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PE in COPD, Board Certification, Neutropenic Cancer, and More

They evaluated these quality measures on 101,251 patients and 36,668 physicians, of which 80% were board certified. In multivariable analyses adjusting for patient, hospital, and physician characteristics, board-certified internal medicine and cardiology physicians (but not family practitioners) were more likely to prescribe ASA and beta-blockers at admission and discharge than non-board certified physicians (adjusted relative risk ranged from 1.04 to 1.20). There was no difference in 30-day and one-year mortality among any specialty after multivariable adjustment.

These results, albeit modest, suggest that physician board certification may be associated with superior quality of care in elderly patients with AMI. The authors offer that board-certified physicians may be more aware or familiar with guidelines or may be more likely to agree with clinical guidelines. Although board-certified physicians have been shown to complete more hours of CME and spend more time reading journals, they caution that board certification should not be used as a surrogate marker of quality. Because 30% of U.S. practicing physicians are not currently board certified, these results certainly warrant further study.

Classic Literature

Clostridium Difficile: Then and Now

Although GI side effects had been a longstanding and well-known complication of antibiotic therapy, it was not until 1978 that John Bartlett and co-workers isolated clostridium difficile from the feces of patients with pseudomembranous colitis and demonstrated the toxigenicity of its pre-formed toxin by tissue culture assay (New Engl J Med. 1978;298:531-534). Within a year, the toxin was purified, a tissue culture assay to detect the toxin was developed, and clinical trials had established the efficacy of oral vancomycin for treatment.

With such substantial progress made in a short time, Bartlett proclaimed in a subsequent editorial in 1980 that “it appears that this dreaded iatrogenic complication is well on the way to being conquered.”

However, even then, he and others recognized the complexities associated with clostridium difficile infection: the inability to adequately predict individual patient’s clinical severity, the implications of a vast number of asymptomatic carriers of the toxin, the high relapse rates experienced after treatment, and the extensive hospital environmental contamination.

More than 25 years later, all of these issues still plague us. Despite widespread epidemiological attempts to control the disease, the current social and economic consequences of it are profound. The 3 million inpatient cases a year result in an average increased length of stay of 3.6 days and more than $1 billion in healthcare costs. We still lack adequate prediction models to determine the clinical severity of individual patient cases. There are escalating rates of severe complications including toxic megacolon, colectomy, shock, and death, and two recent reports outline the effects of hypervirulent strains (New Engl J Med. 2005;353:2433-2449). Asymptomatic carriage is now present in 3% of healthy adults and 20%-40% of hospitalized patients, relapse rates have been sustained at 20% for the last 25 years, and hospital contamination continues to challenge our infection control strategies. Even our treatment of clostridium difficile has not changed substantially, consisting of a standard course of vancomycin or metronidazole, which appear to have similar efficacy in initial treatment response and recurrent rates.

On the horizon are enhanced epidemiological and environmental control strategies, innovative treatment trials for recurrent disease, and ongoing vaccine efforts. However, despite our unyielding attempts to quell this “dreaded iatrogenic complication,” the then-and-now statistics are quite sobering.—DS, SK

PE in COPD

Tillie-Leblond I, Marquette CH, Perez T, et al. Pulmonary embolism in patients with unexplained exacerbation of chronic obstructive pulmonary disease: prevalence and risk factors. Ann Intern Med. 2006 Mar 21;144(6):390-396.

This study sought to evaluate the prevalence and risk factors for pulmonary embolus (PE) in patients with unexplained exacerbations of COPD. All patients with an unexplained COPD exacerbation requiring hospitalization (not ICU) were evaluated for PE by spiral chest CT and lower limb venous ultrasound (USG). The COPD flare was “unexplained” if there were no signs or symptoms of respiratory tract infection, no pneumothorax, or a discrepancy between the clinical/radiologic features and the degree of hypoxemia. Patients were considered to have a PE if either of the two tests (CT or USG) were positive. Patients were not considered to have a PE if both tests were negative, and there was no evidence of PE at three-month follow-up.

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