A case of Wellen’s syndrome

Report and brief review here.

The Winters formula and the thumb rule

The Winters formula is used to assess the appropriateness of the pCO2 response to metabolic acidosis (and thus determine whether a concomitant respiratory acid base disturbance exists). Here’s an interesting post from the archives of the Renal Fellow Network.

Settled science: female physicians are better docs

So says one of the authors of the much talked about study in his somewhat, shall we say, promotional blog posts. [1] [2]

Asymptomatic (incidentally discovered) microscopic hematuria: what’s the most cost effective way to work it up?

The combination of ultrasound and cystoscopy is the winner.

Rivaroxaban versus warfarin and recurrent VTE

From Lancet Hematology:

Methods

In this propensity-matched cohort study, we linked nationwide Danish health registries to identify all patients with a first hospital diagnosis of unprovoked VTE who were new users of rivaroxaban or warfarin. Excluded patients included those who had not been residents in Denmark for at least 1 year before VTE diagnosis, patients with outpatient VTE diagnosis only, patients with other indications for oral anticoagulation treatment, patients with previous experience of oral anticoagulation, patients who did not have a prescription for rivaroxaban or warfarin within 7 days of VTE, and patients who redeemed prescriptions for both rivaroxaban and warfarin, or other oral anticoagulants. Primary effectiveness outcome was recurrent VTE and primary safety outcome was major bleeding. We used propensity matching and Cox regression to compare rates of the outcomes with rivaroxaban versus standard treatment.

Results

From Dec 9, 2011, to Feb 28, 2016, we identified 29 963 patients with incident VTE. After exclusion, we identified 1734 propensity-matched patients given rivaroxaban (1751 before propensity matching) and 2945 propensity-matched patients given warfarin. The rate of recurrent VTE at 6 months' follow-up was 9·9 incidents per 100 person-years with rivaroxaban versus 13·1 incidents per 100 person-years with warfarin, yielding a hazard ratio (HR) of 0·74 (95% CI 0·56–0·96). The rate of major bleeding was 2·4 per 100 person-years at 6 months in rivaroxaban users versus 2·0 in warfarin users (HR 1·19, 95% CI 0·66–2·13).

Interpretation

In this clinical practice setting, rivaroxaban in patients with unprovoked VTE was associated with reduced risk of recurrent VTE compared with standard treatment, without compromising safety.

A related editorial pointed out the potential confounding effects of return visits for INR monitoring being interpreted as recurrent events.

Cardiac cachexia is associated with sympathetic nerve activity in skeletal muscle

From the AHA meeting abstracts:

Introduction: Cardiac cachexia is associated with poor prognosis in patients with heart failure (HF). Sympathetic overactivation might be implicated in the development of muscle wasting, considering the recent data that carvedilol significantly reversed body weight (BW) loss in HF patients…

Methods: We prospectively evaluated changes in BW in 108 non-edematous HFrEF patients in whom muscle sympathetic nerve activity (MSNA) was measured...

Results... One-year combined event rate was significantly higher in BW loss group...MSNA...was significantly higher in BW loss group than in non-BW loss group. Importantly, MSNA burst incidence had a moderate predictability for significant BW loss by receiver-operating characteristic analysis (area under the curve=0.794).

Conclusion: Sympathetic overactivation determined by MSNA could predict significant BW loss in HFrEF patients.

Herpes zoster ophthalmicus

Free full text review in the green journal.

UTI caused by ESBL producing bacteria

Piperacillin-tazobactam works when the lab tells you the isolate is susceptible to it.

Sleep and cardiovascular disease

From a review:

Abstract:

Purpose of review: Sleep plays many roles in maintenance of cardiovascular health. This review summarizes the literature across several areas of sleep and sleep disorders in relation to cardiometabolic disease risk factors.

Recent findings: Insufficient sleep duration is prevalent in the population and is associated with weight gain and obesity, inflammation, cardiovascular disease, diabetes, and mortality. Insomnia is also highly present and represents an important risk factor for cardiovascular disease, especially when accompanied by short sleep duration. Sleep apnea is a well-characterized risk factor for cardiometabolic disease and cardiovascular mortality. Other issues are relevant as well. For example, sleep disorders in pediatric populations may convey cardiovascular risks. Also, sleep may play an important role in cardiovascular health disparities.

Summary: Sleep and sleep disorders are implicated in cardiometabolic disease risk. This review addresses these and other issues, concluding with recommendations for research and clinical practice.

Intention to treat analysis in RCTs

What is it? Why is it important?

Hypokalemia

Free full text review.

Glucagon in the pathogenesis of DM 2: implications for drug therapy

Free full text review.

Using FOAM in the residency curriculum

Free full text article.

Drug interactions in the ICU

Multiple risk factors were identified in this study. Of particular interest was the lack of consistency among four popular interaction checkers.

Clinical pharmacists as ID docs in the ER?

Here are some interesting findings from the Western Journal of Emergency Medicine:

Introduction

Pneumonia impacts over four million people annually and is the leading cause of infectious disease-related hospitalization and mortality in the United States. Appropriate empiric antimicrobial therapy decreases hospital length of stay and improves mortality. The objective of our study was to test the hypothesis that the presence of an emergency medicine (EM) clinical pharmacist improves the timing and appropriateness of empiric antimicrobial therapy for community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP).

Methods

This was a retrospective observational cohort study of all emergency department (ED) patients presenting to a Midwest 60,000-visit academic ED from July 1, 2008, to March 1, 2016, who presented to the ED with pneumonia and received antimicrobial therapy. The treatment group consisted of patients who presented during the hours an EM pharmacist was present in the ED (Monday-Friday, 0900–1800). The control group included patients presenting during the hours when an EM clinical pharmacist was not physically present in the ED (Monday–Friday, 1800–0900, Saturday/Sunday 0000–2400 day). We defined appropriate empiric antimicrobial therapy using the Infectious Diseases Society of America consensus guidelines on the management of CAP, and management of HCAP.

Results

A total of 406 patients were included in the final analysis (103 treatment patients and 303 control patients). During the hours the EM pharmacist was present, patients were significantly more likely to receive appropriate empiric antimicrobial therapy (58.3% vs. 38.3%; p less than 0.001). Regardless of pneumonia type, patients seen while an EM pharmacist was present were significantly more likely to receive appropriate antimicrobial therapy (CAP, 77.7% vs. 52.9% p=0.008, HCAP, 47.7% vs. 28.8%, p=0.005). There were no significant differences in clinical outcomes.

Conclusion

The presence of an EM clinical pharmacist significantly increases the likelihood of appropriate empiric antimicrobial therapy for patients presenting to the ED with pneumonia.

The physical presence of clinical pharmacists in the ER was associated with more appropriate antibiotics according to this study, but we don’t know the nature of their involvement in treatment decisions. The HCAP designation used in the report is now considered obsolete and no longer recognized in the guidelines although it was appropriate for the time frame of the study. The major error in the control group was in categorization of patients as either CAP or HCAP. The strong implication is that pharmacists were better at diagnosing the type of pneumonia than the docs. There is something very wrong here.

IV bolus diltiazem followed by immediate release oral for patients presenting with rapid atrial fibrillation

This seemed to work as well as the traditional bolus-drip method in a small study and has potential to conserve resources.

Delafloxacin

Here’s that new fluoroquinolone everyone’s talking about.

Product labeling: Baxdela.

Are we practicing EBM in the treatment of ARDS?

Far from it, it seems. Just over a quarter of patients with ARDS in the study got low tidal volume ventilation. Moreover, only about half the patients meeting ARDS criteria were acknowledged as such.

Exercise, Parkinson disease and dementia

From a recent Mayo Clinic review:

Parkinson disease is a slowly progressive neurodegenerative condition; after many years, dementia or medication-refractory motor symptoms may develop.

A myriad of animal studies document a direct, favorable effect of aerobic-type exercise on the brain; this includes liberation of neurotrophic hormones and enhancement of a variety of neuroplasticity mechanisms. Exercise tends to protect animals from neurotoxins that induce parkinsonism.

Long-term exercise and fitness in healthy humans is associated with greater volumes of cerebral cortex and hippocampus and less age-related white matter pathology.

Midlife exercise is associated with a significantly reduced later risk of Parkinson disease.

Conclusion from this evidence: Regular aerobic-type exercise tending to lead to fitness is the single strategy with compelling evidence for slowing Parkinson disease progression. All patients with Parkinson disease should be encouraged to engage in regular such exercise.

Dealing with drug allergy

Drug Allergy: An Updated Practice Parameter is an official document promulgated by a collaboration of three professional societies. Although it is a bit dated it is the latest such edition written by the collaboration. Moreover, for penicillin allergy an update was published in Mayo Clinic Proceedings only months ago. The Mayo update generally follows the recommendations of this document. Below are some key points.

The overall classification of drug induced disease encompasses all types of adverse reactions, not just allergic reactions.

From the document:

ADRs are broadly categorized into predictable (type A) and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug…

Unpredictable reactions are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions.

Allergic reactions are defined as immunologic reactions. Although the Gell-Coombs classification remains the framework for thinking about allergic reactions, the current classification has been extended beyond that.

Categories outside the C-G classification include these below. Form the paper:

Hypersensitivity vasculitis Cutaneous or visceral vasculitis Hydralazine, penicillamine, propylthiouracil

DRESS Cutaneous, fever, eosinophilia, hepatic dysfunction, lymphadenopathy Anticonvulsants, sulfonamides, minocycline, allopurinol

Pulmonary drug hypersensitivity Pneumonitis, fibrosis Nitrofurantoin, bleomycin, methotrexate

Systemic drug-induced lupus erythematosus Arthralgias, myalgias, fever, malaise Hydralazine, procainamide, isoniazid

Cutaneous drug-induced lupus erythematosus Erythematous/scaly plaques in photodistribution Hydrochlorothiazide, calcium channel blockers, ACE inhibitors

Drug-induced granulomatous disease Churg-Strauss syndrome, Wegener's granulomatosis Propylthiouracil, leukotriene modifiers

Immunologic hepatitis Hepatitis, cholestatic jaundice Para-aminosalicylic acid, sulfonamides, phenothiazines

Blistering disorders Erythema multiforme, SJS, TEN Sulfonamides, cephalosporins, imidazole anticonvulsants, NSAIDs

Serum sickness–like reactions Erythema multiforme, arthralgias Cefaclor, cefprozil

Immunologic nephropathy Interstitial nephritis, membranous glomerulonephritis Penicillin, sulfonamides, gold, penicillamine, allopurinol

It should be mentioned that some of the categories listed above are poorly understood and may not represent purely immunologic mechanisms.

What is “desensitization?”

More from the paper:

What has often been referred to as drug desensitization is more appropriately described in this parameter as a temporary induction of drug tolerance. Drug tolerance is defined as a state in which a patient with a drug allergy will tolerate a drug without an adverse reaction. Drug tolerance does not indicate either a permanent state of tolerance or that the mechanism involved was immunologic tolerance. Induction of drug tolerance procedures modify a patient's response to a drug to temporarily allow treatment with it safely. They are indicated only in situations where an alternate non–cross-reacting medication cannot be used. Induction of drug tolerance can involve IgE immune mechanisms, non-IgE immune mechanisms, pharmacologic mechanisms, and undefined mechanisms ( Table 2 ). All procedures to induce drug tolerance involve administration of incremental doses of the drug. Through various mechanisms, these procedures induce a temporary state of tolerance to the drug, which is maintained only as long as the patient continues to take the specific drug.

Remember that this technique is recommend only when there is no reasonable alternative, and it doesn’t induce permanent tolerance.

There is also the idea of graded challenge, which is different from tolerance induction (desensitization). Graded challenge is essentially the administration of a test dose.

Remember this, too, from the paper:

Graded challenge (or induction of drug tolerance) should almost never be performed if the reaction history is consistent with a severe non–IgE-mediated reaction, such as SJS, TEN, interstitial nephritis, hepatitis, or hemolytic anemia.

The recommendations for dealing with beta lactam type I allergy are complex

If the allergic history is that of an anaphylactoid reaction there is almost no avoiding the use of special techniques such as skin testing or tolerance induction, were one to strictly follow the document recommendations. Clinical rules cannot assure safe administration of an antibiotic. Consider assessment of side chain similarity for the assessment of safety of cephalosporin administration, for example. Although side chain assessment can be of help in the assessment of risk, in the document there is no recommendation for using it as an assurance of safety. On the other hand, in a couple of cases it can be used to mandate avoidance (such as the use of aztreonam in a patient with an anaphylactoid reaction to ceftazidime).

The application of the special techniques of skin testing, test dosing and tolerance induction is complex and has many contingencies noted in the document and therefore requires expertise.

Practical aspects for the clinician in dealing with type 1 beta lactam allergy

Despite the complexities noted above one can be informed by data on absolute risk. For example, according to the Mayo paper, cross-reactivity between PCN and carbapenems is likely less than 1%, with similar risk for aztreonam. What should one do, for example, when confronted with a patient in septic shock with concern for pseudomonas and ESBL producing bacteria? Considering a mortality increase of 5-10% per hour of non coverage, can you get an allergist on site and skin testing done in time or does the risk of delay exceed a less than 1% chance of a reaction from a carbapenem?

Overview of mechanical ventilation and respiratory failure

Powerpoint from ATS.

Podcasts from the American Thoracic Society

Lots of good stuff here.

New alcoholic liver disease guidelines from the American College of Gastroenterology

Free full text available.

The document is worth reading in its entirety, but there were a few points I found particularly noteworthy:

Patients who are obese should not consume any ethanol at all!

Definitions, from the paper:

Alcoholic fatty liver disease is diagnosed in a patient with AUD with hepatic steatosis on ultrasound and/or elevation in liver enzymes (aspartate aminotransferase (AST) greater than alanine aminotransferase (ALT)), serum bilirubin less than 3 mg/dL, and the absence of other causes of liver disease.

Clinical diagnosis of AH is determined in a patient with rapid development or worsening of jaundice and liver-related complications, with serum total bilirubin greater than 3 mg/dL; ALT and AST elevated greater than 1.5 times the upper limit of normal but less than 400 U/L with the AST/ALT ratio greater than 1.5; documentation of persistent heavy alcohol use until 8 weeks before onset of symptoms; and exclusion of other liver diseases

Baclofen to help patients stop drinking has a conditional recommendation:

In patients with ALD, baclofen is effective in preventing alcohol relapse (Conditional recommendation, low level of evidence).

Pentoxifylline is no longer recommended for severe alcoholic hepatitis. Steroids still are.

At 7 days into steroid therapy the Lille score should be used to determine if the steroids should be continued:

Response to treatment with corticosteroids should be determined at 7 days using the Lille score. Treatment should be discontinued among non-responders to therapy, defined as those with a Lille score greater than 0.45.

The guideline authors acknowledge evidence that N-acetylcysteine infusion in combination with steroids may be associated with improved outcomes in AH. However, they do not feel the evidence is sufficiently strong to justify a guideline recommendation.

Antibiotic therapy is still recommended as part of the overall treatment regimen for variceal bleeding:

Management of the acute variceal bleeding episode involves pharmacological therapy with available vasoactive agents (terlipressin or octreotide), antibiotics, and endoscopic therapy. Endoscopy should ideally be carried out at least 30 min after initiation of vasoactive therapy (54).

As for the optimal timing of endoscopy, that last sentence is confusing to me.

Have a low threshold for starting broad spectrum antibiotics in AH patients who become critical.  

Concerning the gram negative component of the regimen, the guideline recommends merropenem or zosyn, acknowledging that the clinician should pay attention to local sensitivity patterns:

The choice of antibiotics depends on prevailing local antimicrobial resistance patterns. Piperacillin-tazobactam is generally the preferred drug used for sepsis, although vancomycin and meropenem may be considered in patients with penicillin hypersensitivity.

There’s much more.

Autoimmune hemolytic anemia

Case report and review.

Medical cannabis laws related to increased illicit use and use disorders

From JAMA Psychiatry.

Measles information for hospitalists

It’s a shame that a review like this even needed to be written in 2017.

What is a master clinician-teacher?

Via Nephron Power.

A case illustrating the differential diagnosis of long RP tachycardia

Read here.

Idiopathic paroxysmal AV block due to low baseline adenosine levels and heightened receptor sensitivity

This is a fairly recently described entity:

Idiopathic paroxysmal AV block poses a true diagnostic challenge. Although it is true that the clinical presentation does not differ from that of another cardiogenic syncope, the diagnosis of this block requires the lack of a structural cardiac pathology that justifies the observed manifestations and an absence of electrocardiographic disorders prior to an episode. For diagnosis, it is useful the implantable loop recorder to substantiate AV block paroxysms and assess their clinical correlations.

The mechanism associated with idiopathic paroxysmal AV block is unknown. It has been postulated that patients with low basal adenosine levels exhibit hyperaffinity of the adenosine receptors of the AV node. No relevant data have been reported, so it´s necessary that more studies are needed to confirm this hypothesis.

The prognosis of idiopathic paroxysmal AV block is favorable, given the paroxysmal profile of the AV block and the low probability of degeneration into permanent forms of AV block. Permanent stimulation devices can be employed to prevent and avoid the recurrence of syncopal episodes in patients with idiopathic paroxysmal AV block.

Atypical presentation of retroperitoneal hematoma 3 weeks after IVC filter insertion

Report here.

Pitfalls in ICU management

This article in Today's Hospitalist, drawn from recent talks at the UCSF hospitalist conference, has a lot of pearls. Most of the admonitions are about avoiding knee jerk care.

The real gem comes in her discussion of the importance of de-escalation of IV fluids:

“Multiple studies have replicated that, even in sepsis,” Dr. Santhosh noted. “After initial resuscitation with early goal-directed therapy, you want a maintenance or stabilization phase and then de-escalation.” That could mean active diuresis in patients to attain a negative fluid balance once they’re off pressors.

And while it can be a challenge to find the maintenance fluids in your EHR to discontinue them…

That’s right. She said, in effect, that the EHR interferes with the clinician’s ability to discontinue potentially harmful IV fluids. The statement rings true and concerns one of those key provisions of meaningful use: CPOE. Meaningful to patients for sure if it interferes with their care with the potential for harm.

Hypothyroidism and heart disease

Free full text review.

From the review:

Hypothyroidism can result in decreased cardiac output, increased systemic vascular resistance, decreased arterial compliance, and atherosclerosis.

Impaired cardiac muscle relaxation, decreased heart rate, and decreased stroke volume contribute to heart failure in hypothyroidism.

Subclinical hypothyroidism is associated with ischemic heart disease and increased cardiovascular mortality.

Treatment of hypothyroidism may have a beneficial impact on several parameters of cardiac dysfunction, including subclinical hypothyroidism, especially in younger individuals.

Cardiac manifestations of hyperthyroidism

Free full text review.

Hyperparathyroidism

This wonderful free full text review has everything you want to know and probably more.

Hyper- and hypokalemia in the ER

From a recent study:

Conclusion

Hyperkalemia or hypokalemia occur in 1 of 11 ED patients and are associated with inpatient admission and mortality. Treatment of hyperkalemia varies greatly suggesting the need for evidence-based treatment guidelines.

Insulin autoimmune syndrome aka Hirata disease

It’s caused by spontaneous development of insulin antibodies (no prior exposure to insulin). If that’s the case why does it cause hypoglycemia and not just hyperglycemia? From a review:

Although the precise mechanism for hypoglycemia in IAS is unknown, the most widely accepted hypothesis is a mismatch between blood glucose and free insulin concentration, secondary to the binding and release of secreted insulin by autoantibodies.7 Following a meal or oral glucose load, glucose concentration in the bloodstream rises, providing a stimulus for insulin secretion. Autoantibodies bind to these insulin molecules, rendering them unavailable to exert their effects. The resultant hyperglycemia not only promotes further insulin release, but may also explain the increased hemoglobin A1c often seen in IAS patients.6 As glucose concentration eventually falls, insulin secretion also subsides, and the total insulin level decreases. Insulin molecules spontaneously dissociate from the autoantibodies at this time, giving rise to a raised free insulin level inappropriate for the glucose concentration, evoking hypoglycemia.7 Insulin autoantibodies with a high binding capacity and a low affinity are more likely to bring about hypoglycemic symptoms.10 Medications containing a sulfhydryl group have been proposed to induce autoantibody formation by interacting with the disulfide bonds of the insulin molecule and augmenting its immunogenicity;11 however, the true underlying pathophysiology remains unclear at this time. Rarely, the co-existence of both insulin autoantibodies and insulin receptor autoantibodies within the same patient has been described.12

Physician burnout: a public health crisis

An article looks at how it affects hospitalists.

Burn out drivers for hospitalists: being employees; being robbed of their autonomy as clinicians (after all they just want to be doctors); being given another job (ward secretary, aka CPOE) without additional compensation. One could go on and on.

Ramping up the inhaled steroids at the first sign asthma of exacerbation

---reduced progression to severe exacerbation in adults and adolescents.

A similar trial conducted in children, published in the same issue of NEJM, no benefit and a risk of stunted growth.

Apps you can use

I found some good ones I had not heard about in this list.

Can someone explain to me why I need AHRQ?

According to this Kevin MD post we'll all suffer if it becomes marginalized anymore than it already is. I've never used it. What am I missing?

Hereditary hemorrhagic telangectasia

Free full text review.

Renin-angiotensin blockade in heart failure with preserved EF? Mixed results.

From a recent review:

Studies with angiotensin‐converting enzyme inhibitors (ACE‐Is) and angiotensin receptor blockers (ARBs) in patients with heart failure with preserved ejection fraction (HFpEF) have yielded inconsistent results. To conduct a systematic review and meta‐analysis of all evidence for ACE‐I and ARBs in patients with HFpEF, we searched PubMed, Ovid SP, Embase, and Cochrane database to identify randomized trials and observational studies that compared ACE‐I or ARBs against placebo or standard therapy in HFpEF patients. Random‐effect models were used to pool the data, and I 2 testing was performed to assess the heterogeneity of the included studies. A total of 13 studies (treatment arm = 8676 and control arm = 8608) were analysed. Pooled analysis of randomized trials for ACE‐I and ARBs (n = 6) did not show any effect on all‐cause mortality [relative risk (RR) = 1.02, 95% confidence interval (CI) = 0.93–1.11, P = 0.68, I 2 = 0%], while results from observational studies showed a significant improvement (RR = 0.91, 95% CI = 0.87–0.95, P = 0.005, I 2 = 81.5%). In pooled analyses of all studies, ACE‐I showed a reduction of all‐cause mortality (RR = 0.91, 95% CI = 0.87–0.95, P = 0.01). There was no reduction in cardiovascular mortality seen, but in pooled analysis of randomized trials, there was a trend towards reduced HF hospitalization risk (RR = 0.91, 95% CI = 0.83–1.01, I 2 = 0%, P = 0.074). These data suggest that ACE‐I and ARBs may have a role in improving outcomes of patients with HFpEF, underscoring the need for future research with careful patient selection, and trial design and conduct.

Not challenging science is anti-science??

But I thought science was inherently self-challenging. To Dr. John’s credit, though, he does make some good points about the thought police. They’re everywhere in medicine.

Doctors in the US make too much money

---according to a policy wonk at one progressive think tank. So, says he, we must apply pressure from all sides to break up the cartel and reduce doctors’ pay. The fact that patients generally like their doctors doesn’t help.

Valproic acid overdose

Case report and literature review.

Blood letting for the common cold?

This is the kind of thing I would expect to find in BMJ, maybe, but not in the journal Medicine. I hear it didn’t go well for George Washington.

Cardiovascular disease in acromegaly

Free review.

New trends in GERD

Severe adverse effects of PPIs are increasingly recognized so now what?

Inappropriate antibiotic prescribing for patients sent home from the ER

An opportunity for education:

Results

Of 1579 ED antibiotic prescriptions in 2015, we reviewed a total of 159 (10.1%) prescription records. The most frequently prescribed antimicrobial classes included penicillins (22.6%), macrolides (20.8%), cephalosporins (17.6%), and fluoroquinolones (17.0%). The most common indications for antibiotics were bronchitis or upper respiratory tract infection (URTI) (35.1%), followed by skin and soft tissue infection (SSTI) (25.0%), both of which were the most common reason for unnecessary prescribing (28.9% of bronchitis/URTIs, 25.6% of SSTIs). Of the antimicrobial prescriptions reviewed, 39% met criteria for inappropriateness. Among 78 prescriptions with a consensus on appropriate indications, 13.8% had inappropriate dosing, duration, or expense.

Conclusion

Consistent with national outpatient prescribing, inappropriate antibiotic prescribing in the ED occurred in 39% of cases with the highest rates observed among patients with bronchitis, URTI, and SSTI. Antimicrobial stewardship programs may benefit by focusing on initiatives for these conditions among ED patients. Moreover, creation of local guideline pocketbooks for these and other conditions may serve to improve prescribing practices and meet the Core Elements of Outpatient Stewardship recommended by the Centers for Disease Control and Prevention.

Gastroparesis

Free full text review.