations of proton-pump inhibitors, histamine-2 receptor antagonists and calcium carbonate were clearly associated with development of iron deficiency anemia. Overt iron-deficiency anemia is probably uncommon in patients who use acid-modifying medications and who have no other conditions that predispose to iron deficiency. Nevertheless, clinicians should be aware of this potential complication, given widespread use of these agents.

Getting Past Words: Futility and the Professional Ethics of Life-Sustaining Treatment

For nearly three decades, clinicians and bioethicists have debated about use of the term futile to describe end-of-life medical interventions that clinicians believe are no longer warranted. In clinical practice, the term is most often invoked when a family of a dying or permanently unconscious patient insists upon such interventions, despite the medical team's belief or recommendation that they be withheld or withdrawn. This essay argues that each of the commonly used terms for these interventions (futile, inappropriate, and nonbeneficial) captures an important, different, and complementary facet of these conflicts in end-of-life medical care. Rather than continuing to debate which term is best, clinicians and bioethicists should direct their attention to the professional ethics of end-of-life care and the clinical and organizational factors that create or contribute to these so-called "futility cases."

The case against identifying carotid stenosis in asymptomatic patients

Carotid ultrasonography is performed frequently to identify carotid stenosis in patients with no history of carotid-territory cerebrovascular ischemia. The premises of such testing are that the potential benefit of endarterectomy or stenting exceeds the potential harm in patients with asymptomatic stenosis and that discovery of asymptomatic stenosis may trigger beneficial changes in lifestyle or medical management that otherwise would not have occurred. However, given low contemporary rates of stroke in medically managed patients with asymptomatic carotid stenosis, invasive carotid procedures cannot be justified in this population. Moreover, among patients at increased cardiovascular risk, there is no evidence that carotid imaging motivates behavioral change or improves risk stratification beyond consideration of conventional risk factors. In this focused review, we address topics that should help health care professionals advise patients who inquire about carotid screening and patients in whom asymptomatic carotid stenosis has already been identified. We conclude that there is currently no role for carotid imaging in patients without a history of carotid-territory stroke or transient ischemic attack.

Cardiovascular safety of long acting beta agonist-inhaled corticosteroid combination products in adult patients with asthma: a systematic review

INTRODUCTION

Long-acting beta agonists and inhaled corticosteroids combination products (LABA-ICS) are widely used in the treatment of asthma. However, there appears to be little data on their cardiovascular safety. The purpose of this study was to conduct a systematic review of the available studies and trials on the cardiovascular safety of LABA-ICS in adults with asthma.

METHODS

Two independent reviewers screened citations from PubMed and National Clinical Trials registry to identify studies and trials on the cardiovascular effects of LABA-ICS in patients with asthma.

RESULTS

A total of 15 studies (with 17 cohorts on LABA-ICS to compare with a comparator or placebo) with 5,440 total study participants met the inclusion criteria. Two studies on budesonide-formoterol and one on fluticasone-salmeterol reported treatment emergent cardiovascular adverse events, all of which were dysrhythmias. For comparison, the pooled estimate of the Peto odds ratio (0.72; 95 % confidence interval [CI] 0.17-3; p = 0.65) and the summary risk ratio (0.77; 95 % CI 0.26-2.3; p = 0.64) indicated a nonsignificant difference between LABA-ICS and comparator/placebo groups.

CONCLUSIONS

Our systematic review found that few studies and trials reported treatment emergent cardiovascular adverse events with LABA-ICS. However, the Peto odds ratio and risk ratio for these outcomes was statistically nonsignificant. This suggests that LABA-ICS products may have a safe cardiovascular profile in asthma patients.

Physicians have a responsibility to meet the health care needs of society

People often need medical care unexpectedly and through no fault of their own. Although the system of health care in the United States is seriously flawed, our beliefs and values nevertheless commit us to rescue people with urgent medical needs. The medical profession - society's primary instrument for provision of health services - shoulders a responsibility to meet society's health care needs. In carrying out that responsibility, physicians should advocate for a less chaotic, more compassionate, and ultimately more effective system with universal, timely, access to health care. Such a system will increase physicians' job satisfaction, allow physicians to focus more sharply on clinical problem-solving and building relationships with patients, and improve the general health of the population. At the same time, the medical profession must embrace a responsibility to eliminate useless medical interventions and to practice more cost-effectively.

Mentioning race at the beginning of clinical case presentations: a survey of US medical schools

OBJECTIVES

Medical students and doctors in the USA frequently mention the patient's race at the beginning of oral or written clinical case presentations. However, this practice is controversial. We aimed to determine whether US medical schools explicitly teach students to mention race at the beginning of case presentations, and to collect additional information on the schools' perspectives on this practice.

METHODS

An Internet-based questionnaire was submitted to directors of courses on history taking and physical examination at all US medical schools.

RESULTS

The response rate was 85%. Students are taught to mention race routinely at 11% of schools and selectively at 63% of schools; this practice is discouraged at 9% of schools and not addressed at 18% of schools. Most respondents noted that resident doctors at their institutions routinely mention race at the beginning of case presentations. Even at schools in which mentioning race is discouraged or not addressed, students tend to include race during their clinical rotations. Respondents were divided on whether a standardised approach to inclusion of race should exist at US schools.

CONCLUSIONS

Teaching about inclusion or exclusion of race in the opening statement of clinical case presentations varies across US medical schools. This variation presents an opportunity for medical educators to discuss tensions between stereotyping and cultural competence in medical education.

Primary HIV Infection Presenting with Acute Rhabdomyolysis

In several reported cases, rhabdomyolysis has been a manifestation of primary infection with HIV. However, other potential causes of rhabdomyolysis were either present or not excluded in most of those cases. We describe a patient in whom acute rhabdomyolysis was a presenting manifestation of primary HIV infection, and in whom other plausible causes of rhabdomyolysis were reasonably excluded.

Coccidioidomycosis diagnosed in South Carolina

Primary care physicians in the Eastern United States rarely consider coccidioidomycosis in the differential diagnosis of pulmonary infections or febrile illnesses. However, the mobility of the population mandates consideration of this diagnosis, particularly in patients with fever and cough that do not resolve rapidly and in patients with adenopathy on chest radiography. In this report, we describe two unrelated cases encountered during a single week in a South Carolina internal medicine practice. These cases highlight the importance of obtaining travel histories from patients with atypical pulmonary infections. Early consideration of coccidioidomycosis confers several benefits, including allaying patient anxiety by more timely diagnosis, minimizing the empiric use of antibiotics, and reducing the need for extensive and possibly invasive diagnostic testing.

Hidradenitis Suppurativa Complicated by Squamous Cell Carcinoma and Paraneoplastic Neuropathy

Squamous cell carcinoma is a rare complication of chronic, severe, hidradenitis suppurativa. We describe a patient with a 20-year history of extensive perineal hidradenitis suppurativa who presented with subacute muscle weakness and sensory symptoms. He was subsequently diagnosed with squamous cell carcinoma arising in the area of hidradenitis. The neurologic symptoms and signs resolved after complete excision of the tumor. This presentation is consistent with a paraneoplastic neuropathy, which has not been reported previously in patients with squamous cell carcinoma arising in patients with hidradenitis suppurativa.

Fibrosing colonopathy in an adult cystic fibrosis patient after discontinuing pancreatic enzyme therapy

Fibrosing colonopathy, a complication of cystic fibrosis, has generally been reported in young children with exposure to high doses of pancreatic enzymes. The authors report the case of a 25-year-old male with cystic fibrosis who presented with gradually progressive symptoms of bowel obstruction. Pathologic examination of the right colon revealed findings consistent with fibrosing colonopathy. This case is distinctive because of the adult presentation, and because the patient's symptoms developed long after he had discontinued taking a high-strength enzyme preparation. This case suggests that multiple etiologic factors, and not simply exposure to pancreatic enzymes, may result in fibrosing colonopathy in adults with cystic fibrosis.

Are gifts from pharmaceutical companies ethically problematic? A survey of physicians

BACKGROUND

Personalized pharmaceutical marketing to physicians, including the provision of gifts and sponsorship of educational and recreational activities, raises ethical issues. We sought to determine the degree to which physicians regarded common pharmaceutical marketing activities as ethically problematic, and to compare the views of experienced physicians and physicians-in-training.

METHODS

A questionnaire that included 18 scenarios portraying interactions between physicians and the pharmaceutical industry was distributed to residents and faculty members at a US medical school.

RESULTS

Most marketing activities were not thought to pose major ethical problems. Respondents tended to make distinctions about the ethical appropriateness of gifts on the basis of the monetary value and type of gift. Some respondents' views would be in violation of recent professional guidelines that address interactions between physicians and pharmaceutical companies. However, some respondents were troubled by activities that are permitted by professional guidelines. The responses of residents and faculty physicians were similar.

CONCLUSIONS

Despite the recent publicity about ethical problems in relationships between physicians and the pharmaceutical industry, inexperienced and experienced physicians at a single institution continue to have a rather permissive view about a variety of marketing activities.

"Inappropriate" treatment near the end of life: conflict between religious convictions and clinical judgment

Not infrequently, Christian patients and families provide religious justifications for an insistence on aggressive medical care near the end of life. Four commonly invoked reasons are (1). hope for a miracle, (2). refusal to give up on the God of faith, (3). a conviction that every moment of life is a gift from God and is worth preserving at any cost, and (4). a belief that suffering can have redemptive value. For each of these 4 reasons, however, there are alternative Christian interpretations that point in the direction of limiting medical intervention under certain circumstances. When clinicians believe that an intervention is medically inappropriate or inhumane, they are not necessarily obligated to provide it simply because it is demanded on religious grounds. Instead, clinicians-preferably assisted by chaplains or clergy-should discuss alternative religious interpretations with the patient or family, and should attempt to reach a consensus on the appropriate limits to life-sustaining treatment.

The adequacy of informed consent for placement of gastrostomy tubes

BACKGROUND

Gastrostomy tubes are placed commonly in patients with limited life expectancy. However, it is unclear whether the process of informed consent is adequate in these patients. This study examined the quality of informed consent in hospitalized patients undergoing placement of gastrostomy tubes.

METHODS

Retrospective review of the medical records of a cohort of 154 consecutive hospitalized adults undergoing placement of gastrostomy tubes in the context of chronic progressive illness, in the setting of a large community-teaching hospital.

RESULTS

The medical record documented a procedure-specific discussion of benefits and burdens of and alternatives to tube feeding in only 1 of 154 patients. Only 12 of 33 definitely or probably competent patients signed the hospital consent form; in the remaining 21, a surrogate decision-maker signed the form. The cumulative 1-year mortality for this cohort was 50%.

CONCLUSIONS

The quality of informed consent for placement of gastrostomy tubes was inadequate in a large community-teaching hospital. Indirect evidence from the literature suggests that these results are not unique to this institution. Physicians should become more familiar with the medical and ethical issues relevant to medically administered nutrition near the end of life, and institutions should develop procedures to improve the quality of decision-making for patients considering this intervention.

Intravenous immunoglobulin therapy for Stevens-Johnson syndrome

Stevens-Johnson syndrome (SJS) is an acute mucocutaneous disorder that can be associated with considerable morbidity. Several previous reports, all involving either adults with acquired immunodeficiency syndrome or children, suggest that intravenous immunoglobulin may be an effective treatment for SJS. We report a case of SJS in an immunocompetent adult whose condition improved dramatically after therapy with intravenous immunoglobulin.

Acute renal insufficiency due to oral acyclovir in a man with sickle cell trait

Several published reports have suggested that oral acyclovir can cause renal insufficiency, but baseline renal function was either abnormal or unclear in those reports. We describe a patient with oral acyclovir-induced acute renal failure and a normal serum creatinine level documented just before exposure to the drug. Conceivably, competition with a cephalosporin for renal tubular elimination predisposed our patient to nephrotoxic serum levels of acyclovir. In addition, the patient had sickle cell trait, which might have contributed to a disproportionate degree of hyperkalemia and acidosis seen early in the patient's clinical course.

Simultaneous pancreatitis and hepatitis associated with trimethoprim-sulfamethoxazole

A 34-yr-old woman developed simultaneous pancreatitis and hepatitis following exposure to trimethoprim-sulfamethoxazole (TMP/SMX). The episode occurred 4 yr after a previous episode of hepatitis associated with TMP/SMX. This patient represents the second case of concurrent TMP/SMX-induced pancreatitis and hepatitis reported in the literature. However, it is the first in which the adverse reaction was documented following an inadvertent rechallenge with the drug.