J. Rush Pierce

Stroke following Application of a Nicotine Patch

TO THE EDITOR: Transdermal nicotine (the nicotine patch) has been promoted as an aid in the treatment of tobacco addiction. It is generally safe, having minimal serious adverse effects except in patients with coronary artery disease. I This report of a postcraniotomy patient who developed a stroke shortly after applying a nicotine patch suggests that nicotine may precipitate cerebral vasospasm. A 40-year-old mansuddenly developed severe headache andsyncope. He was admined to a hospital with meningismus, butexhibited nootherneurologic abnormalities. Cranial computed tomography (CT)demonstrated blood in thesubarachnoidspace. Treatment withdexamethasone 16mg/dand nimodipine 360mg/d wasbegun. Cerebral angiography demonstrated spasm of theright middle cerebral artery andan aneurysm of the rightinternal carotid artery at itsjunction withthe posteriorcommunicating artery. Ninedays after admission thisaneurysm was clipped. Postoperatively thepatient developed leukocytosis (maximum leukocyte count46 x 1091L), but no feveror neurologic abnormalities. As thedexamethasonedosage wasdecreased, his leukocytosis resolved. Six daysafter surgery a cerebral arteriogram wasnormal exceptfor mild residual spasm of the right middlecerebral artery. Against hospital policyand the adviceof his physicians, the patient smoked cigarenes in thehospital before andaftersurgery. At the timeof discharge he requested a nicotine patch to helphimstopsmoking. Sevendaysaftersurgery and after17daysof nimodipine therapy, thepatient wasdischarged on cimetidine 800 mg/danddexamethasone 4 mg/d. Hewasgiven a prescription fornicotine patches.Nimodipine wasdiscontinued at thetimeof discharge. Theday afterdischarge the patient applied for thefirsttimea IO-mg nicotine patch. Hedenied cigarene smoking afterdischarge. About fourhours afterapplyingthepatch hedeveloped drowsiness, difficulty walking, anda leftfacial droop. He returned to the hospital. Examination showed normal bloodpressure, confusion,rightgazepreference, left homonymous hemianopia, left hemiparesis, and left-sided neglect. Leukocyte count,serumelectrolytes, and electrocardiogram werenormal. Cranial CT failed to demonstrate acutehemorrhage. Transcranial Doppler ultrasonography (TCD) demonstrated spasm of bothmiddle cerebral arteries,more prominent ontheright. These studies were consistent withtheclinical diagnosis ofa vasospastic infarct inthedistribution of theright middle cerebral artery. Largevolumes of NaCl0.9%and plasmaproteinfraction wereinfused. Nimodipine wasadministered andthedexamethasone dosage wasincreased. Thepatientsneurologic abnormalities improved andhe wastransferred to a rehabilitation unit. Three months laterhewasableto return to parttime work with someleft arm weakness andcognitive deficits. Serious adverse effects associated with the nicotine patch have been few and limited almost entirely to patients with coronary artery disease. I This patient experienced a stroke shortly after applying a nicotine patch. TCD suggested that the stroke was caused by intracranial vasospasm. Delayed intracranial vasospasm may occur spontaneously after subarachnoid hemorrhage, typically 4-14 days after the initial event. In this case, the close temporal relationship between the application of the patch and the onset of stroke suggests that the nicotine patch may have precipitated cerebral vasospasm. Though the vasospastic effects of nicotine are believed to be minimal. caution is advised when prescribing transdermal nicotine in patients with vasospastic disorders such as Prinzmetal s variant angina and Buergers disease. In contrast, no precaution is advised when the nicotine patch is used in patients with migraine headaches, a condition associated with intracranial vasospasm. As the underlying mechanism of cerebral vasospasm remains unknown, the possibility that nicotine may precipitate cerebral vasospasm in a susceptible individual should be considered. Diffuse cerebral vasospasm has been angiographically demonstrated in a patient with headaches who was using nicotine patches. In addition, nicotine also has procoagulant effects, which could increase the risk of thrombosis. Nimodipine, a calcium-channel blocker that inhibits cerebral vasospasm,Z was administered during the patients hospitalization and discontinued at the time of discharge. The discontinuation of nimodipine may have played a role in the patients stroke, since he smoked throughout hospitalization (while taking nimodipine) without incident. Though he denied smoking after application of the patch, his history may not have been reliable. Smoking while wearing a patch provides higher peak concentrations of nicotine and increases the potential for adverse effects. Serious cardiac toxicity has been reported in patients who smoked while wearing the patch.I This case should alert clinicians to the fact that the detrimental health effects of smoking arecaused partly by the nicotine content, and thus, replacement of smoking with the use of the nicotine patch poses continued health risks.

Prostatic Abscess Due to Community-Acquired Methicillin-Resistant Staphylococcus aureus

We report what we believe to be the second case of a prostatic abscess due to community-acquired methicillin-resistant Staphylococcus aureus (MRSA). A previously healthy diabetic man presented with dysuria, fatigue, weight loss, a tender prostate, and leukocytosis. Computerized tomography of the abdomen and pelvis demonstrated a large prostatic abscess at the base of the bladder. Blood, urine, and pus obtained by percutaneous aspiration grew MRSA. Percutaneous drainage and prolonged therapy with intravenous vancomycin resulted in cure. Prostatic abscess is most often caused by Gram-negative organisms. Community-acquired MRSA, which usually causes skin and soft tissue infections, may also cause prostatic abscess. The mainstay of treatment of prostatic abscess is drainage, which can be accomplished either percutaneously or transurethrally. Gram stain and culture of the drainage will direct proper antibiotic selection.

Living near a trail is associated with increased odds of walking among patients using community clinics

We tested the hypothesis that living near a walking or cycling trail was associated with greater odds of walking. This has been previously studied in healthy and unselected populations, but to our knowledge has not been studied in patients attending community clinics. A cross-sectional survey was completed by 1211 persons in five community clinics that serve poor populations. We performed univariate analysis and developed a multivariate logistic regression model for walking adjusting for 12 independent variables including self-rated health, frequent mental distress, lifestyle and demographic variables, and environmental characteristics of the neighborhood including perceived proximity to a walking or cycling trail. Compared to those who reported not living close to a trail, persons who reported living near a trail were more likely to meet recommended levels of walking of at least 30xa0minutes fives times per week (unadjusted odds ratioxa0=xa01.49, 95% confidence intervalsxa0=xa01.04–2.13). In the multivariate model, male gender (unadjusted odds ratioxa0=xa01.63, 95% confidence intervalsxa0=xa01.15–2.30), having three or more convenient destinations (unadjusted odds ratioxa0=xa01.78, 95% confidence intervalsxa0=xa01.37–2.32), and living near a trail (unadjusted odds ratioxa0=xa01.45, 95% confidence intervalsxa0=xa01.01–2.09) were positively associated with walking at statistically significant levels. The odds of walking were lower in non-Hispanic blacks (odds ratioxa0=xa00.59, 95% confidence intervalsxa0=xa00.40–0.87) and current smokers (odds ratioxa0=xa00.66, 95% confidence intervalsxa0=xa00.57–0.76). For patients attending community clinics, environmental strategies to encourage walking may include mixed-land-use neighborhoods and construction of trails.

Cholesterol embolism: diagnosis antemortem by bone marrow biopsy.

Excerpt Widespread cholesterol microembolism from atherosclerotic plaques may produce a multisystem illness resembling polyarteritis, allergic vasculitis, subacute bacterial endocarditis, or left a...

Propranolol and Retroperitoneal Fibrosis

Excerpt To the editor: We have recently treated a patient who developed retroperitoneal fibrosis while taking propranolol. A 51-year-old black man had an uncomplicated inferior myocardial infarctio...

Place-of-residence errors on death certificates for two contiguous U. S. counties

BackgroundBased on death certificate data, the Texas Department of Health Bureau of Vital Statistics calculates age adjusted all-cause mortality rates for each Texas county yearly. In 1998 the calculated rates for two adjacent Texas counties was disparate. These counties contain one city (Amarillo) and are identical in size. This study examined the accuracy of recorded county of residence for deaths in the two counties in 1998. In our jurisdiction, the county of residence is assigned by funeral homes.MethodsA random sample of 20% of death certificates was selected. The accuracy of the county of residence was verified by using a large area map, Tax Appraisal District records, and U.S. Census Bureau databases. Inaccuracies in recording the county or zip code of residence was recorded.ResultsEighteen of 354 (5.4%) death certificates recorded the incorrect county and 21 of 354 (5.9%) of death certificates recorded the zip code improperly. There was a 14.4% county recording error rate for one county compared to a 0.82% for the other county. The zip code error rate was similar for the two counties (5.9% vs. 5.8%). Of the county errors, 83% occurred for addresses within a zip code that contained addresses in both counties.ConclusionThis study demonstrated a large error rate (14%) in recording county of residence for deaths in one county. A similar rate was not seen in an adjacent county. This led to significant miscalculation of mortality rates for two counties. We believe that errors may have arisen in part from use of internet programs by funeral homes to assign the county of residence. With some of these programs, the county is determined by zip code, and when a zip code straddles two counties, the program automatically assigns the county whose name appears first in the alphabet. This type of error could be avoided if funeral homes determined the county of residence from Tax Appraisal District or Census Bureau records, both of which are available on the internet. This type of error could also be avoided if vital statistics offices verified the county and zip code of residence using official sources.

Case Report: Cimetidine-Associated Depression and Loss of Libido in a Woman

A healthy young woman developed marked depression and loss of libido while taking cimetidine. Her symptoms promptly resolved after discontinuation of cimetidine suggesting that her symptoms represent an adverse drug reaction. Mental confusion and other neurologic symptoms have been attributed to cimetidine administration, but depression has not been previously reported. This case can not be explained by the presently accepted theory regarding the pathogenesis of cimetidine-associated central nervous system abnormalities.

Improving long-term care facility disaster preparedness and response: a literature review

Long-term care facilities (LTCFs) and their residents are especially susceptible to disruptions associated with natural disasters and often have limited experience and resources for disaster planning and response. Previous reports have offered disaster planning and response recommendations. We could not find a comprehensive review of studied interventions or facility attributes that affect disaster outcomes in LTCFs and their residents. We reviewed articles published from 1974 through September 30, 2015, that studied disaster characteristics, facility characteristics, patient characteristics, or an intervention that affected outcomes for LTCFs experiencing or preparing for a disaster. Twenty-one articles were included in the review. All of the articles fell into 1 of the following categories: facility or disaster characteristics that predicted preparedness or response, interventions to improve preparedness, and health effects of disaster response, most often related to facility evacuation. All of the articles described observational studies that were heterogeneous in design and metrics. We believe that the evidence-based literature supports 6 specific recommendations for facilities, governmental agencies, health care communities and academia. These include integrated and coordinated disaster planning, staff training, careful consideration before governments order mandatory evacuations, anticipation of the increased medical needs of LTCF residents following a disaster, and the need for more outcomes research. (Disaster Med Public Health Preparedness. 2017;11:140-149).

Narcotic administration and fall-related injury in the hospital: implications for patient safety programs and providers.

OBJECTIVEnIdentify factors that predict fall-related injury in hospitalized adults.nnnDESIGNnRetrospective records review.nnnSETTINGn435-bed university hospital.nnnPARTICIPANTSnInpatients with reported falls in 2010.nnnRESULTSnMedical records were available for 286/293 (98%) of reported falls in 251 patients. 25% (63/286) of falls were associated with injury, 4% (11/286) with serious injury. Compared to all fallers, patients with injury did not differ by gender or age. In univariate analysis, patients who reported hitting their head, had pre-fall confusion, or who received narcotics within 24 hours before falling were more likely to suffer injury (estimated odds ratios 6.04, 2.00 and 5.1, respectfully). In multivariate analysis, receiving a narcotic prior to falling was the strongest predictor of injury (estimated odds ratio 5.38; 95% confidence intervals 2.07-13.98, p < 0.001).nnnCONCLUSIONSnIn this single-institution study, 25% of patients who fell suffered injury and 4% serious injury. Neither age nor gender predicted fall-related injury. Recent narcotic administration was the strongest predictor of injury. Strategies to prevent fall-related injury in the hospital should target patients receiving narcotics. When evaluating inpatients who have fallen, providers should be especially vigilant about injury in patients who have pre-fall confusion, hit their head, or have received recent narcotics.

Brief structured observation of medical student hospital visits

INTRODUCTIONnStudents clinical, communication, and professionalism skills are best assessed when faculty directly observe clinical encounters with patients. Prior to 2009, third-year medical students at our institution had one observed clinical encounter by clinic-based faculty during a required internal medicine clerkship. These observations averaged 45 minutes, feedback was not standardized, and student and faculty satisfaction was low.nnnMETHODSnTwo hospital-based faculty members redesigned a shorter, standardized exercise during which a faculty member observed the student making rounds on a hospitalized patient that they were actively following. On a checklist, faculty recorded observations about communication (8 items), physical examination (5 items), and professionalism (4 items). Faculty provided immediate feedback.nnnRESULTSnFacultys direct observation of medical students prerounding on hospitalized internal medicine patients averaged 27 minutes including the feedback to students. In one year, 67/71 (94%) students completed the exercise; records were available for 66 (99%) of these encounters. Time of observation averaged 13.5 minutes (range 3-26 minutes). Feedback averaged 13.4 minutes (range 8-25 minutes). Faculty provided feedback in the following areas (proportion of students): Communication (66/66, 100%); examination skills (63/66, 95%); and professionalism (65/66, 98%). Forty-three students (64%) completed an anonymous satisfaction survey. Thirty-nine of these (91%) found the exercise useful or very useful (average 5-point Likert score = 4.30) and 38 (88%) found it easy or very easy to schedule (average 5-point Likert score = 4.30).nnnDISCUSSIONnStudents found this exercise useful and easy to schedule. Faculty consistently provided feedback to students in areas of communication, physical examination, and professionalism.