Impact of cardiology referral: clinical outcomes and factors associated with physicians' adherence to recommendations

OBJECTIVES: Cardiology referral is common for patients admitted for non-cardiac diseases. Recommendations from cardiologists may involve complex and aggressive treatments that could be ignored or denied by other physicians. The purpose of this study was to compare the outcomes of patients who were given recommendations during cardiology referrals and to examine the clinical outcomes of patients who did not follow the recommendations. METHODS: We enrolled 589 consecutive patients who received in-hospital cardiology consultations. Data on recommendations, implementation of suggestions and outcomes were collected. RESULTS: Regarding adherence of the referring service to the recommendations, 77% of patients were classified in the adherence group and 23% were classified in the non-adherence group. Membership in the non-adherence group (p<0.001; odds ratio: 10.25; 95% CI: 4.45-23.62) and advanced age (p = 0.017; OR: 1.04; 95% CI: 1.01-1.07) were associated with unfavorable outcomes. Multivariate analysis identified four independent predictors of adherence to recommendations: follow-up notes in the medical chart (p<0.001; OR: 2.43; 95% CI: 1.48-4.01); verbal reinforcement (p = 0.001; OR: 1.86; 95% CI: 1.23-2.81); a small number of recommendation (p = 0.001; OR: 0.87; 95% CI: 0.80-0.94); and a younger patient age (p = 0.002; OR: 0.98; 95% CI: 0.96-0.99). CONCLUSIONS: Poor adherence to cardiology referral recommendations was associated with unfavorable clinical outcomes. Follow-up notes in the medical chart, verbal reinforcement, a limited number of recommendations and a patient age were associated with greater adherence to recommendations. .

Perioperative cardiovascular evaluation: heads or tails?

When dealing with surgical patients, a perioperative evaluation is essential to anticipate complications and institute measures to reduce the risks. Several algorithms and exams have been used to identify postoperative cardiovascular events, which account for more than 50% of perioperative mortality. However, they are far from ideal. Some of these algorithms and exams were proposed before important advances in cardiology, at a time when pharmacological risk reduction strategies for surgical patients were not available. New biomarkers and exams, such as C-reactive protein, brain natriuretic peptide, and multislice computed tomography have been used in cardiology and have provided important prognostic information. The ankle-brachial index is another significant marker of atherosclerosis. However, specific information regarding the perioperative context of all these methods is still needed. The objective of this article is to evaluate cardiovascular risk prediction models after noncardiac surgery.

Anthropometric measurements of nutritional status in chronic pancreatitis in India: comparison of tropical and alcoholic pancreatitis.

Aim Undernutrition is considered to be a cause of tropical pancreatitis (TP) since this disease is commonly seen in the underprivileged populations of the world. This study was done to compare the nutritional status in patients with TP and alcoholic chronic pancreatitis (ACP) using anthropometric measurements. Methods Anthropometric measurements were done in patients with TP and ACP aged >18 years and matched healthy controls. Presence of pain, recent dietary restriction, diabetes mellitus (DM), calcification, serum prealbumin (PAB), and quantitative fecal elastase (FE) was assessed. Premorbid body mass index (BMI) was determined from weight before the onset of illness as reported by the patients. Results Of 54 patients (47 male), 39 (72.2%) had TP and the rest had ACP. Patients with TP were younger than those with ACP; the frequency of pain, DM, calcification, and exocrine insufficiency was similar in the two groups. Compared to control subjects, patients had lower BMI, triceps skin fold thickness (TSFT) and mid-arm circumference (MAC) (p<0.01), but waist-to-hip ratio (W/H) was similar. Undernutrition was equally common in TP and ACP (15 [38.5%] vs. 6 [40%]). The BMI, TSFT, MAC, and W/H were similar in TP and ACP. The premorbid BMI was higher than that at presentation (20.2 [3.8] kg/m² vs. 19.1 [3.3] kg/m², p<0.01). There was no association between BMI and features contributing to undernutrition (DM, pain, recent dietary restriction, FE level, and calcification) on univariate analysis. Conclusions Energy undernutrition occurs equally commonly in TP and ACP and this appears to develop after the onset of illness.

A case report of herpetic and candidal esophagitis in an immunocompetent adult

Reports of combined candidal and herpetic esophagitis in immunocompetent states are rare and sporadic. A 44-year-old previously healthy lady presented with a one week history of progressive dysphagia, odynophagia and fever. Esophagogastroduodenoscopy (EGD) showed extensive desquamation of the entire esophagus except for distal 4 cm. Histopathological examination revealed ulcerated and inflamed squamous epithelium with the margin of ulcer showing a few overhanging squamous cells with dense eosinophilic cytoplasm, multinucleated and faceted nuclei with glassy chromatin, and an occasional Cowdry type A intranuclear inclusion bodies. Few candidal spores were seen in the underlying stroma. Intravenous acyclovir, fluconazole and pantoprazole were initiated. Oral analgesics were given for pain relief. She was treated for a total of 14 days. She showed significant improvement and was tolerating oral intake after discharge. The patient was asymptomatic with no evidence of recurrence at a 2-month follow-up.

Hepatic cerebrospinal fluid pseudocyst: a case report and review of the literature.

An abdominal pseudocyst is a rare, but important complication in patients with a ventriculo-peritoneal (VP) shunt insertion. Several predisposing factors for this complication have been suggested, including infection, obstruction or dislodgement, but the pathophysiology is still unknown. However, the abdominal inflammatory process is accepted widely as a hypothesis for the formation of an abdominal pseudocyst. In this study, we report the case of a 21-year-old male that presented with a high-grade fever, poor appetite, shortness of breath and unconsciousness 1 week after receiving a VP shunt insertion for obstructive hydrocephalus. Ultrasonography and computed tomographic scans of the abdomen revealed a well-defined large hepatic cyst surrounding the peritoneal tube of the VP shunt. A hepatic cerebrospinal fluid (CSF) cyst was diagnosed and Staphylococcus epidermis was cultured via CSF. After externalization of the VP shunt and adequate antibiotic treatment, the hepatic cyst was resolved. There was no recurrence observed in the regular follow up.

A pilot study of the antioxidant effect of curcumin in tropical pancreatitis.

BACKGROUND & OBJECTIVES: Oxidative stress occurs in association with painful exacerbations of chronic pancreatitis and antioxidant supplementation appears to benefit this condition. Curcumin, the active constituent of turmeric, is known to exhibit antioxidant activity. This pilot study was therefore undertaken to evaluate the effect of oral curcumin with piperine on the pain, and the markers of oxidative stress in patients with tropical pancreatitis (TP). METHODS: Twenty consecutive patients with tropical pancreatitis were randomised to receive 500 mg of curcumin with 5 mg of piperine, or placebo for 6 wk, and the effects on the pattern of pain, and on red blood cell levels of malonyldialdehyde (MDA) and glutathione (GSH) were assessed. RESULTS: There was a significant reduction in the erythrocyte MDA levels following curcumin therapy compared with placebo; with a significant increase in GSH levels. There was no corresponding improvement in pain. INTERPRETATION & CONCLUSION: Oral curcumin with piperine reversed lipid peroxidation in patients with tropical pancreatitis. Further studies with large sample are needed to define its effect on the pain and other manifestations of tropical pancreatitis.

Quadruple therapy for initial eradication of Helicobacter pylori in peptic ulcer: comparison with triple therapy.

BACKGROUND: Quadruple therapy appears to be more effective than standard triple therapy in the management of patients with Helicobacter pylori infection who harbor drug-resistant organisms. No data are available on the relative efficacies of triple and quadruple drug regimens from India. METHODS: Consecutive patients with peptic ulcer and H. pylori infection were randomized to receive lansoprazole 30 mg twice daily along with either amoxycillin (500 mg four times daily) and clarithromycin (500 mg twice a day) (Group A), or tri-potassium dicitrato bismuthate (120 mg four times daily), metronidazole (400 mg thrice daily) and tetracycline (500 mg 4 times daily) (Group B) for 10 days. Presence of H. pylori infection was looked for using an in-house urease test and histology before starting treatment, and 30 days after completion of treatment. RESULTS: Twenty-nine of 35 patients in Group A and 24 of 33 in Group B had eradication of infection (82.8% and 72.7% by intention-to-treat analysis, and 87.9% and 85.7% by per protocol analysis, respectively; p = ns). Side-effects occurred in 4 (12%) and 5 (18%) patients in Groups A and B, respectively (p = ns); discontinuation of drugs was required in two patients in group B. CONCLUSIONS: Quadruple therapy for initial treatment of H. pylori infection does not offer any advantage over standard triple therapy in Indian patients.

Hepatic abscess caused by Salmonella typhi.

A 64 years diabetic man presented with recurrent episodes of fever and abdominal pain. Ultrasonography revealed the presence of an abscess in the right lobe of the liver and a distended gall bladder with multiple calculi. Salmonella typhi was grown from the liver aspirate. Cholelithiasis may act as a predisposing factor for hepatic abscess formation in Salmonella carriers.

An unusual paratyphoid fever.

Salmonella typhi is known to produce acalculous cholecystitis and related gall bladder perforation. Following is a documentation of a patient of sub-phrenic abscess and gall bladder perforation which was possibly a result of Salmonella paratyphi A.

Precut papillotomy using needle knife fashioned from discarded standard papillotomes.

AIM: To evaluate the results of precut papillotomy using needle-knife papillotomes fashioned from discarded standard sphincterotomes. METHODS: Case records of 50 patients undergoing precut papillotomy for access to either common bile duct or pancreatic duct during endoscopic retrograde cholangiopancreatography were reviewed. Precut was performed using needle-knife papillotomes fashioned from standard pull-type sphicterotomes that were discarded because of broken cutting wires. A diagnostic procedure was planned in all 50 patients (bile duct = 39, pancreatic duct = 9, both ducts = 2) and therapeutic procedure in 36 patients (bile duct = 31, pancreatic duct = 5). RESULTS: Of the 47 patients who needed precut prior to diagnostic ERCP, 44 (93.6%) underwent successful cannulation of the duct of choice. Therapeutic procedures were planned in 36 patients; these were successful in 24 (67%; bile duct = 22, pancreatic duct = 2). The complications included cholangitis in 8 patients (16%) and pancreatitis in 2 (4%). None had bleeding or perforation. CONCLUSIONS: Precut needle-knife papillotomes fashioned from discarded standard sphincterotomes can be used effectively and can help in cost containment in endoscopic retrograde cholangiopancreatography.

Is Crohn's disease rare in India?

BACKGROUND: Crohn's disease (CD) is believed to be rare in India. OBJECTIVE: To analyze the data pertaining to patients with CD seen in a tertiary referral center. METHODS: Data on patients with chronic inflammatory bowel disease attending our Unit over a 5-year period were analyzed. The diagnosis of CD was established by the presence of characteristic segmental bowel involvement, consistent histological picture, exclusion of infectious causes, relapsing nature of the disease, response to appropriate drug therapy, and lack of evidence for another etiological factor. RESULTS: Of the 25 patients (age range 12-52, mean 31.7, years) 13 were men. Abdominal pain was present in 21 (84%) patients, diarrhea in 20 (80%), blood per rectum in 11 (44%) and fever in 4 (16%). The ileocecal region was involved in 6 (24%) patients and anal canal in 4 (16%); 19 (76%) had patchy involvement of different segments of the large bowel. Colonoscopic biopsies revealed granulomas in 12 (48%). During a mean follow up of 36.4 (range 6-54) months, 15 (60%) patients had 21 relapses. Despite initial response to 5-aminosalicylic acid in five patients, 23 needed glucocorticoid therapy at least once. CONCLUSIONS: CD may not be rare in India. Because of the high prevalence of intestinal tuberculosis there is a possibility that CD may be under-recognized in India.

Evidence for oxidant stress in chronic pancreatitis.

BACKGROUND: Oxidant stress leading to lipid peroxidation is reported to be the common link in the pathogenesis of chronic pancreatitis irrespective of etiology. AIM: To look for evidence of lipid peroxidation in duodenal juice in patients with chronic pancreatitis. METHODS: 19 patients with chronic pancreatitis (14 tropical, 5 alcoholic) and 19 age- and sex-matched subjects with abdominal pain without any cause were studied. Contents were aspirated from the second part of the duodenum during gastroduodenoscopy. Malonyl dialdehyde (MDA) levels were measured in duodenal juice by the thiobarbituric acid method. RESULTS: MDA levels were higher in patients than in the control group (mean [SD] 42.6 [17.0] vs 29.2 [11.7] nmol/mL; p < 0.05). On linear and multiple regression analysis, none of the disease factors correlated with duodenal juice MDA levels. CONCLUSIONS: Lipid peroxidation products are increased in patients with chronic tropical and alcoholic pancreatitis.

A modified radiographic method for estimating segmental colonic transit time in subjects with rapid gut transit.

In this study on Indian subjects, the single X-ray method was assessed for its reliability in measuring the transit of particulate matter through the colon, and if inaccurate a suitable and simple alternative was to be devised. Radio-opaque markers were serially followed in 20 normal male volunteers. This was done by three 12 hourly radiographs and by stool collection to determine the transit time through the colon and its segments. It was compared with similar parameters calculated from the same data using one radiograph and three combinations of two radiographs each. The mean +/- SD colonic transit time determined by using three X-rays was 18.0 +/- 6.6 h which agreed well with the mean mouth-to-anus transit time of 24.2 +/- 6.8 h (mean +/- SDdiff = -6.2 +/- 2.9). When two of the three X-rays were used in various combinations, the best results were obtained with the method including radiographs at 12 and 36 h. Parameters calculated from a single radiograph done 36 h after the ingestion of makers showed lesser agreement with the results of the three radiograph method. Therefore in subjects with rapid gut transit, the simplified method for estimating the colonic and segmental transit times using a single X-ray is inaccurate. Using two radiographs enhances the accuracy.