Usual opioid dosing does not adversely affect the course of healthcare-associated Clostridioides difficile infection.

Aim: We sought to determine if opioid exposure may have a detrimental effect on the course of Clostridioides difficile infection (CDI). Materials & methods: We compared opioid exposure in patients with well-defined severe CDI and non-severe CDI. Results: Following exclusions, 403 records were reviewed. Of this group, 128/403 (31.7%) were determined to have severe CDI by strict criteria, and 275/403 (68.3%) were found to have non-severe CDI. Full multivariate regression and reduced model of potential predictors for severe CDI showed no association with opioids prescribed. Conclusion: Opioid exposure (predominantly in modest range) does not appear to be a risk factor for severe healthcare-associated CDI.

Eosinophilic esophagitis presenting with spontaneous esophageal rupture: a case report.

BACKGROUND: Eosinophilic esophagitis, once considered a rare disorder, has been increasingly recognized as a leading cause of dysphagia and food impaction in children and adults over the last few decades. It predominantly occurs in young men with a history of atopy. Dysphagia and food impaction are the most common presentations. However, rarely, spontaneous perforation (Boerhaave's syndrome) may occur in association with eosinophilic esophagitis. CASE PRESENTATION: A 40-year-old white woman with known history of eosinophilic esophagitis, who was non-compliant with treatment, presented with chest pain and developed acute spontaneous transmural esophageal perforation while eating a snack. Surgical repair was required. CONCLUSION: In a relatively young patient who presents with spontaneous esophageal perforation, eosinophilic esophagitis should always be ruled out as subsequent treatment may prevent recurrent perforation.

Proton pump inhibitors not associated with hypomagnesemia, regardless of dose or concomitant diuretic use.

BACKGROUND AND AIM: Proton pump inhibitors (PPIs) are among the most commonly prescribed medications worldwide, with dramatic efficacy for upper gastrointestinal acid-related disorders. In recent years, however, the safety of long-term PPI use has been questioned. One issue based on scant and conflicting literature is the possibility of PPI-related hypomagnesemia. Our purpose was to assess for any clinically significant alteration in serum magnesium levels in large groups of patients taking different PPIs in varying doses, with or without diuretics. METHODS: This was a retrospective review of patient records at time of hospitalization, from February 2012 to December 2014. Two thousand four hundred patients were randomly selected from a pool of 12 058 magnesium levels performed at or within 24 h of hospital admission. Patients were categorized in six groups based on outpatient PPI and/or diuretic use. The main outcome studied was hypomagnesemia, defined as serum magnesium level < 1.6 mg/dL. RESULTS: Mean magnesium levels were normal in PPI users (1.84 ± 0.29 mg/dL [normal 1.6 to 2.5 mg/dL]) and PPI nonusers (1.85 ± 0.30 mg/dL), P = 0.40, and there was no statistical difference in the prevalence of hypomagnesemia (14.7% vs 15.1%, P = 0.77). In separate groups, there were also no significant differences in serum magnesium levels between those taking PPIs of varying doses, with or without concomitant diuretics, and those not taking PPIs or diuretics. CONCLUSION: Regardless of PPI dosage or concomitant diuretics prescribed, magnesium levels were unaffected. Routine screening of serum magnesium in PPI patients appears unnecessary.

Detecting initial orthostatic hypotension: a novel approach.

Our purpose, by modification of standard bedside tilt-testing, was to search for lesser known but important initial orthostatic hypotension (IOH), occurring transiently within the first 30 seconds of standing, heretofore only detectable with sophisticated continuous photoplethysmographic monitoring systems, not readily available in most medical facilities. In screened outpatients over 60 years of age, supine blood pressure (BP) parameters were recorded. To achieve readiness for immediate BP after standing, the cuff was re-inflated prior to standing, rather than after. Immediate, 1-, and 3-minute standing BPs were recorded. One hundred fifteen patients were studied (mean age, 71.1 years; 50.5% male). Eighteen (15.6%) had OH, of whom 14 (12.1%) had classical OH, and four (3.5%) had IOH. Early standing BP detection time was 20.1 ± 5.3 seconds. Immediate transient physiologic systolic BP decline was detected in non-OH (-8.8 ± 9.9 mm Hg; P < .0001). In contrast to classical OH (with lesser but persistent orthostatic BP decrements), IOH patients had immediate mean orthostatic systolic/diastolic BP change of -32.8 (±13.8) mm Hg/-14.0 (±8.5) mm Hg (P < .02), with recovery back to baseline by 1 minute. Two of the four IOH patients had pre-syncopal symptoms. For the first time, using standard inflation-deflation BP equipment, immediate transient standing physiologic BP decrement and IOH were demonstrated. This preliminary study confirms proof of principle that manual BP cuff inflation prior to standing may be useful and practical in diagnosing IOH, and may stimulate direct comparative studies with continuous monitoring systems.

Proton pump inhibitor prescribing and costs in a large outpatient clinic.

UNLABELLED: Concerns have been raised regarding potential adverse effects and high costs of proton pump inhibitors (PPIs). Our objective was to assess issues of PPI utilization and expense in a large outpatient clinic population. METHODS: Two hundred-fifty-nine outpatient records were reviewed regarding PPI prescribing and indications during 2009. A cost analysis was performed to project cost differences if histamine-2 receptor antagonists (H2RAs) were used as an alternative to PPIs in appropriate clinical situations. RESULTS: Eighty-three (32.0%) were taking PPIs. Problem-listed gastroesophageal reflux disease (GERD) was the primary diagnosis in 69 (83.1%) of patients on PPIs. GERD was not apparent by documented history and/or endoscopy in 46.3% of problem-listed GERD patients. Symptom severity had been documented in only 36.2%. Cost analysis projected substantial savings if H2RAs had been used initially for mild to moderate symptoms. CONCLUSIONS: Outpatient PPI prescribing indications are not well documented and PPI use is probably excessive. H2RA therapy is likely underutilized.

Niacin induced coagulopathy as a manifestation of occult liver injury.

Niacin is an effective lipid-lowering agent which occasionally may cause hepatic failure. Liver enzymes are periodically tested during niacin therapy to assess for hepatic injury. We report a case of suppressed synthesis of hepatically derived coagulation factors and other liver proteins in a patient on niacin with no elevation of hepatic aminotransferases. The protein abnormalities reversed rapidly on discontinuation of niacin. It appears that niacin can cause occult liver injury without frank aminotransferase elevations, and may portend severe hepatotoxicity. Periodic assessment of prothrombin time should be considered in addition to aminotransferase levels to screen for liver injury. We believe this is the first reported case of occult hepatic injury due to extended release niacin, presenting as coagulopathy.

Dramatic decline in prevalence of Helicobacter pylori and peptic ulcer disease in an endoscopy-referral population.

PURPOSE: To determine if endoscopic Helicobacter pylori and peptic ulcer disease prevalence has changed over an 11-year period in a rural region. METHODS: Current endoscopic records were reviewed and compared with similar data obtained over a time period 11 years earlier at the same institution with regard to H. pylori status, endoscopic findings, microscopic pathologic findings, and medication use. RESULTS: There were 251 records reviewed in the current study group (mean age 52.8 years, 59.0% female) and 263 in the previous group (mean age 60.1 years, 56.7% female). H. pylori was positive in 17 (6.8%) in the current study and 173 (65.8%) in the earlier study (P <.0001). Peptic ulcer disease (PUD) was present in 14 (5.6%) in the current study and in 102 (38.8%) in the earlier study (P <.0001). H. pylori was positive in 1 of the 14 PUD patients (7.1%) in the current study and in 78 of 102 (76.5%) in the previous study (P <.0001). CONCLUSIONS: Endoscopic H. pylori prevalence in our rural locality has decreased substantially over the past decade and may reflect local overall prevalence trends, although underestimation is likely due to widespread prior noninvasive H. pylori diagnosis and treatment. Endoscopic PUD also has decreased precipitously, possibly related to changes in regional H. pylori characteristics and prolific use of antisecretory agents. Changing geographic trends regarding acid-peptic disease may prompt modification of diagnostic approach and treatment.

Approach to pain management in a large outpatient clinic population.

Though it is our ethical imperative to minimize discomfort, physicians often struggle to manage pain effectively, mainly due to time constraints, lack of training, and fear of litigation regarding over-prescribing of controlled substances. In addition, physicians also now must face potential litigation for under treatment of persistent pain. This dilemma often leaves the physician with a sense of insecurity and stress. We have provided a brief review of our approach to seek improvement in excluding substance abusers/drug diverters from those in need of aggressive pain management in the internal medicine outpatient clinics of a teaching institution. Multiple combined treatment modalities are usually employed, including physical interventions, evaluation and treatment of concomitant depression and psychosocial issues, pain modulators and analgesics, and consultations as indicated by clinical presentation. Experience and intuition are required in many cases. In our large volume, high complexity clinic setting, we continue to pursue guidelines to improve and streamline screening for substance abuse or the potential for abuse, particularly in younger individuals. In the elderly, since abuse potential is less likely and disease documentation is often more readily apparent, we feel relatively comfortable in initiating careful prescribing of opioid therapy early on. As we become more adept at our approach toward pain management issues, we will attempt some assessment of outcomes by observing changes in several parameters, including numbers of opioid prescriptions and comparative adequacy of pain control over time. National and local pain/addiction information and referral resources are available as follows: http:// www.nationalsubstanceabuseindex .org and http://www.wvupc. org/charleston/painlist.