Narayan Neupane

Inappropriate Use of Intravenous PPI for Stress Ulcer Prophylaxis in an Inner City Community Hospital

Background Proton pump inhibitors (PPIs) are used for the treatment and prophylaxis of variety of acid peptic conditions including stress ulcers. There has been a persistent practice of their inappropriate use for stress ulcer prophylaxis. Purpose of our study was to measure the inappropriate use of Intravenous Proton Pump Inhibitors for stress ulcer prophylaxis and to estimate the financial burden. Methods We carried out a retrospective, analytic study from July 2008 to June 2009 in internal medicine department. Hospital pharmacy records were used to identify all patients who received IV PPI during hospital stay. Seventy-five percent of records were randomly chosen (n=1104). PPI application was defined as indicated according to AGA guidelines. Results Intravenous proton pump inhibitor (IV PPI) was prescribed for 68.5% of patients without any proper indication. The estimated cost of medication for inappropriate IV PPIS use during the study year was 18337 USD. Conclusions A more rational use of PPI will have better impact on health care cost and is likely to add to patient safety. Keywords Inappropriate use of PPI; Stress ulcer prophylaxis; Healthcare cost

Disseminated Mycobacterium avium intracellulare infection in an "immunocompetent" host.

We are reporting the case of a 37-year-old immunocompetent patient who presented with anterior chest wall swelling, jaw swelling and pain, back pain, night sweats, and unintentional weight loss. He underwent mediastinoscopy with lymph node biopsy, which revealed caseating and noncaseating granuloma and special stains positive for acid-fast bacteria. Cultures from two different sites surprisingly grew Mycobacterium avium intercellulare (MAI), and a diagnosis of disseminated MAI was made. He was switched from antituberculous treatment to MAI treatment.

Pain in right thigh: a benign presentation of a life-threatening disease.

To the Editor A 25-year-old African–American gentleman with no known medical history presented with vomiting and pain in his right thigh for 1 day. According to the patient, he had attended a party the previous night when he participated in a group dance for about 15 min. About 2 h later, he was engaged in sexual activity, but had to stop because of the sudden onset of severe pain and tightness in his right thigh. The pain was 8/10 in intensity and aching in nature. He tried Tylenol to relieve pain, but to no effect. Next morning he had three episodes of nonbloody projectile vomiting. He also noticed that his urine was red in color. He did not complain of shortness of breath, chest pain, cough, headache or trauma, and reported no smoking or drug abuse. He works in Home Depot as clerk and only drinks alcohol socially. Family history: his father had myocardial infarction at 62 and his mother had diabetes mellitus. On physical examination, the patient was alert, awake and oriented, lying in bed in moderate distress because of the pain in his right thigh. Vitals showed blood pressure of 131/85 mmHg, pulse of 65/min and temperature of 99.28F (37.38C). His chest was clear to auscultation with bilateral vesicular breathing. Both heart sounds were regular with no added sound. The right thigh was tender on the medial side. No discoloration or bruising was noticed. Pulses were equal in both limbs. Laboratory data showed severe rhabdomyolysis [creatine phosphokinase (CPK) 332674] and hemoconcentration. ECG showed normal sinus rhythm. Chest radiograph was normal, with no infiltrates, effusions or mediastinal widening.