Inadequate documentation of asthma management in hospitalized adult patients.

Undocumented patient information in the medical record (MR) is a barrier to providing high quality care. Inadequate documentation has recently been reported for two cardiovascular diseases. This study was designed to evaluate the documentation of asthma management in the MR to determine if it is consistent with the NIH asthma guidelines. We performed a retrospective chart review of patients (ages 18-49) admitted to the hospital with an ICD-9 code for a primary diagnosis of asthma between January 2004 and May 2007. Patients admitted with a hospitalization for >24 hours and had <10 pack per year smoking history were included. We assessed medication regimens, documentation of asthma education, asthma action plans, referrals, and exacerbating factors. There were 233 admissions for 144 unique patients analyzed. At discharge, 85% of patients lacked documentation of asthma education, 97% lacked documentation of a written asthma action plan being given, and 79% did not have referral to an asthma specialist. Respiratory infection was the most common factor associated with admission; 58% of admissions were lacking documentation of the exacerbating factor. Only 47% of patients were receiving inhaled corticosteroids (ICS) prior to admission; 25% of patients did not have ICS prescribed for maintenance therapy upon discharge. Documentation of asthma management, specifically asthma education in the MR, is insufficient and may reflect a deficiency in care. Additionally, an inadequate number of patients were receiving ICS for maintenance therapy. Based on these findings, mechanisms are needed to ensure appropriate documentation and optimal care.

Intracerebral hemorrhage secondary to a warfarin-metronidazole interaction.

BACKGROUND: It has been >25 years since the interaction between warfarin and metronidazole was last reported in the literature. The current case report represents the first documentation of this interaction associated with intracerebral hemorrhage. CASE SUMMARY: We present a case of a 78-year-old white woman started on metronidazole (250 mg every 8 hours for 5 days) and levofloxacin (500 mg QD for 6 days) for an upper respiratory tract infection after visiting a walk-in clinic. The patient did not notify any of the health care professionals involved that she was on concomitant warfarin therapy, which had been stable over the last 3 months. Her warfarin dose was 7 mg daily, and her most recent international normalized ratio (INR) reading was 2.5. Nine days after her clinic visit, the patient was admitted to the hospital for a profuse nosebleed with an INR of 8.0 and was found to have an intraparenchymal hemorrhage of the left occipital lobe. The Naranjo adverse drug reaction probability scale indicated that the association with metronidazole was probable and the association with levofloxacin was possible (scores of 7 and 4, respectively). After a 1-week hospital stay, she was discharged. CONCLUSIONS: This adverse event is highly suggestive of a drug interaction caused primarily by metronidazole, which produces an increase in S-warfarin concentrations. Treatment provided by health care providers who were not familiar with the patient and the use of a different pharmacy (where the pharmacist was unaware of her current medications) likely contributed to the event.

Inadequate skill of healthcare professionals in using asthma inhalation devices.

Inadequate skill in the use of asthma inhalation devices by healthcare professionals has been well documented over the past 25 years. We performed a PubMed search of the English literature for studies regarding skill by physicians, medical students, pharmacists, nurses, and respiratory therapists in using asthma inhalation devices. This review summarizes 20 studies that were identified. Results of these studies consistently showed lack of skill in using metered-dose inhalers, spacers, and dry powder inhalers by a majority of healthcare professionals. National and international guidelines for asthma management include detailed patient education as an essential component of care, yet a large percentage of healthcare professionals are not competent in using inhalation devices. Practical solutions to this problem are needed to enhance the care of asthma patients.

Receptor autoradiographic correlates of deafferentation-induced reorganization in adult primate somatosensory cortex.

The primate somatosensory system provides an excellent model system with which to investigate adult neural plasticity. We have previously shown that transection of the median and ulnar nerves is followed by an expansion in the representation of radial nerve skin, and that this plasticity proceeds in stages. Immediately following nerve injury, new receptive fields are "unmasked" in a fraction of the affected cortex. The remaining deprived cortex regains responsiveness to tactile stimulation over the following days to weeks. Given these progressive changes, it has been suggested that different mechanisms might account for the earlier and later phases of reorganization. In the present experiments, we quantified receptor autoradiographic binding data for GABAA and GABAB, AMPA, and NMDA receptors in the primary somatosensory cortices of adult squirrel monkeys at four postnerve injury survival durations: immediately (1-3 hours), 3 days, 1 month, and 2 months. We found dramatic reductions in GABAA binding in layer IV within hours following nerve injury, and this reduction was maintained across all survival durations. This finding is consistent with the idea that the earliest reorganizational changes are due to a relaxation in tonic inhibitory mechanisms permitting the expression of formerly subthreshold receptive fields. GABAB receptor binding is decreased in layer IV by 1 month after nerve injury, while binding for AMPA receptors is increased in layer IV by this time. These findings are consistent with our previous suggestion that the second stage of reorganization proceeds via mechanisms comparable to those revealed to account for NMDA-dependent long-term potentiation in the hippocampus.

Auditory cortical neurons respond to somatosensory stimulation.

The prevailing hierarchical model of cortical sensory processing holds that early processing is specific to individual modalities and that combination of information from different modalities is deferred until higher-order stages of processing. In this paper, we present physiological evidence of multisensory convergence at an early stage of cortical auditory processing. We used multi-neuron cluster recordings, along with a limited sample of single-unit recordings, to determine whether neurons in the macaque auditory cortex respond to cutaneous stimulation. We found coextensive cutaneous and auditory responses in caudomedial auditory cortex, an area lying adjacent to A1, and at the second stage of the auditory cortical hierarchy. Somatosensory-auditory convergence in auditory cortex may underlie effects observed in human studies. Convergence of inputs from different sensory modalities at very early stages of cortical sensory processing has important implications for both our developing understanding of multisensory processing and established views of unisensory processing.

MR imaging of diffuse adenomyosis changes after GnRH analog therapy.

PURPOSE: To evaluate uterine changes on MRI before and after GnRH analog (GnRHa) treatment in diffuse adenomyosis. MATERIALS AND METHODS: Thirty-one patients with MRI features suggestive of diffuse adenomyosis received GnRHa for 6 months. Diffuse adenomyosis was sub-classified as: symmetric (symmetric/ entire widening of the junctional zone [JZ]) and asymmetric (asymmetric/ partial widening of JZ). Pre- and post-high signal intensity (SI) foci and JZ width, and post-demarcated change (interface of adenomyosis with the myometrium became more discrete with a concomitant decrease in JZ width) were analyzed. RESULTS: Before therapy, 15 of 18 asymmetric contained high SI foci compared to none of symmetric. After therapy, JZ width decreased (P < 0.0001). Eight asymmetric and none of symmetric showed demarcated change with resolved high SI foci. CONCLUSION: Our results suggest the use of GnRHa is associated with a decrease of JZ width in adenomyosis. Asymmetric adenomyosis with high SI foci appears to be the most sensitive to hormonal therapy.