Darius A. Rastegar

Survey of physician knowledge regarding antiretroviral medications in hospitalized HIV-infected patients

BackgroundAntiretroviral prescribing errors are common among hospitalized patients. Inadequate medical knowledge is likely one of the factors leading to these errors. Our objective was to determine the proportion of hospital physicians with knowledge gaps about prescribing antiretroviral medications for hospitalized HIV-infected patients and to correlate knowledge with length and type of medical training and experience.MethodsWe conducted an electronic survey comprising of ten clinical scenarios based on antiretroviral-prescribing errors seen at two community teaching hospitals. It also contained demographic questions regarding length and type of medical training and antiretroviral prescribing experience. Three hundred and forty three physicians at both hospitals were asked to anonymously complete the survey between February 2007 and April 2007.ResultsOne hundred and fifty-seven physicians (46%) completed at least one question. The mean percentage of correct responses was 33% for resident physicians, 37% for attending physicians, and 93% for Infectious Diseases or HIV (ID/HIV) specialist physicians. Higher scores were independently associated with ID/HIV specialty, number of outpatients seen per month and physician reported comfort level in managing HIV patients (P <.001).ConclusionNon-ID/HIV physicians had uniformly poor knowledge of common antiretroviral medication regimens. Involvement of ID/HIV specialists in the prescribing of antiretrovirals in hospitalized patients might mitigate prescribing errors stemming from knowledge deficits.

Antiretroviral Medication Errors among Hospitalized Patients with HIV Infection

BACKGROUND Highly active antiretroviral therapy (HAART) has improved survival for persons living with human immunodeficiency virus (HIV) infection. However, effective therapy requires high levels of adherence over extended periods of time. Previous studies suggest that patients receiving long-term medication are at risk for unintended medication discrepancies at the time of hospital admission. METHODS We retrospectively identified every HIV-infected patient admitted to our hospital over a 1-year period who received an antiretroviral agent. We collected information on medications and renal function from the hospital computerized provider order entry system. We reviewed the medical records for those admissions for which a potential error was identified. We defined errors using Department of Health and Human Services guidelines and included only those errors that were not corrected within 24 h after initial entry. RESULTS There were a total of 209 admissions during a 1-year period in which an HIV-infected patient received antiretroviral therapy. After review of the medical records for 77 admissions with a potential error, 61 uncorrected errors from 54 admissions were identified (percentage of total admissions, 25.8%; 95% confidence interval, 20.1%-32.3%). The most common type of error was an error with respect to the amount or frequency of dosage, which occurred in 34 (16.3%) of the admissions; 18 of these errors were attributable to failure to appropriately adjust dosage for renal insufficiency. The next most common error was combining antiretroviral drugs with a contraindicated medication; this occurred in 12 (5.2%) of the admissions. Patients erroneously received <or=2 antiretroviral agents in 8 (3.8%) of the admissions and had an unexplained delay in continuing HAART in 7 (3.3%). CONCLUSIONS HIV-infected patients receiving HAART are at substantial risk for antiretroviral medication errors at the time of hospitalization. More needs to be done to ensure that these patients receive appropriate therapy during their inpatient stay.

T Cell Dynamics and the Response to HAART in a Cohort of HIV-1-Infected Elite Suppressors

Elite controllers or suppressors are untreated human immunodeficiency virus type 1 (HIV-1)-infected patients who maintain undetectable viral loads. In this study, we show that most elite suppressors do not experience significant changes in T cell counts over a 10-year period. Interestingly, treatment of an elite suppressor with highly active antiretroviral therapy (HAART) led to a marked decrease in immune activation.

Chronic diarrhea associated with Vibrio alginolyticus in an immunocompromised patient.

was oxidase-, catalase-, and nitrate-positive, and it was capable of growth at 42°C. The isolate oxidized but did not ferment glucose and did not utilize xylose, mannitol, sucrose, maltose, or lactose. It did not reduce nitrate or split urea, and the indole test was negative. The lysine, arginine, and ornithine enzymatic reactions were negative. Results of clinical laboratory testing of the strain isolated from our patient were consistent with the growth and biochemical patterns established by the CDC for CDC Group O1 organisms [1]. By microtiter dilution testing, the strain was found to be susceptible to piperacillin, ceftazidime, ceftizoxime, ciprofloxacin, chloramphenicol, amikacin, imipenem, ticarcillin/clavulanic acid, and ampicillin/sulbactam but resistant to aztreonam. This case represents the first report of the CDC Group O1 bacterium as the etiologic agent of necrotizing aspiration pneumonia. The development of this pneumonia appears to have followed the witnessed aspiration event; therefore, we speculate that the source of this microorganism was either oropharyngeal or gastrointestinal flora. Although the pneumonia may have been the product of a polymicrobial infection, no other organisms other than CDC Group O1 bacteria were isolated from cultures of specimens collected at the time of the initial febrile episode. The CDC has received 62 different clinical isolates of this organism from various sources. The sources are quite diverse and include blood (55% of isolates), CSF (6%), pleural fluid (6%), wound (5%), cervix (5%), and other sites (23%), including vagina, heart valves, lymph nodes, eye, intravenous fluid, platelets, sternum, scapula, finger, bone marrow, peritoneal fluid, allergenic extract, a water bath, and “unknown” [1]. Although the invasive potential for this organism is obvious, no clinical data have appeared in the literature, and the clinical significance of these isolates is unknown. This report suggests that this bacillus is invasive enough to cause necrotizing pneumonia with complicating bronchopleural fistula and bacteremia. Therapy consisted of simple local drainage as well as dual antimicrobial treatment directed by the reported susceptibility patterns of the isolate. A broad pattern of susceptibility to antibiotics was apparent, but we would recommend dual therapy for infections with the CDC Group O1 bacterium on the basis of occasional recalcitrance of syndromes caused by similar nosocomial gramnegative rods [2].

A Patient with Primary Human Immunodeficiency Virus Infection Who Presented with Acute Rhabdomyolysis

Primary human immunodeficiency virus (HIV) infection is usually symptomatic, and infected patients can present with a variety of symptoms. We describe a 51-year-old man who presented at our hospital with acute self-limited rhabdomyolysis and who was found to have primary HIV infection. Our case and other reports suggest that a diagnosis of primary HIV infection needs to be considered for patients who present with acute rhabdomyolysis.

Physician Familiarity With Diagnosis and Management of Hypertension According to JNC 7 Guidelines

Physician knowledge of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines is unknown and may contribute to the prevalence of uncontrolled hypertension. Our objective was to determine physician knowledge of JNC 7 guidelines and whether online instruction could improve knowledge. A pretest served as baseline knowledge, and comparison with a post‐test after completing an online didactic demonstrated improvement in knowledge. Participants included 1280 physicians at 45 internal medicine residency training programs. Average baseline knowledge of six concepts of hypertension was 51.2%. Attending physicians performed better than trainees on some but not all concepts (p<0.05). Third‐year post‐graduate trainees performed better than first‐year trainees on some but not all concepts (p<0.05). Knowledge increased significantly on all concepts after completing the curriculum (p<0.05). The authors demonstrated that physician knowledge of JNC 7 guidelines is poor but can be improved by an online curriculum. Further study is needed to determine the impact of physician education on clinical outcomes in individuals with hypertension.

Long-term opioid therapy, aberrant behaviors, and substance misuse: comparison of patients treated by resident and attending physicians in a general medical clinic.

OBJECTIVE To compare rates of opioid prescribing, aberrant behaviors, and indicators of substance misuse in patients prescribed long-term opioids by resident physicians or attending physicians in a general internal medicine practice. DESIGN Medical records of 333 patients who were prescribed opioids for at least three consecutive months were reviewed. Aberrant behaviors over a 2-year period were documented, including reporting lost or stolen medications or receiving opioids from more than one provider. Indicators of substance misuse were also recorded, including positive urine drug testing for illicit substances, addiction treatment, overdose, and altering prescriptions. RESULTS An estimated 13.6 percent of the patients followed by residents had been prescribed opioids for three or more months; this was significantly higher than the rate for attendings (5.9 percent, p < 0.001). Patients followed by residents were more likely to have reported lost or stolen prescriptions or medication (25.7 percent vs 12.2 percent, p = 0.03) or to have received opioids from another provider (17.8 percent vs 7.6 percent, p = 0.008); they were also more likely to exhibit an indicator of substance misuse (24.8 percent vs 7.6 percent, p < 0.001). However, in multivariate analyses, aberrant behaviors and indicators of substance misuse were not significantly associated with having a resident physician. CONCLUSIONS Resident physicians at our institution are following a disproportionate number of patients on long-term opioids, many of whom exhibit aberrant behaviors and indicators of substance misuse. This underscores a need for better resident training and supervision to provide effective and safe care for patients with chronic pain.

Safety and effectiveness of a fixed-dose phenobarbital protocol for inpatient benzodiazepine detoxification

Benzodiazepine dependence is a common problem. However, there is limited data on safe and effective detoxification protocols for benzodiazepine-dependent patients. We reviewed the medical records of 310 patients treated with a 3-day fixed-dose phenobarbital taper for benzodiazepine dependence over a 5-year period between 2004 and 2009. We recorded the incidence of seizures, falls, delirium, and emergency department (ED) visits or readmission to our institution within 30 days as markers for safety; we also recorded how many patients had doses held because of sedation. The taper was well tolerated, although one quarter of the patients had at least one dose held because of sedation. There were no seizures, falls, or injuries reported. Six percent had a readmission, and 7% had an ED visit at our institution within 30 days of discharge, but only 3 patients required readmission for withdrawal symptoms. Overall, this protocol appears to be safe and effective.

Entry into primary care-based buprenorphine treatment is associated with identification and treatment of other chronic medical problems

BackgroundBuprenorphine is an effective treatment for opioid dependence that can be provided in a primary care setting. Offering this treatment may also facilitate the identification and treatment of other chronic medical conditions.MethodsWe retrospectively reviewed the medical records of 168 patients who presented to a primary care clinic for treatment of opioid dependence and who received a prescription for sublingual buprenorphine within a month of their initial visit.ResultsOf the 168 new patients, 122 (73%) did not report having an established primary care provider at the time of the initial visit. One hundred and twenty-five patients (74%) reported at least one established chronic condition at the initial visit. Of the 215 established diagnoses documented on the initial visit, 146 (68%) were not being actively treated; treatment was initiated for 70 (48%) of these within one year. At least one new chronic medical condition was identified in 47 patients (28%) during the first four months of their care. Treatment was initiated for 39 of the 54 new diagnoses (72%) within the first year.ConclusionsOffering treatment for opioid dependence with buprenorphine in a primary care practice is associated with the identification and treatment of other chronic medical conditions.

The Effect of a Payer-Mandated Decrease in Buprenorphine Dose on Aberrant Drug Tests and Treatment Retention Among Patients with Opioid Dependence

BACKGROUND The optimal dose for office-based buprenorphine therapy is not known. This study reports on the effect of a change in payer policy, in which the insurer of a subset of patients in an office-based practice imposed a maximum sublingual buprenorphine dose of 16 mg/day, thereby forcing those patients on higher daily doses to decrease their dose. This situation created conditions for a natural experiment, in which treatment outcomes for patients experiencing this dose decrease could be compared to patients with other insurance who were not challenged with a dose decrease. METHODS Subjects were 297 patients with opioid use disorder in a primary care practice who were prescribed buprenorphine continuously for at least 3 months. Medical records were retrospectively reviewed for urine drug test results and treatment retention. Rates of aberrant urine drug tests were calculated in the period before the dose decrease and compared to rate after it with patients serving as their own controls. Comparison groups were formed from patients with the same insurance on buprenorphine doses of 16 mg/day or lower, patients with different insurance on 16 mg/day or lower, and patients with different insurance on greater than 16 mg/day. Rates of aberrant drug tests and treatment retention of patients on 16 mg/day or less of buprenorphine were compared to that of patients on higher daily doses. RESULTS The rate of aberrant urine drug tests among patients who experienced a dose decrease rose from 27.5% to 34.2% (p=0.043). No comparison group showed any significant change in aberrant drug test rates. Moreover, all groups who were prescribed buprenorphine doses greater than 16 mg/day displayed lower rates of aberrant urine drug tests than groups prescribed lower doses. Retention in treatment was also highest among those prescribed greater than 16 mg/day (100% vs. 86.8%, 90.1%, and 84.4% p=0.010). DISCUSSION An imposed buprenorphine dose decrease was associated with an increase in aberrant drug tests. Patients in a control group with higher buprenorphine doses had greater retention in treatment. These findings suggest that buprenorphine doses greater than 16 mg/day are more effective for some patients and that dose limits at this level or lower are harmful.