Soma Wali

Formulated collagen gel accelerates healing rate immediately after application in patients with diabetic neuropathic foot ulcers

We assessed the safety and efficacy of Formulated Collagen Gel (FCG) alone and with Ad5PDGF‐B (GAM501) compared with Standard of Care (SOC) in patients with 1.5–10.0 cm2 chronic diabetic neuropathic foot ulcers that healed <30% during Run‐in. Wound size was assessed by planimetry of acetate tracings and photographs in 124 patients. Comparison of data sets revealed that acetate tracings frequently overestimated areas at some sites. For per‐protocol analysis, 113 patients qualified using acetate tracings but only 82 qualified using photographs. Prior animal studies suggested that collagen alone would have little effect on healing and would serve as a negative control. Surprisingly trends for increased incidence of complete closure were observed for both GAM501 (41%) and FCG (45%) vs. Standard of Care (31%). By photographic data, Standard of Care had no significant effect on change in wound radius (mm/week) from during Run‐in to Week 1 (−0.06±0.32 to 0.78±1.53, p=ns) but both FCG (−0.08±0.61 to 1.97±1.77, p<0.002) and GAM501 (−0.02±0.58 to 1.46±1.37, p<0.002) significantly increased healing rates that gradually declined over subsequent weeks. Both GAM501 and FCG appeared to be safe and well tolerated, and alternate dosing schedules hold promise to improve overall complete wound closure in adequately powered trials.

Attaining resident duty hours compliance: the acute care nurse practitioners program at Olive View-UCLA Medical Center.

The institution of resident duty hours limits by the Accreditation Council for Graduate Medical Education (ACGME) has made it difficult for some programs to cover inpatient teaching services. The medical literature is replete with editorials criticizing the hour limits and the resulting problems but is nearly silent on the topic of constructive solutions to compliance. In this article, the authors describe a new program, initiated in 2003 at the Olive View–UCLA Medical Center, of using acute care nurse practitioners to allow for compliance with the “24 + 6” continuous duty hours limit, as well as the 80-hour workweek limit. Each post-call team is assigned a nurse practitioner for the day, allowing residents to sign out by 2 pm while ensuring quality care for patients. Nurse practitioners participate in evaluation of residents and, in turn, are evaluated by them. Using this system, the authors report 99% compliance with ACGME work-hour restrictions, with average work hours for inpatient ward residents decreasing from 84 to 76 hours per week. Physician satisfaction with the new system is high; anonymous evaluation by residents and faculty returned average scores of 8.8 out of 9 possible points. The authors report that using nurse practitioners on post-call days provides excellent, continuous patient care without impinging on scheduling and without sacrificing responsibility, continuity, or education for the residents. This system has several potential advantages over previously described work-hour solutions. Addition of a nurse practitioner to the post-call team is an effective solution to the problem of compliance with resident duty hours limitations.

Cost-effectiveness of a hospitalist service in a public teaching hospital.

Purpose The authors report implementing an academic hospitalist team as a cost-effective solution to the problem of an inpatient census that exceeds their public hospitals teaching service limits. Medi-Cal (Californias Medicaid program) per diem reimbursement was the primary source of revenue, which rendered moot some traditional advantages of hospitalist services. Method The authors assessed cost-effectiveness by comparing average inpatient census, payment denial rate, and Medi-Cal reimbursement for internal medicine in 2008 and in 2007. They also focused on Medi-Cal patients admitted with low-risk chest pain in 2008, comparing the length-of-stay and denied-day rate data with data from 2005. Results Overall Medi-Cal reimbursement was

Deep Vein Thrombosis /Pulmonary Embolism in a Patient with Retroperitoneal Fibrosis: A Case Report

2,310,000 higher in 2008 than in 2007. Overall payment denial rate fell from 29% to 27.4%, while yearly admissions increased from 8,069 to 8,643, and the average daily census increased from 97.7 to 107.1 patients. For low-risk chest pain admissions, length of stay decreased from 2.48 to 1.92 days, denial rate decreased from 43.8% to 31.8%, and average reimbursement per inpatient day increased from

The Role of Percutaneous Coronary Intervention in the Treatment of Chronic Total Occlusions: Rationale and Review of the Literature

787 to

Immobilization-induced hyperphosphatemia: successful therapy with biphosphonates

955. Total salary outlay for the first year of the service was approximately

Use of alternative medicine among Hispanics.

310,000. Conclusions By reducing payment denials and increasing the inpatient census, hospitalists were able to more than offset their compensation with a substantial increase in revenue under per diem reimbursement, which adds a new dimension to prior reports of cost-effectiveness of hospitalist services in diagnosis-based, capitated, or fee-for-service reimbursement systems. Hospitalists are a cost-effective solution to the problem of increasing inpatient workloads at public teaching hospitals.

Supporting handheld technologies in a medical school curriculum: lessons from three years of design, development and implementation

Introduction: Retroperitoneal Fibrosis (RPF) is a clinicopathological condition characterized by inflammatory fibrotic reaction around infrarenal aorta, iliac vessels and surrounding retroperitoneum with myriad presentations. This case report shows how a Deep Vein Thrombosis (DVT) and subsequent Pulmonary Embolism (PE) can be a potential complication of this disease. A potential temporal association was seen with chronic beta blocker use and retroperitoneal fibrosis. Case presentation: A 62-year-old Caucasian male with history of hypertension on chronic beta-blocker therapy for 2 years (Metoprolol 50 mg twice daily) presented with sub-acute left sided non-radiating lower back pain of 5-day duration. Computerized Tomography (CT) scan with contrast of the abdomen and pelvis revealed large segment of inflammatory stranding involving the periaortic retroperitoneum extending from the level of the kidneys upto the pelvis and incasing the left Iliac veins. CT guided retroperitoneal core biopsy was done which was consistent with retroperitoneal fibrosis. Two months later, patient presented with complain of acute onset shortness of breath and increasing lower extremity edema, on the left side. Electrocardiogram was consistent with a finding of new onset Atrial fibrillation (A fib). Ultra Sono Gram (USG) Doppler study of lower extremities unveiled occlusive left sided DVT of the popliteal vein. A CT Angiography demonstrated segmental and sub-segmental pulmonary emboli of the right lower lobe with no evident pulmonary edema. He was treated with steroids, digoxin and warfarin. On follow up a repeat CT scan three months later of the abdomen and pelvis showed stable retroperitoneal mass with no further progression. Conclusion: Our patient presented with lower extremity edema and imaging revealed extension of RPF to involve common iliac vessels. With beta-blockers as a possible inciting event, RPF causing venous stasis, iliac vein compression and thus DVT/PE is the most plausible explanation This case reports add to the medical literature how DVT/PE can be cause by an underlying disease entity not related to the usual causes and if not worked up patients may be labeled as having unprovoked events. Any relationship between beta blockers and RFP is questionable and has not been proven in any randomized trials, but should be thought of by the physician if such clinical situation is encountered.

Burkitt lymphoma presenting with hypercalcemic emergency.

BACKGROUND Chronic total occlusion (CTO) of a coronary artery is defined as an occluded segment with no antegrade flow and a known or estimated duration of at least 12 weeks. OBJECTIVE We considered the current literature describing the indications and clinical outcomes for denovo CTO- percutaneous coronary intervention (PCI), and discuss the role of CTO-PCI and future directions for this procedure. METHODS Databases (PubMed, the Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL were searched and relevant studies of CTO-PCI were selected for review. RESULTS The prevalence of coronary artery CTOs has been reported to be ~ 20% among patients undergoing diagnostic coronary angiography for suspected coronary artery disease. Revascularization of any CTO can be technically challenging and a time-consuming procedure with relatively low success rates and may be associated with a higher incidence of complications, particularly at non-specialized centers. However, with an increase in experience and technological advances, several centers are now reporting success rates above 80% for these lesions. There is marked variability among studies in reporting outcomes for CTO-PCI with some reporting potential mortality benefit, better quality of life and improved cardiac function parameters. Anecdotally, properly selected patients who undergo a successful CTO-PCI most often have profound relief of ischemic symptoms. Intuitively, it makes sense to revascularize an occluded coronary artery with the goal of improving cardiovascular function and patient quality of life. CONCLUSION CTO-PCI is a rapidly expanding specialized procedure in interventional cardiology and is reasonable or indicated if the occluded vessel is responsible for symptoms or in selected patients with silent ischemia in whom there is a large amount of myocardium at risk and PCI is likely to be successful.

Thiazolidinedione-associated congestive heart failure and pulmonary edema. Authors' reply

A 54-year-old man with history of traumatic brain injury several months earlier was referred to our hospital. On presentation, patient was noted to have an elevated serum phosphorous of 5.3 mg/dl (normal: 2.4-4.7 mg/dl), persistently high-normal total serum calcium levels [range 9.3-10.0 mg/dl, normal: 8.9-10.3 mg/dl], normal ionized calcium [range 5.1-5.4 mg/dl, normal: 4.8-5.6 mg/dl], normal renal function, suppressed levels of parathyroid hormone (PTH) 7 pg/m [normal: 1565 pg/ml] and 1,25 di-hydroxy vitamin D < 8 pg/ml [normal: 18-72 pg/ml]. Body stores of vitamin D were adequate as reflected by normal serum 25-hydroxy vitamin D [38.1 ng/ml, normal 30-96 ng/ml]. Urine phosphate was 960 mg/24 h [normal: 360-1600 mg/24 h]. Trials of lowphosphate diet and chelating agent calcium acetate were not effective in lowering serum phosphate. On hospital day 30, pamidronate 30 mg was given intravenously. Patient’s serum phosphorous and PTH levels normalized 48 hours later (Figure 1).