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1.  Avoidable Antibiotic Exposure for Uncomplicated Skin and Soft Tissue Infections in the Ambulatory Care Setting 
The American journal of medicine  2013;126(12):1099-1106.
Background
Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotics. A detailed understanding of current prescribing practices is necessary to optimize antibiotic use for these conditions.
Methods
This was a retrospective cohort study of children and adults treated in the ambulatory care setting for uncomplicated cellulitis, wound infection, or cutaneous abscess between March 1, 2010 and February 28, 2011. We assessed the frequency of avoidable antibiotic exposure, defined as: use of antibiotics with broad gram-negative activity, combination antibiotic therapy, or treatment for 10 or more days. Total antibiotic-days prescribed for the cohort were compared to antibiotic-days in four hypothetical short-course (5 – 7 days), single-antibiotic treatment models consistent with national guidelines.
Results
364 cases were included for analysis (155 cellulitis, 41 wound infection, and 168 abscess). Antibiotics active against methicillin-resistant Staphylococcus aureus were prescribed in 61% of cases of cellulitis. Of 139 cases of abscess where drainage was performed, antibiotics were prescribed in 80% for a median of 10 (interquartile range 7 – 10) days. Of 292 total cases where complete prescribing data were available, avoidable antibiotic exposure occurred in 46%. This included use of antibiotics with broad gram-negative activity in 4%, combination therapy in 12%, and treatment for 10 or more days in 42%. Use of the short-course, single-antibiotic treatment strategies would have reduced prescribed antibiotic-days by 19 – 55%.
Conclusions
Nearly half of uncomplicated skin infections involved avoidable antibiotic exposure. Antibiotic use could be reduced through treatment approaches utilizing short courses of a single antibiotic.
doi:10.1016/j.amjmed.2013.08.016
PMCID: PMC4075054  PMID: 24262724
skin and soft tissue infection; cellulitis; abscess; uncomplicated skin and soft tissue infection; antimicrobial stewardship
2.  Trends in Reporting Methadone-Associated Cardiac Arrhythmia, 1997–2011 
Annals of internal medicine  2013;158(10):735-740.
Background:
Long-acting opioids are a leading cause of accidental death in the United States, and methadone is associated with greater mortality rates. Whether this increase is related to the proarrhythmic properties of methadone is unclear.
Objective:
To describe methadone-associated arrhythmia events reported in the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS).
Design:
Description of national adverse event registry data before and after publication of a 2002 report describing an association between methadone and arrhythmia.
Setting:
FAERS, November 1997 and June 2011.
Patients:
Adults with QTc prolongation or torsade de pointes and ventricular arrhythmia or cardiac arrest.
Measurements:
FAERS reports before and after the 2002 report.
Results:
1646 cases of ventricular arrhythmia or cardiac arrest and 379 cases of QTc prolongation or torsade de pointes were associated with methadone. Monthly reports of QTc prolongation or torsade de pointes increased from a mean of 0.3 (95% CI, 0.1 to 0.5) before the 2002 publication to a mean of 3.5 (CI, 2.5 to 4.8) after it. After 2000, methadone was the second-most common primary suspect in cases of QTc prolongation or torsade de pointes after dofetilide (a known proarrhythmic drug) and was associated with disproportionate reporting similar to that of antiarrhythmic agents known to promote torsade de pointes. Antiretroviral drugs for HIV were the most common coadministered drugs.
Limitation:
Reports to FAERs are voluntary and selective, and incidence rates cannot be determined from spontaneously reported data.
Conclusion:
Since 2002, reports to FAERS of methadone-associated arrhythmia have increased substantially and are disproportionately represented relative to other events with the drug. Coadministration of methadone with antiretrovirals in patients with HIV may pose particular risk.
Primary Funding Source:
Colorado Clinical and Translational Sciences Institute, National Institutes of Health, and Agency for Healthcare Research and Quality.
doi:10.7326/0003-4819-158-10-201305210-00008
PMCID: PMC3793842  PMID: 23689766
3.  Targets for Antibiotic and Health Care Resource Stewardship in Inpatient Community-Acquired Pneumonia: A Comparison of Management Practices with National Guideline Recommendations 
Infection  2012;41(1):135-144.
Purpose
Community-acquired pneumonia (CAP) is the most common infection leading to hospitalization in the U.S. The objective of this study was to evaluate management practices for inpatient CAP in relation to IDSA/ATS guidelines to identify opportunities for antibiotic and health care resource stewardship.
Methods
This was a retrospective cohort study of adults hospitalized for CAP at a single institution from April 15, 2008 – May 31, 2009.
Results
Of 209 cases, 166 (79%) were admitted to a medical ward and 43 (21%) to the intensive care unit (ICU). 61 (29%) cases were candidates for outpatient therapy per IDSA/ATS guidance with a CURB-65 score of 0 or 1 and absence of hypoxemia. 110 sputum cultures were ordered; however, an evaluable sample was obtained in 49 (45%) cases, median time from antibiotic initiation to specimen collection was 11 (IQR 6–19) hours, and a potential pathogen was identified in only 18 (16%). Blood cultures were routinely obtained for both non-ICU (81%) and ICU (95%) cases, but 15 of 36 (42%) positive cultures were false-positive results. The most common antibiotic regimen was ceftriaxone plus azithromycin (182, 87% cases). Discordant with IDSA/ATS recommendations, oral step-down therapy consisted of a new antibiotic class in 120 (66%), most commonly levofloxacin (101, 55%). Treatment durations were typically longer than suggested with a median of 10 (IQR 8 – 12) days.
Conclusions
In this cohort of patients hospitalized for CAP, management was frequently inconsistent with IDSA/ATS guideline recommendations revealing potential targets to reduce unnecessary antibiotic and health care resource utilization.
doi:10.1007/s15010-012-0362-2
PMCID: PMC3567260  PMID: 23160837
pneumonia; community-acquired pneumonia; guidelines; Infectious Diseases Society of America; antimicrobial stewardship; Streptococcus pneumoniae; fluoroquinolones
4.  Introducing standardized “readbacks” to improve patient safety in surgery: a prospective survey in 92 providers at a public safety-net hospital 
BMC Surgery  2012;12:8.
Background
Communication breakdowns represent the main root cause of preventable complications which lead to harm to surgical patients. Standardized readbacks have been successfully implemented as a main pillar of professional aviation safety for decades, to ensure a safe closed-loop communication between air traffic control and individual pilots. The present study was designed to determine the perception of staff in perioperative services regarding the role of standardized readbacks for improving patient safety in surgery at a single public safety-net hospital and level 1 trauma center.
Methods
A 12-item questionnaire was sent to 180 providers in perioperative services at Denver Health Medical Center. The survey was designed to determine the individual participants’ perception of (1) appropriateness of current readback processes; (2) willingness to attend a future training module on this topic; (3) specific scenarios in which readbacks may be effective; and (4) perceived major barriers to the implementation of standardized readbacks. Survey results were compared between departments (surgery versus anesthesia) and between specific staff roles (attending or midlevel provider, resident physician, nursing staff), using non-parametric tests.
Results
The response rate to the survey was 50.1 % (n = 92). Respondents overwhelmingly recognized the role of readbacks in reducing communication errors and improving patient safety. There was a strong agreement among respondents to support participation in a readbacks training program. There was no difference in the responses between the surgery and anesthesia departments.
There was a statistically significant difference in the healthcare providers willingness to attend a short training module on readbacks (p < 0.001). Resident physicians were less likely to endorse the importance of readbacks in reducing communication errors (p = 0.01) and less willing to attend a short training module on readbacks (p < 0.001), as compared to staff providers and nursing staff.
The main challenge for respondents, which emanated from their responses, appeared to relate to determining the ideal scenarios in which readbacks may be most appropriately used. Overall, respondents strongly felt that readbacks had an important role in patient handoffs, patient orders regarding critical results, counting and verifying surgical instruments, and delegating multiple perioperative tasks.
Conclusion
The majority of all respondents appear to perceive standardized readbacks as an effective tool for reducing and/or preventing adverse events in the care of surgical patients, derived from a breakdown in communication among perioperative caregivers. Further work needs to be done to define the exact clinical scenarios in which readbacks may be most efficiently implemented, including the definition of a uniform set of scripted quotes and phrases, which should likely be standardized in concert with the aviation safety model.
doi:10.1186/1471-2482-12-8
PMCID: PMC3418160  PMID: 22713158
6.  Complement C3 serum levels in anorexia nervosa: a potential biomarker for the severity of disease? 
Background
Anorexia nervosa carries the highest mortality rate of any psychiatric disorder. Even the most critically ill anorexic patients may present with normal 'standard' laboratory values, underscoring the need for a new sensitive biomarker. The complement cascade, a major component of innate immunity, represents a driving force in the pathophysiology of multiple inflammatory disorders. The role of complement in anorexia nervosa remains poorly understood. The present study was designed to evaluate the role of complement C3 levels, the extent of complement activation and of complement hemolytic activity in serum, as potential new biomarkers for the severity of anorexia nervosa.
Patients and methods
This was a prospective cohort study on 14 patients with severe anorexia nervosa, as defined by a body mass index (BMI) <14 kg/m2. Serum samples were obtained in a biweekly manner until hospital discharge. A total of 17 healthy subjects with normal BMI values served as controls. The serum levels of complement C3, C3a, C5a, sC5b-9, and of the 50% hemolytic complement activity (CH50) were quantified and correlated with the BMIs of patients and control subjects.
Results
Serum C3 levels were significantly lower in patients with anorexia nervosa than in controls (median 3.7 (interquartile range (IQR) 2.5-4.9) vs 11.4 (IQR 8.9-13.7, P <0.001). In contrast, complement activation fragments and CH50 levels were not significantly different between the two groups. There was a strong correlation between index C3 levels and BMI (Spearman correlation coefficient = 0.71, P <0.001).
Conclusions
Complement C3 serum levels may represent a sensitive new biomarker for monitoring the severity of disease in anorexia nervosa. The finding from this preliminary pilot study will require further investigation in future prospective large-scale multicenter trials.
doi:10.1186/1744-859X-10-16
PMCID: PMC3110119  PMID: 21542928
7.  Nutritional Rehabilitation: Practical Guidelines for Refeeding the Anorectic Patient 
Weight restoration is crucial for successful treatment of anorexia nervosa. Without it, patients may face serious or even fatal medical complications of severe starvation. However, the process of nutritional rehabilitation can also be risky to the patient. The refeeding syndrome, a problem of electrolyte and fluid shifts, can cause permanent disability or even death. It is essential to identify at-risk patients, to monitor them carefully, and to initiate a nutritional rehabilitation program that aims to avoid the refeeding syndrome. A judicious, slow initiation of caloric intake, requires daily management to respond to entities such as liver inflammation and hypoglycemia that can complicate the body's conversion from a catabolic to an anabolic state. In addition, nutritional rehabilitation should take into account clinical characteristics unique to these patients, such as gastroparesis and slowed colonic transit, so that measures can be taken to ameliorate the physical discomforts of weight restoration. Adjunct methods of refeeding such as the use of enteral or parenteral nutrition may play a small but important role in a select patient group who cannot tolerate oral nutritional rehabilitation alone.
doi:10.1155/2010/625782
PMCID: PMC2925090  PMID: 20798756
8.  The management of pneumothorax in patients with anorexia nervosa: A case report and review of the literature 
Of the many body systems adversely affected by severe anorexia nervosa (AN), the pulmonary system is relatively spared. However, in the face of severe malnutrition of AN, the lung may undergo architectural changes that adversely affect its integrity and healing capacity. We report herein a case of a pneumothorax in a patient with severe AN, in which standard approaches to manage the pneumothorax were unsuccessful. Despite prolonged tube thoracostomy drainage, and subsequent thoracoscopic pleuredesis, the patient continued to have an air leak and non-resolution of her pneumothorax. We review the literature and discuss alternative approaches in this patient population.
doi:10.1186/1754-9493-4-1
PMCID: PMC2825503  PMID: 20205853
9.  Access and care issues in urban urgent care clinic patients 
Background
Although primary care should be the cornerstone of medical practice, inappropriate use of urgent care for non-urgent patients is a growing problem that has significant economic and healthcare consequences. The characteristics of patients who choose the urgent care setting, as well as the reasoning behind their decisions, is not well established. The purpose of this study was to determine the motivation behind, and characteristics of, adult patients who choose to access health care in our urgent care clinic. The relevance of understanding the motivation driving this patient population is especially pertinent given recent trends towards universal healthcare and the unclear impact it may have on the demands of urgent care.
Methods
We conducted a cross-sectional survey of patients seeking care at an urgent care clinic (UCC) within a large acute care safety-net urban hospital over a six-week period. Survey data included demographics, social and economic information, reasons that patients chose a UCC, previous primary care exposure, reasons for delaying care, and preventive care needs.
Results
A total of 1, 006 patients were randomly surveyed. Twenty-five percent of patients identified Spanish as their preferred language. Fifty-four percent of patients reported choosing the UCC due to not having to make an appointment, 51.2% because it was convenient, 43.9% because of same day test results, 42.7% because of ability to get same-day medications and 15.1% because co-payment was not mandatory. Lack of a regular physician was reported by 67.9% of patients and 57.2% lacked a regular source of care. Patients reported delaying access to care for a variety of reasons.
Conclusion
Despite a common belief that patients seek care in the urgent care setting primarily for economic reasons, this study suggests that patients choose the urgent care setting based largely on convenience and more timely care. This information is especially applicable to the potential increase in urgent care volume in a universal healthcare system. Additionally, this study adds to the body of literature supporting the important role of timely primary care in healthcare maintenance.
doi:10.1186/1472-6963-9-222
PMCID: PMC2795751  PMID: 19961588
11.  Can America’s Urban Safety Net Systems be a Solution to Unequal Treatment? 
Eliminating disparities in care for racial and ethnic minorities remains a challenge in achieving overall quality health care. One approach to resolving issues of inequity involves utilizing an urban safety-net system to address preventive and chronic care disparities. An analysis was undertaken at Denver Health (DH), an urban safety net which serves 150,000 patients annually, of which 78% are minorities and 50% uninsured. Medical charts for 4,795 randomly selected adult patients at ten DH-associated community health centers were reviewed between July 1999 and December 2001. Logistic regression was used to identify differences between racial/ethnic groups in cancer screening, blood pressure control, and diabetes management. No disparities in care were found, and in most instances, the quality of care met or exceeded available benchmarks, leading us to conclude that treatment in urban integrated safety net systems committed to caring for minority populations may represent one approach to reducing disparity.
doi:10.1007/s11524-008-9296-5
PMCID: PMC2527432  PMID: 18553134
Disparities; Safety-net; Hypertension; Cancer screening; Diabetes
13.  Medical Comorbidity in Schizophrenia 
doi:10.1007/s11606-007-0219-z
PMCID: PMC2219726  PMID: 17476543
15.  Resting tachycardia, a warning sign in anorexia nervosa: case report 
Background
Among psychiatric disorders, anorexia nervosa has the highest mortality rate. During an exacerbation of this illness, patients frequently present with nonspecific symptoms. Upon hospitalization, anorexia nervosa patients are often markedly bradycardic, which may be an adaptive response to progressive weight loss and negative energy balance. When anorexia nervosa patients manifest tachycardia, even heart rates in the 80–90 bpm range, a supervening acute illness should be suspected.
Case presentation
A 52-year old woman with longstanding anorexia nervosa was hospitalized due to progressive leg pain, weakness, and fatigue accompanied by marked weight loss. On physical examination she was cachectic but in no apparent distress. She had fine lanugo-type hair over her face and arms with an erythematous rash noted on her palms and left lower extremity. Her blood pressure was 96/50 mm Hg and resting heart rate was 106 bpm though she appeared euvolemic. Laboratory tests revealed anemia, mild leukocytosis, and hypoalbuminemia. She was initially treated with enteral feedings for an exacerbation of anorexia nervosa, but increasing leukocytosis without fever and worsening left leg pain prompted the diagnosis of an indolent left lower extremity cellulitis. With antibiotic therapy her heart rate decreased to 45 bpm despite minimal restoration of body weight.
Conclusions
Bradycardia is a characteristic feature of anorexia nervosa particularly with significant weight loss. When anorexia nervosa patients present with nonspecific symptoms, resting tachycardia should prompt a search for potentially life-threatening conditions.
doi:10.1186/1471-2261-4-10
PMCID: PMC503388  PMID: 15257758
anorexia nervosa; bradycardia; tachycardia; malnutrition
16.  LETTER TO THE EDITOR 
doi:10.1046/j.1525-1497.2002.20934.x
PMCID: PMC1495075  PMID: 12133151
17.  Letter to the Editor 
doi:10.1111/j.1525-1497.2001.01121.x
PMCID: PMC1495183  PMID: 11318919
18.  LETTER TO THE EDITOR 
doi:10.1111/j.1525-1497.2001.01015.x
PMCID: PMC1495174  PMID: 11251768
19.  Cervical Cancer Screening in the Urgent Care Setting 
OBJECTIVE
To determine the feasibility of cervical cancer screening in an urgent care clinic.
DESIGN
Prospective randomized trial.
SETTING
Public teaching hospital.
PATIENTS
Women presenting to the urgent care clinic whose evaluation necessitated a pelvic examination were eligible for participation. Women who had a hysterectomy, had a documented Pap test at our institution in the past year, did not speak English or Spanish, or had significant vaginal bleeding were excluded. Women presenting to the gynecology clinic for a scheduled Pap test were used as a comparison group for rates of follow-up, Pap smear adequacy, and Pap smear abnormalities.
INTERVENTIONS
Women randomized to the intervention group had a Pap test performed as part of their pelvic examination, while women in the usual care group were encouraged to schedule an appointment in the gynecology clinic at a later date. The women in the two groups completed identical questionnaires regarding cervical cancer risk factors and demographic information.
MEASUREMENTS AND MAIN RESULTS
Ninety-four (84.7%) of 111 women in the intervention group received a Pap test, as compared with 25 (29%) of 86 in the usual care group (P < .01). However, only 5 (24%) of 21 women with abnormal Pap smears in the intervention group received follow-up compared with 6 (60%) of 10 women seen during the same time period in the gynecology clinic for self-referred, routine annual examinations (P = .11). Pap smears obtained in the urgent care clinic were similar to those in the gynecology clinic with regard to abnormality rate (22.3% vs 20%; P = .75, respectively) and specimen adequacy (67% vs 72%; P = .54, respectively).
CONCLUSIONS
Urgent care clinic visits can be used as opportunities to perform Pap test screening in women who are unlikely to adhere to cervical cancer screening recommendations. However, to accrue the full potential benefit from this intervention, an improved process to ensure patient follow-up must be developed.
doi:10.1046/j.1525-1497.2000.08001.x
PMCID: PMC1495471  PMID: 10886473
cervical cancer screening; urgent care clinic; Pap smears
20.  Author's response 
Western Journal of Medicine  2000;172(6):365.
PMCID: PMC1070949  PMID: 18751299
22.  Smoking as a Risk Factor for Nephropathy in Non-Insulin-Dependent Diabetics 
This study examines whether there was an association between smoking and nephropathy in patients with non-insulin-dependent diabetes mellitus enrolled in the Appropriate Blood Pressure Control in Diabetes Trial. Sixty-one percent of the patients were smokers; 26% had microalbuminuria, and 14% had overt nephropathy. There was a univariate association between diabetic nephropathy and gender, smoking status, duration of diabetes, hypertension, glycosylated hemoglobin level, creatinine level, body mass index, and cholesterol level. Stepwise logistic regression demonstrated an independent association between smoking and diabetic nephropathy (odds ratio 1.61; 95% confidence interval 1.01, 2.58). These findings may have important implications for patients with non-insulin-dependent diabetes mellitus who smoke.
doi:10.1046/j.1525-1497.1998.00249.x
PMCID: PMC1497038  PMID: 9844083
nephropathy; non-insulin-dependent diabetes mellitus; smoking

Results 1-22 (22)