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Biomedical subjects

Philip S Mehler

Publications and source records attributed to Philip S Mehler.

At least 19 recordsLinked to original sources
PubMed2006

Lack of ethnic disparities in adult immunization rates among underserved older patients in an urban public health system.

BACKGROUND: In some settings, immunization rates for ethnic minorities are less than those of non-Hispanic white populations. This study examines demographic differences in the rate of pneumococcal and influenza immunization in an ethnically diverse older patient population seeking care at an urban primary care clinic system. METHODS: The setting is an integrated system of 11 federally qualified community health centers serving approximately 100,000 unduplicated patients annually. We linked data from chart audits performed in 2001-2003 for quality assurance purposes with patient registration data to evaluate vaccination rates in 740 patients age 66 years and older who had at least 3 primary care visits in the previous 2 years. RESULTS: Factors significantly associated with receipt of pneumococcal vaccination in multivariable analysis were Hispanic ethnicity (odds ratio [OR] 1.66-1.77, P = 0.01), medical comorbidities (OR 1.48, P = 0.03), psychiatric comorbidities (OR 2.0, P = 0.001), use of a family medicine versus internal medicine clinic (OR 2.3, P < 0.001), and age (OR 1.04 for 1 year increase, P = 0.004). Factors significantly associated with influenza vaccination were having insurance (OR 2.25, P = 0.014), medical comorbidities (OR 1.71, P = 0.036), age (OR 1.03 for 1 year increase, P = 0.045), later year of audit (OR 1.68-1.73, P = 0.015), and a greater number of clinic visits (OR 1.69, P = 0.006). CONCLUSIONS: Among older regular users of our public community health centers, minority populations have equal or higher immunization rates compared with non-Hispanic whites.

Age Factors↗
PubMed2005

QT interval dispersion and resting metabolic rate in chronic anorexia nervosa.

OBJECTIVE: During the starvation phase of anorexia nervosa (AN), cardiac and skeletal muscle mass decreases, whereas electrocardiographic QT dispersion, a marker of arrhythmia risk, increases. QT dispersion during the chronic phase of AN and its relationship to resting metabolic rate (RMR) have not been described previously and is the subject of the current investigation. METHOD: Six AN patients were compared with 10 age-matched control subjects. Serum electrolyte levels, electrocardiography, anthropomorphic data, and indirect calorimetry were obtained for all participants. RESULTS: Corrected QT interval (QTc) did not differ between groups, but QT dispersion was significantly greater in AN patients. QT dispersion correlated negatively with resting oxygen consumption and RMR. The relationship between QT dispersion and RMR did not persist after correcting for lean body mass. CONCLUSIONS: AN patients with a low RMR may be at risk for increased QT dispersion. QT dispersion is a widely available and inexpensive measure, which may reflect both metabolic status and arrhythmia potential.

Adolescent↗
PubMed2005

The paradox of normal serum albumin in anorexia nervosa: a case report.

OBJECTIVE: Anorexia nervosa (AN) is associated with marked decreases in caloric intake and a corresponding reduction in body weight due to abnormal self body image. Although counterintuitive, hypoalbuminemia and vitamin deficiencies are not expected consequences of this disorder. Etiologic considerations for hypoalbuminemia are discussed. METHOD: The case report of a patient with AN and marked hypoalbuminemia is presented and a focused literature review is reported. RESULTS: Hypoalbuminemia was initially attributed to starvation. However, occult infection was ultimately responsible. Serum albumin concentration normalized with antibiotic therapy despite minimal restoration of body weight. DISCUSSION: Hypoalbuminemia should not be considered a characteristic feature of AN even in the setting of progressive weight loss. The presence of other potentially life-threatening conditions should be sought, as reduced serum albumin concentration is a marker of inflammation in AN.

Anorexia Nervosa↗
PubMed2005

Bridging the quality gap in diabetic hyperlipidemia: a practice-based intervention.

PURPOSE: Dyslipidemia treatment dramatically decreases coronary heart disease risk in diabetes, yet only a minority of these patients are screened or achieve optimal low-density lipoprotein (LDL) cholesterol levels. Our aim was to increase the percentage of diabetic patients in whom lipid management was achieved through electronic and direct educational detailing. METHODS: The study cohort comprised 884 diabetic patients at 12 primary care practices. Practice sites were randomized to one of three intervention groups: electronic educational detailing, direct (face-to-face) educational detailing, or control. Direct and electronic detailing were performed over a 12-month period. All sites were notified of our goal to enhance lipid testing among diabetic patients. Chart abstraction was performed 15 months after the start of the intervention. For the entire population (n=884), the proportion of patients with lipid testing was calculated, and changes from pre- to postintervention were compared across groups. We compared pre- and postintervention LDL-cholesterol changes between groups using least square means to account for site variation. RESULTS: Favorable provider actions increased significantly with the intervention (+22% compared with +6% in controls, P=.01). By logistic regression, electronic detailing increased the likelihood of lipid testing (odds ratio 3.0, confidence interval 1.6-5.7), as did direct detailing (odds ratio 1.8, confidence interval 0.9-3.7) in patients with no preintervention LDL test (n=432). Lipid testing tended to increase to a greater extent at intervention sites (+23% for the combination of electronic and direct detailing vs +11% for controls, P=.06). CONCLUSIONS: Brief educational detailing either through direct or electronic communication favorably impacts provider behavior regarding dyslipidemia care for diabetic patients.

Aged↗
PubMed2005

Cocaine-related torsade de pointes in a methadone maintenance patient.

A patient maintained on methadone for opioid-dependency developed recurrent syncope. Episodes occurred within hours after using cocaine, and were initially presumed secondary to seizure disorder. However, the patient subsequently suffered a cardiac arrest, and polymorphic ventricular tachycardia (torsade de pointes) was documented. Other than cocaine and methadone the patient was receiving no additional agents known to prolong the QT interval. Low serum methadone concentrations and marked reversible left ventricular systolic dysfunction were noted during the hospitalization. These findings, in conjunction with a history of torsade de pointes temporally related to cocaine abuse, suggest that cocaine was a major precipitant of arrhythmia. Recent experimental studies have shown that cocaine and methadone prolong the QT interval through the same mechanism. We examine the effects of cocaine and methadone on cardiac conduction in the context of the opioid-dependent population.

Cocaine↗
PubMed2005

Effects of buprenorphine on cardiac repolarization in a patient with methadone-related torsade de pointes.

Torsade de pointes is a rare but potentially fatal ventricular arrhythmia that is often triggered by drugs that prolong the rate-corrected QT (QTc) interval. This arrhythmia has been attributed to levacetylmethadol and methadone, synthetic opioids used to treat heroin addiction. Levacetylmethadol, a derivative of methadone, is being withdrawn from the United States market because its use waned after a black box warning was issued to require electrocardiographic monitoring. Therefore, methadone and buprenorphine are the only opioids available for the treatment of heroin addiction. To our knowledge, the cardiac safety of buprenorphine in patients with methadone-related QTc prolongation has not been described. We report a patient who developed torsade de pointes while receiving high-dose methadone and was successfully inducted onto buprenorphine under close medical supervision. No clinically important QTc prolongation was observed in the acute setting or during follow-up. This observation suggests that buprenorphine may be a safe alternative to oral methadone in patients with opioid addiction who develop torsade de pointes.

Analgesics, Opioid↗
PubMed2004

Resting tachycardia, a warning sign in anorexia nervosa: case report.

BACKGROUND: Among psychiatric disorders, anorexia nervosa has the highest mortality rate. During an exacerbation of this illness, patients frequently present with nonspecific symptoms. Upon hospitalization, anorexia nervosa patients are often markedly bradycardic, which may be an adaptive response to progressive weight loss and negative energy balance. When anorexia nervosa patients manifest tachycardia, even heart rates in the 80-90 bpm range, a supervening acute illness should be suspected. CASE PRESENTATION: A 52-year old woman with longstanding anorexia nervosa was hospitalized due to progressive leg pain, weakness, and fatigue accompanied by marked weight loss. On physical examination she was cachectic but in no apparent distress. She had fine lanugo-type hair over her face and arms with an erythematous rash noted on her palms and left lower extremity. Her blood pressure was 96/50 mm Hg and resting heart rate was 106 bpm though she appeared euvolemic. Laboratory tests revealed anemia, mild leukocytosis, and hypoalbuminemia. She was initially treated with enteral feedings for an exacerbation of anorexia nervosa, but increasing leukocytosis without fever and worsening left leg pain prompted the diagnosis of an indolent left lower extremity cellulitis. With antibiotic therapy her heart rate decreased to 45 bpm despite minimal restoration of body weight. CONCLUSIONS: Bradycardia is a characteristic feature of anorexia nervosa particularly with significant weight loss. When anorexia nervosa patients present with nonspecific symptoms, resting tachycardia should prompt a search for potentially life-threatening conditions.

Anorexia Nervosa↗
PubMed2004

Treating opioid dependence. Growing implications for primary care.

Almost 3 million Americans have abused heroin. The most effective treatment for this concerning epidemic is opioid replacement therapy. Although, from a historical perspective, acceptance of this therapy has been slow, growing evidence supports its efficacy. There are 3 approved medications for opioid maintenance therapy: methadone hydrochloride, levomethadyl acetate, and buprenorphine hydrochloride. Each has unique characteristics that determine its suitability for an individual patient. Cardiac arrhythmias have been reported with methadone and levomethadyl, but not with buprenorphine. Due to concerns about cardiac risk, levomethadyl use has declined and the product may ultimately be discontinued. These recent safety concerns, specifics about opioid detoxification and maintenance, and new federal initiatives were studied. Opioid detoxification has a role in both preventing acute withdrawal and maintaining long-term abstinence. Although only a minority of eligible patients are engaged in treatment, opioid maintenance therapy appears to offer the greatest public health benefits. There is growing interest in expanding treatment into primary care, allowing opioid addiction to be managed like other chronic illnesses. This model has gained wide acceptance in Europe and is now being implemented in the United States. The recent Drug Addiction Treatment Act enables qualified physicians to treat opioid-dependent patients with buprenorphine in an office-based setting. Mainstreaming opioid addiction treatment has many advantages; its success will depend on resolution of ethical and delivery system issues as well as improved and expanded training of physicians in addiction medicine.

Analgesics, Opioid↗
PubMed2004

Smoking abstinence after hospitalization: predictors of success.

BACKGROUND: Our objective was to explore the relationship between baseline characteristics of hospitalized smokers and 6-month to 2-year self-reported quit rates. METHODS: We surveyed adult smokers (n = 154) admitted to the Medicine service of an urban public hospital. We used the pharmacy database, a follow-up telephone survey, and medical records to characterize nicotine patch use and post-discharge smoking abstinence. RESULTS: Among the 102 patients for whom smoking status at least 6 months after discharge was known, 18 (18%) were not smoking at last contact (mean follow-up 20 months). Individual factors associated with quitting include confidence to quit within 1 week, stage of change other than precontemplation, filling a nicotine patch prescription after discharge, number of previous quit attempts, and increasing age. With multivariate modeling, only confidence to quit [OR 9.8, confidence interval (CI), 2.8-35.0] and the number of previous quit attempts (OR 1.3 per attempt, 95% CI, 1.0-1.5) remained significantly associated with future abstinence. CONCLUSIONS: A high level of confidence to quit and multiple prior quit attempts are strongly associated with future abstinence among hospitalized patients who smoke. Using a simple confidence-to-quit scale to target interventions to patients with high confidence may improve the effectiveness of smoking cessation programs.

Adult↗
PubMed2004

Impact of a cardiac risk reduction program in vulnerable patients hospitalized with coronary artery disease.

STUDY OBJECTIVE: To increase the use of guideline-based pharmacotherapy in vulnerable patients (ethnic minorities and the poor) with coronary artery disease (CAD) through a nurse-based quality-improvement program. DESIGN: Retrospective program evaluation. SETTING: Inner-city hospital in Denver, Colorado. PATIENTS: One hundred fifty-one consecutive patients hospitalized with a CAD-related diagnosis. INTERVENTION: A nurse-management program was initiated for patients with angiographically documented CAD, and rates of guideline-based care were compared with rates for historic controls. The intervention consisted of two key elements: patient counseling with language-appropriate education materials and direct physician education regarding the importance of cardioprotective drugs. The 151 patients in the intervention group were compared with 125 historic control patients hospitalized before the program was begun. Multivariable logistic regression analysis was used to assess differences in care with regard to ethnicity, education level, and insurance status, and to adjust for different baseline characteristics. MEASUREMENTS AND MAIN RESULTS: At hospital discharge, patients in the intervention group were more likely to receive statins (71% vs 52%, p=0.001) and angiotensin-converting enzyme inhibitors (79% vs 51%, p<0.001) compared with controls. These differences remained after adjusting for ethnicity, education level, insurance status, and baseline clinical characteristics. Also, a trend was noted toward greater use of aspirin (92% vs 86%, p=0.13) and beta-blockers (79% vs 73%, p=0.24) in the intervention group compared with controls. Patients in the intervention group were more likely to receive counseling for smoking cessation. CONCLUSION: An inpatient nurse-management program improved the quality of care for patients with CAD regardless of sociodemographic status. Properly designed disease-management initiatives can be effective for disadvantaged patients, who often obtain health care through emergency and inpatient services.

Colorado↗