Impact and effect of imaging referral guidelines on patients and radiology services: a systematic review.

OBJECTIVES: The objective of this systematic review was to offer a comprehensive overview and explore the associated outcomes from imaging referral guidelines on various key stakeholders, such as patients and radiologists. MATERIALS AND METHODS: An electronic database search was conducted in Medline, Embase and Web of Science to retrieve citations published between 2013 and 2023. The search was constructed using medical subject headings and keywords. Only full-text articles and reviews written in English were included. The quality of the included papers was assessed using the mixed methods appraisal tool. A narrative synthesis was undertaken for the selected articles. RESULTS: The search yielded 4384 records. Following the abstract, full-text screening, and removal of duplication, 31 studies of varying levels of quality were included in the final analysis. Imaging referral guidelines from the American College of Radiology were most commonly used. Clinical decision support systems were the most evaluated mode of intervention, either integrated or standalone. Interventions showed reduced patient radiation doses and waiting times for imaging. There was a general reduction in radiology workload and utilisation of diagnostic imaging. Low-value imaging utilisation decreased with an increase in the appropriateness of imaging referrals and ratings and cost savings. Clinical effectiveness was maintained during the intervention period without notable adverse consequences. CONCLUSION: Using evidence-based imaging referral guidelines improves the quality of healthcare and outcomes while reducing healthcare costs. Imaging referral guidelines are one essential component of improving the value of radiology in the healthcare system. CLINICAL RELEVANCE STATEMENT: There is a need for broader dissemination of imaging referral guidelines to healthcare providers globally in tandem with the harmonisation of the application of these guidelines to improve the overall value of radiology within the healthcare system. KEY POINTS: The application of imaging referral guidelines has an impact and effect on patients, radiologists, and health policymakers. The adoption of imaging referral guidelines in clinical practice can impact healthcare costs and improve healthcare quality and outcomes. Implementing imaging referral guidelines contributes to the attainment of value-based radiology.

Appropriateness of lumbar spine radiography and factors influencing imaging ordering patterns: paving the path toward value-driven health care.

The demand for diagnostic imaging continues to rise. Against the backdrop of rising health care costs and finite resources, this has prompted a paradigm shift toward value-driven patient care. Inappropriate imaging is a barrier toward achieving this goal, which runs counter to prevailing evidence-based guidelines and contributes to rising healthcare costs. Our objective was to evaluate the appropriateness of lumbar spine X-rays in a tertiary referral Emergency Department (ED) and assess whether physicians' specialization and years of experience influence appropriateness. A total of 1030 lumbar spine radiographs performed in the ED of an academic medical center over a consecutive 3-month period were reviewed retrospectively. Referral indications were reviewed for adherence to 2021 American College of Radiology appropriateness guidelines for lower back pain, and referral patterns were evaluated among physician groups based on specialists' training and years in practice. 63.8% of lumbar spine radiographs were appropriate, with trauma being the most common indication. 36.2% of orders were inappropriate, with lower back pain of <6 weeks duration being the most common indication. Significant differences in inappropriate orders were found (P < .001) across physician groups: qualified Emergency Medicine specialists (20.9% inappropriate orders), specialists in training (27.8%), and non-specialists with ≥3 (60.0%) and <3 (36.9%) years in practice, respectively. Approximately one-third of lumbar spine radiographs performed in the ED were inappropriately ordered by American College of Radiology guidelines; specialists training and years in practice affected referral patterns. Integrating evidence-based appropriateness guidelines into the physician order workflow and targeting older non-specialists may promote more judicious imaging and reduce health care costs.

Adapting an integrated care pathway for implementing electronic patient reported outcomes assessment in routine oncology care: Lessons learned from a case study.

RATIONALE, AIMS AND OBJECTIVE: Details of the development and implementation of integrated care pathways (ICPs) in the context of electronic collection of patient reported outcomes (ePROs) for cancer patients are largely lacking in the literature. This study describes what, why and how decisions were made to adapt and implement an ePROs ICP for patients with lung cancer. METHODS: A consensus process was utilized, with the implementation advisory group including multidisciplinary representation from three participating hospitals, to identify local champions and adapt and incorporate the ePRO ICP into the local contexts. Engagement meetings were documented via meeting transcripts, and detailed notes from October 2019 to November 2020 were content-analysed to identify decision-making themes based on the Consolidated Framework for Implementation Research; workflows and process maps were reviewed and modified to integrate ePROs. RESULTS: In total, 55 engagement activities were held (24 meetings, 20 workshops 11 educational sessions), with n = 96 staff from multiple disciplines participating in the ePROs implementation through advisory meetings, process mapping, change management and staff education. Decisions were made regarding eligible patient cohorts to include, the process for onboarding patients onto the ePRO system, and follow-up and referral pathways. Rationales for decisions included alignment with existing workflows, utilizing available staff, minimizing staff and patient burden and maximizing patient engagement. CONCLUSION: Existing resources, staff input and technical and logistical reasons often guided the ICP decisions, highlighting the need for in-depth engagement across all stakeholders for optimal implementation of ePRO ICPs. The ePRO implementation required substantial dialogue and systematic resolution to reach agreement on the final processes. Adapting the local ICP through rigorous engagement facilitated the successful implementation of ePROs as business-as-usual at all three cancer centres. Involving all relevant stakeholders is critical to the successful adaptation of ICPs before their introduction into routine care.

Validation of an electronic food intake tool and its usability and efficacy in the healthcare setting.

BACKGROUND: Accurate dietary intake data are critical to nutrition care planning. Commonly used food record charts (FRC) are paper-based, time consuming, require nutrient analysis estimations, and may provide limited accuracy. The present study aimed to validate Mobile Intake® (MI) (an electronic food intake tool incorporating the five-point visual scale and providing automatic nutrient analysis) for usability and efficacy in quantifying dietary intake in the healthcare setting. METHODS: Two research stages within two tertiary hospitals included: (1) examining criterion validity and efficiency of dietary intake quantification using FRC and MI compared to the gold standard weighed food record (WFR) in a controlled environment and (2) comparing efficiency and effectiveness of FRC and MI in usual care conditions. RESULTS: In Stage 1, dietary intake was calculated (n = 90) with a significant difference across all methods (FRC, MI and WFR) for energy (p = 0.04), but not between MI and WFR (p = 1.00). The time taken for MI (40 s) was significantly less than FRC (174 s) and WFR (371 s) (p < 001). In Stage 2, dietary intake was determined (n = 210) using FRC and MI. Sufficient data to complete dietary analysis were available for 35% of meals from FRC compared to 98% from MI. Calculated mean daily energy intake (4764 ± 1432 kJ vs. 6636 ± 2519 kJ, p = 0.002) and mean daily protein intake (62.9 ± 12.7 g vs. 78.5 ± 22.2 g, p = 0.007) were significantly lower with FRC compared to MI. Average time to complete MI was 14.4 seconds. CONCLUSIONS: MI demonstrates efficacy as an accurate measure of dietary intake compared to WFR, as well as usability, providing faster, more accurate and comprehensive real-time intake data in practice than FRC.

Implementation of a peer review program using the validated DIET-COMMS tool to assess dietitians' communication skills in the workplace.

AIMS: Communication is the main method used by dietitians to conduct their practice. Yet, few evidence-based tools are available to assess dietitians' communication skills to guide skill development. Further, workplace peer review programs for assessment of communication skills are not standard practice. DIET-COMMS is a validated tool to assess dietitians' communication skills in patient consultations. The aims of this study were to implement a workplace peer review program using the DIET-COMMS tool, assess dietitians' communication skills, evaluate inter-rater reliability and dietitian satisfaction. METHODS: Single site study within Australian hospital dietetics department. Training for DIET-COMMS usage was undertaken with assessors (senior dietitians) and dietitians being assessed using an online training package and face-to-face group sessions. The peer review process consisted of two rounds, occurring four to six months apart. The first round was undertaken with two assessors to evaluate inter-rater reliability. An online survey was conducted to evaluate dietitian satisfaction. RESULTS: Seventeen dietitians completed the program. In the first round, 13 of 17 dietitians scored 76% to 100% on the DIET-COMMS tool (median = 85%, interquartile range [IQR] = 77-93). All dietitians scored 76-100% (median = 98%, IQR = 94-100) in the second round, with significantly higher scores compared to the first (98% vs 85%; P-value <.001). The intra-class correlation coefficient was 0.86 (95% confidence interval = 0.64-0.95), indicating good-excellent inter-rater reliability. All dietitians reported the tool measured the nutrition care process adequately and was applicable to practice. CONCLUSIONS: The peer review program using DIET-COMMS was successfully implemented within a workplace environment. Widespread implementation of peer review programs using DIET-COMMS is recommended as a standard practice for the profession.

Preparing for an aging Australia: The development of multidisciplinary core competencies for the Australian health and aged care workforce.

Appropriately skilled staff are required to meet the health and care needs of aging populations yet, shared competencies for the workforce are lacking. This study aimed to develop multidisciplinary core competencies for health and aged care workers in Australia through a scoping review and Delphi survey. The scoping review identified 28 records which were synthesized through thematic analysis into draft domains and measurable competencies. Consensus was sought from experts over two Delphi rounds (n = 111 invited; n = 59 round one; n = 42 round two). Ten domains with 66 core competencies, to be interpreted and applied according to the worker's scope of practice were finalized. Consensus on multidisciplinary core competencies which are inclusive of a broad range of registered health professionals and unregistered aged care workers was achieved. Shared knowledge, attitudes, and skills across the workforce may improve the standard and coordination of person-centered, integrated care for older Australians from diverse backgrounds.

Magnetic resonance imaging of the hip: anatomy and pathology.

The aim of this review is to outline the normal anatomy of the hip and to discuss common painful conditions of the hip that affect the general adult population. Hip pain is a common complaint with many different etiologies. In this review, hip pathologies are divided by location into osseous, intra-articular and extra-articular lesions. Magnetic resonance imaging (MRI) is the modality of choice for investigating painful hip conditions due to its multiplanar capability and high contrast resolution. This review focuses on the characteristic MRI features of common traumatic and pathologic conditions of the hip.

Computed tomography-based diagnosis of occult fragility hip fractures offer shorter waiting times with no inadvertent missed diagnosis.

PURPOSE: Surgical delay due to the wait for advanced cross-sectional imaging in occult fragility hip fracture management is not well studied. Our study aims to investigate computed tomography (CT) as an alternative to the gold standard magnetic resonance imaging (MRI) in occult hip fracture workup to decrease surgical delay. METHODS: We conducted a retrospective review of all CTs and MRIs performed between 2015 and 2017 for patients with clinically suspected fragility hip fractures and negative plain radiographs to investigate surgical delay resulting from the wait for advanced imaging and representations due to missed fractures. RESULTS: A total of 243 scans (42 CTs and 201 MRIs) were performed for occult hip fracture workup over the study timeframe, of which 49 patients (20%) had occult hip fractures [CT: 6 (14%), MRI: 43 (21%), p = 0.296)]. There were no readmissions for fracture in the 12 months following a negative scan. The CT group had shorter waiting times (CT: 29 ± 24 h, MRI: 44 ± 32 h, p = 0.004) without significantly reducing surgical delay (CT: 82 ± 36 h, MRI: 128 ± 58 h, p = 0.196). The MRI group had a higher number of patients with a cancer history (p = 0.036), reflective of the practice for workup of possible metastases as a secondary intention. CONCLUSION: Advanced cross-sectional imaging wait times in occult hip fracture workup contribute significantly to surgical delay. Modern CT techniques are not inferior to MRI in detecting occult fractures and may be a suitable alternative in the absence of a cancer history if MRI cannot be obtained in a timely fashion or is contraindicated. Clinicians should utilize the more readily available imaging modality to reduce surgical delay.

The association between dietetic consultation and time to dialysis for patients attending a pre-dialysis clinic: A retrospective cohort study.

AIM: A multidisciplinary approach, including dietetics, is considered the optimal model of care for dialysis preparation. Dietetic consultation (DC) focuses on symptom management and dietary changes to delay time to dialysis. Evidence of the effectiveness of DC on time to dialysis is limited. This study aimed to investigate the impact of DC on time to dialysis for patients attending a pre-dialysis clinic. METHODS: A retrospective cohort study was designed to include all patients attending outpatient pre-dialysis clinics at a large metropolitan renal service between January 2014 and March 2018. Time to dialysis (days) was compared between patients that received DC and those who did not. Cox proportional hazards analysis allowing for adjustment of differences and confounders was undertaken. RESULTS: A cohort of 246 patients was identified. Median estimated glomerular filtration rate was 16mL/min per 1.73 m2 (interquartile range = 13-20) at initial pre-dialysis clinic visit and 63% commenced dialysis during the study period. Only 41% of patients received dietetic consultation. Significantly fewer patients needed to commence dialysis in the DC group compared to the no-DC group (hazards ratio 0.63; 95% confidence interval (CI) 0.45-0.89; P = 0.008 Cox proportion hazard). The DC group commenced dialysis significantly later than the no-DC group; 933 days (95% CI 832-1034) versus 710 days (95% CI 630-790) respectively, after the initial pre-dialysis clinic visit; log-rank 0.005. CONCLUSION: DC provided to patients attending a pre-dialysis clinic was associated with a delayed time to dialysis. Standardised referral pathways to improve patient access to renal dietetic services are recommended to optimise care.

Pharmacogenetics of Warfarin in a Diverse Patient Population.

INTRODUCTION: Many warfarin-related genotypes have shown to impact the average daily warfarin (ADW) dose requirements; however, information in non-Caucasian populations is limited. OBJECTIVES: To identify the frequencies of 4 warfarin-related gene polymorphisms in an ethnically diverse patient population and to examine their impact with other clinical variables on ADW dose requirements. METHODS: Patients were recruited from 2 anticoagulation clinics in the Los Angeles area. Blood samples were collected and genotyped for vitamin K epoxide reductase (VKORC1), CYP2C9*2, CYP2C9*3, and CYP4F2 after informed consent. Charts were reviewed to collect demographic, clinical, and warfarin dosing data. RESULTS: A total of 291 patients were included (120 Caucasians, 127 Hispanics, and 44 Asians). In patients with wild-type genotypes for VKORC1, CYP2C9*2, CYP2C9*3, and CYP4F2, the highest warfarin requirement was found in Caucasians, lower in Hispanics, and lowest in Asians. Homozygous VKORC1 variant carriers were detected in 15%, 15%, and 79% in Caucasians, Hispanics, and Asians, respectively. Progressive lowering of ADW doses were associated with each VKORC1 variant in Caucasians and Hispanics, but the results in wild-type/ heterozygote Asians were unclear. CYP2C9 variants were associated with lower ADW doses; frequencies of CYP2C9*2 and CYP2C9*3 mutations were higher in Caucasians than in Hispanics but rare to none in Asians. The frequencies of CYP4F2 variant were similar across all ethnicities, but their impact on warfarin dose requirement were insignificant. Clinical factors such as age, body surface area, history of coronary artery disease, deep vein thrombosis or atrial fibrillation, and concomitant amiodarone or HMG-CoA reductase inhibitors had varying impact on the ADW requirements in the ethnicities studied. CONCLUSIONS: Our study demonstrated differences among 3 ethnic groups in terms of ADW dose requirements and the impact of associated clinical variables. The results suggest that a single model for all ethnicities may not provide the best performance in predicting warfarin dose requirements.

Repair of syndesmosis injury in ankle fractures: Current state of the art.

Conventional treatment of syndesmosis injuries in rotationally unstable ankle fractures is associated with an unacceptably high rate of malreduction, and this has led to a paradigm shift in the approach to a newer concept of anatomical repair.In the anatomical approach, the principle is to 'directly fix what is broken and repair what is torn'. The approach is effective in reducing the rate of syndesmosis malreduction, increasing the biomechanical strength of syndesmosis fixation and avoiding the need for trans-syndesmotic fixation and its secondary removal.The objective of this review article is to compare the conventional treatment of these injuries (accepted usage, general consent, traditional, generally accepted) with a newer anatomical approach to be considered as a shift in thinking. Cite this article: EFORT Open Rev 2018;3:24-29. DOI: 10.1302/2058-5241.3.170017.

Nutritional status, management and clinical outcomes in patients with esophageal and gastro-oesophageal cancers: A descriptive study.

AIM: The aims of this study were to investigate the nutritional management practice and nutritional status of patients with oesophageal and gastro-oesophageal cancers, and to propose strategies for improving their nutritional and clinical outcomes. METHODS: All patients diagnosed with oesophageal and gastro-oesophageal cancers and treated with chemotherapy and/or radiotherapy at the Liverpool Cancer Therapy Centre (between August 2010 and February 2014) were included in this retrospective study. Patient and tumour characteristics, nutritional status and management were compared to clinical outcomes. RESULTS: A total of 69 patients met the inclusion criteria. The median weight loss prior to treatment commencement was 10.5% (Interquartile Range (IQR) = 6.6-15.4). A decline in nutritional status continued throughout the treatment course. The median percentage of weight loss during treatment was 3.53% (IQR = 0.00-6.84). Seven and 19 patients required nutrition intervention using a feeding tube or stent insertion to manage dysphagia, respectively. In patients treated with a curative intent, radiotherapy was completed in 100% of those with a nasogastric tube insertion as compared to 80% who had a stent insertion. There was a higher percentage of patients from culturally and linguistically diverse (CALD) background, experiencing significant weight loss when compared with their non-CALD counterparts (P = 0.04). CONCLUSIONS: Patients with oesophageal and gastro-oesophageal cancers commonly present with significant weight loss and this continues during the course of their anti-cancer treatment. A standardised protocol of nutrition management for these cancer patients is recommended, focusing on assisting patients from CALD backgrounds.

Masquelet Technique for Midfoot Reconstruction Following Osteomyelitis in Charcot Diabetic Neuropathy: A Case Report.

CASE: We describe a case of ulcerative midfoot osteomyelitis in a patient with Charcot diabetic neuropathy. After debridement, an extensive osseous defect led to staged reconstruction in an attempt to salvage the foot. We describe the presentation, the treatment, and the technical points of this challenging case. CONCLUSION: We reconstructed the midfoot defect with use of the induced-membrane Masquelet technique, successfully reestablishing a stable, well-aligned, plantigrade, ulcer-free foot.

Clinics in diagnostic imaging (155). Incidental PDA with secondary pulmonary arterial hypertension.

We report the case of a 70-year-old man with an asymptomatic large patent ductus arteriosus (PDA) incidentally detected on triple-rule-out computed tomography (CT). CT clearly demonstrated a vascular structure connecting the descending thoracic aorta to the roof of the proximal left pulmonary artery, consistent with a PDA. Secondary pulmonary arterial hypertension was also evident on CT. The patient was eventually diagnosed with acute coronary syndrome and was successfully treated with coronary artery bypass graft surgery and concomitant patch closure of the PDA. This article aims to outline the imaging features of PDA and highlight the information provided by CT, which is crucial to treatment planning. The pathophysiology, clinical manifestations and closure options of PDA are also briefly discussed.

Dual-incision approach for repair of peroneal tendon dislocation associated with fractures of the calcaneus.

Dislocation of the peroneal tendons associated with calcaneus fractures should be repaired during fracture fixation to prevent complications. The only documented approach for repair is by proximal extension of the vertical limb of the lateral extensile approach to the calcaneus. However, enlarging the inherently fragile calcaneus flap places it at further risk of damage. Using a separate anterior incision to repair the dislocation, thus avoiding problems caused by excessive flap elevation, seemed intuitive. This approach proved technically effective and reliable in producing favorable outcomes in a series of 14 patients.

Calamine lotion to reduce skin irritation in children with cast immobilisation.

PURPOSE. To evaluate the effect of calamine lotion in reducing skin irritation in children with cast immobilisation and to identify factors correlating with skin irritation. METHODS. 250 children aged 6 to 15 years who underwent cast immobilisation for limb fractures were assigned into calamine (n=122) and non-calamine (n=128) groups. Data were collected at the time the cast was applied and removed. Potential confounders (gender, age, race, medical history, drug allergy, cast type, duration of casting, and extent of itch prior to casting) were identified. Each patient graded his levels of itch, sweat, and heat using a 5-point scale (with 5 indicating most severe). The on-duty plaster technician recorded the presence and type of skin lesions (blisters, wounds, or others) during cast removal. RESULTS. Children in the calamine group were less likely to develop skin lesions (1 vs. 9, odds ratio [OR]=0.115, p=0.009), had less itch during casting (mean difference=0.74, p<0.0001), had a greater decrease in the itch level (mean difference=0.84, p<0.0001), and had lower sweat levels (p=0.048). After adjusting for confounders, the chance of developing skin lesions remained lower in the calamine group (OR=0.063, p=0.003). Being an older child and having shorter duration of casting were associated with presence of skin lesions. The odds for having skin lesions increased by 39.2% per year increase in age (OR=1.392, p=0.04) and decreased by 9.4% per day increase in casting duration (OR=0.906, p=0.03). The decrease in itch level remained significantly greater in the calamine group after adjusting for confounders (p<0.0001). CONCLUSION. Calamine lotion may reduce skin irritation in children with full casts.

Management of syndesmosis injuries in the elite athlete.

This article reviews the basics and evidence base thus far on syndesmosis injuries, focusing on its management in the elite sporting population. A syndesmosis injury or "high ankle sprain" is a significant injury, especially in the elite athlete. Among all ankle sprains, the syndesmotic injury is most predictive of persistent symptoms in the athletic population. Late diagnosis of unstable syndesmosis injuries leads to a poor outcome and delayed return to sports. A high index of suspicion and an understanding of the mechanism of injury is required to ensure an early diagnosis. Incomplete/inaccurate reduction leads to a poor outcome.

Estimation of glomerular filtration rate by using serum cystatin C and serum creatinine concentrations in patients with human immunodeficiency virus.

STUDY OBJECTIVE: To compare the predictive performance of four equations for estimating glomerular filtration rate (GFR) relative to the gold standard measurement, iothalamate clearance, in patients with human immunodeficiency virus (HIV) who have various degrees of kidney function. DESIGN: Prospective, cross-sectional analysis. SETTING: General clinical research center. PATIENTS: Twenty-two adult (mean age 51 yrs) HIV-positive patients with various degrees of stable kidney function and with lean body mass considered normal for a well-nourished person. INTERVENTION: Patients were administered a single dose of intravenous iothalamate 456 mg as a rapid infusion over 3 minutes, 1 hour after an oral fluid load of 600 ml of caffeine-free, sugar-free liquids. MEASUREMENTS AND MAIN RESULTS: Serial blood and urine samples were obtained for determination of measured GFR. Estimated GFR values were calculated by using four equations: the Cockcroft-Gault equation, the simplified Modification of Diet in Renal Disease Study (MDRD) equation, an equation that incorporates serum creatinine and cystatin C concentrations, and an equation incorporating only serum cystatin C concentration. The predictive performance of the equations was determined by comparing the bias, accuracy, and precision of the estimates with the measured values. Body composition was determined by dual-energy x-ray absorptiometry. The four predictive equations underestimated the measured GFR obtained by the iothalamate method, but the differences were not statistically significant. The MDRD equation and the equation that included both serum cystatin C and creatinine concentrations, as well as age, sex, and race, provided the least bias, most precision, and best accuracy in estimating the measured GFR. CONCLUSION: The MDRD equation and the equation that included both serum cystatin C and creatinine concentrations appear to provide accurate, precise, and relatively unbiased estimates of GFR in patients with HIV. Larger studies are needed that include patients with muscle wasting and lipodystrophy in order to validate these preliminary observations and the effects of body composition on the predictability of GFR with use of these equations.

Effects of pharmacists' interventions on patient outcomes in an HIV primary care clinic.

PURPOSE: The effects of pharmacists' interventions on patient outcomes in an HIV primary care clinic were studied. METHODS: All study participants were referred to a pharmacist-managed drug optimization clinic (DOC) in a county-based HIV primary care clinic between November 1, 2003, and September 30, 2004. Patients were eligible for study participation if they were 18 years of age or older and gave informed consent to participate. Pharmacists' interventions were categorized as follows: patient education, addition of a medication, dosage adjustment, discontinuation of a medication, and interpretation of viral-resistance tests. Changes in baseline CD4+ T-lymphocyte counts and viral load were also measured over the study period. Toxicities related to highly active antiretroviral therapy were recorded and graded from 0 to 4, with 0 indicating no toxicity and 4 indicating severe toxicity. Study participants used a standardized survey to measure their own health-related quality of life. Changes in CD4+ lymphocyte counts and viral load were analyzed using Student's t test and analysis of variance. Toxicity grades were analyzed using the Wilcoxon signed-rank test. RESULTS: A total of 34 patients completed the study. Pharmacists made a total of 253 interventions, most of which were categorized as patient education. The mean CD4+ lymphocyte count increased from baseline levels by 54 +/- 78 cells/mm3 over the study period (p < 0.0002). The mean +/- S.D. reduction in circulating viral load over the study period was 1.02 log10 copies/mL ( p < 0.004). CONCLUSION: HIV-infected patients who were managed by pharmacists in a DOC demonstrated significant improvement from baseline in their CD4+ lymphocyte counts, viral loads, and drug-related toxicities.

Warfarin-induced leukocytoclastic vasculitis.

Skin reactions associated with oral coumarin-derived anticoagulants are an uncommon occurrence. Leukocytoclastic vasculitis (LV) is primarily a cutaneous small vessel vasculitis, though systemic involvement may be encountered. We report 4 patients with late-onset LV probably due to warfarin. All 4 patients presented with skin eruptions that developed after receiving warfarin for several years. The results of skin lesion biopsies were available in 3 patients, confirming LV Cutaneous lesions resolved in all patients after warfarin was discontinued. In 2 of the 4 patients, rechallenge with warfarin led to recurrence of the lesions. LV may be a late-onset adverse reaction associated with warfarin therapy.