Days Of Initial Visit Research Articles

Estimates of eskd risk and timely kidney replacement therapy education

BackgroundKidney replacement therapy (KRT) needs preparation and its timing is difficult to predict. Nephrologists’ predictions of kidney failure risk tend to be more pessimistic than the Kidney Failure Risk Equation (KFRE) predictions. We aimed to explore how physicians’ risk estimate related to referral to KRT education, vs. the objective calculated KFRE.MethodsProspective observational study of data collected in chronic kidney disease (CKD) clinics of the Veterans Affairs Medical Center San Diego and the University of California, San Diego. The study included 257 participants who were aged 18 years or older, English speaking, prevalent CKD clinic patients, with estimated glomerular filtration rate (eGFR) < 60 mL/min per 1.73 m2 (MDRD equation). The exposure consisted of end stage kidney disease (ESKD) risk predictions. Nephrologists’ kidney failure risk estimations were assessed: “On a scale of 0–100%, without using any estimating equations, give your best estimate of the risk that this patient will need dialysis or a kidney transplant in 2 years.” KFRE was calculated using age, sex, eGFR, serum bicarbonate, albumin, calcium, phosphorus, urine albumin/creatinine ratio. The outcomes were the pattern of referral to KRT education (within 90 days of initial visit) and kidney failure evaluated by chart review. The population was divided into groups either by nephrologists’ predictions or by KFRE. Referral to KRT education was examined by group and sensitivity and specificity were calculated based on whether participants reached kidney failure at 2 years.ResultsA fifth were referred for education by 90 days of enrollment. Low risk patients by both estimates had low referral rates. In those with nephrologists’ predictions ≥ 15% (n = 137), sensitivity was 71% and specificity 76%. In those with KFRE ≥ 15% (n = 55), sensitivity was 85% and specificity 41%.ConclusionsAlthough nephrologists tend to overestimate patients’ kidney failure risk, they do not appear to act on this overestimation, as the rates of KRT education referrals are lower than expected when a nephrologist identifies a patient as high risk.Clinical Trial NumberNot applicable

Clinician approaches to new spine pain cases in primary care: Balance of opioid prescribing and early linkage to exercise therapy and spinal manipulation.

Spine pain (SP) is common and often disabling. Clinical practice guidelines discourage opioid treatment and outline the value of varied nonpharmacologic therapies (NPTs). This study elucidates the amount of variability in primary-care clinicians' (PCPs') prescribing of opioids and in their cases' receipt of the two most common NPTs (exercise therapy and spinal manipulation). The design was a retrospective cohort study examining variation in the treatment of PCPs' new SP cases, classified by receipt of (a) prescription of an opioid at the initial visit; (b) exercise therapy and/or spinal manipulation within 30 days of initial visit. The study was set in the primary care clinics at military treatment facilities of the US Military Health System in the period between October 2011 and September 2016. The majority of cases did not receive a study treatment (66.3%); 19.6% of cases received only NPT within 30 days of initial visit; 11.5% were prescribed only an opioid at the initial visit with receipt of both NPT and opioid during early treatment rare (2.6%). Exercise therapy within 30 days exhibited more than a twofold difference in interquartile percentile rates (IQR) (median provision 15.8%, IQR 9.8%-22.1%). The other treatments exhibited even greater variation; specifically, spinal manipulation (median 8.5%, IQR 3.3%-15.8%), and opioid at initial visit (median 10.3%, IQR 4.4%-18.2%). The availability of physical therapists and doctors of chiropractic had significant association with several clinical provision rates. Among providers of spine care for a sample of Army soldiers, there was substantial variation in the early provision of exercise therapy, spinal manipulation, and opioid prescriptions. The magnitude of the case-mix adjusted variation and its association with facility availability of providers suggests that quality of care initiatives may help reduce this variation.

The rising burden of acute urological disease at an urban, academic hospital network.

Urological presentations to the emergency department (ED) can represent a significant burden of disease. We aimed to evaluate trends in the incidence, management, and followup of urological presentations to the ED at an urban, academic, tertiarycare hospital network over a 10-year period. A retrospective cohort study was conducted to include all patients presenting with renal colic (RC), gross hematuria (GH), or acute urinary retention (AUR) to EDs in the University Health Network in 2008-2009 and 2018-2019. Patient demographics and outcomes were compared between these two periods and between urological presentations. Multilevel regression analyses identified predictors of in-patient admission, return to the ED, and clinic wait time. A total of 2751 patients and 3510 ED visits were included (991 visits from 2008-09 and 2519 visits from 2018-19). Over time, increases were observed in all three presentations, largely driven by an almost five-fold increase in RC presentations. Multilevel regression analyses showed that older patients were more likely to be admitted from the ED, while age, 2018-19 era, and residence within the "downtown core" independently predicted return to the ED within 30 days of initial visit. Time to be seen in urology clinic increased over time for the entire cohort, and 14.4% of clinic visits were preceded by multiple ED visits. The incidence of acute urological presentations increased significantly over a 10-year period at a tertiary-care hospital network. These findings demonstrate an increasing burden of acute urological disease that is outpacing population growth and straining available resources.

PD32-05 RATE OF PROGRESSION TO SEPSIS FOLLOWING PRESENTATION FOR ACUTE CYSTITIS

You have accessJournal of UrologyCME1 May 2022PD32-05 RATE OF PROGRESSION TO SEPSIS FOLLOWING PRESENTATION FOR ACUTE CYSTITIS Daniela Kaefer, Jeffrey Chiang, and A. Lenore Ackerman Daniela KaeferDaniela Kaefer More articles by this author , Jeffrey ChiangJeffrey Chiang More articles by this author , and A. Lenore AckermanA. Lenore Ackerman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002583.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary tract infection is one of the leading causes of bacterial infections in adults, with an annual incidence of 3% for males and 12.6% for females. Annual cost of UTI care is in excess of $3 billion dollars in the US alone, and with abundant outpatient antibiotic prescriptions written for cystitis despite a lack of evidence that this improves outcomes. We aimed to evaluate the incidence of presentation for cystitis at a tertiary academic medical center, associated rate of culture confirmed urinary tract infections, and rate of progression to sepsis based on initial visit type. We hypothesized a higher positive culture rate and progression to sepsis for patients initially presenting in the hospital setting. METHODS: We queried the Discovery Data Mart administered by the UCLA Office of Health Informatics and Analytics to identify direct patient encounters for acute cystitis based on corresponding ICD code from January 1, 2013 through July 1, 2021. Encounters were characterized as outpatient (office or telemedicine), or hospital-based encounters. Corresponding urinalysis and culture data was obtained in addition to patient demographics. Encounters were screened for subsequent outpatient encounters, hospital admissions, or sepsis diagnosis within seven days of initial visit. RESULTS: We identified 511,622 encounters for acute cystitis, of which 181,568 met inclusion criteria. The majority of encounters were office visits (74.5%) compared to hospital-based (21.9%) or telemedicine (3.6%) visits. Only 32,326 (17.8%) were associated with a positive urine culture. A urinalysis was not ordered in 67,386 (37.1%) of encounters, with telemedicine having a significantly lower rate of UA orders (3% vs 78% hospital and 61% office, p<0.00001). 42,772 patients had a follow up encounter within 7 days, of which only 6,411 were hospital encounters. Only 946 patients (0.5%) progressed to sepsis within 7 days, the majority of which were hospital encounters (1% vs 0.3 office and telemedicine, p<0.00001). CONCLUSIONS: Overall rate of progression to sepsis within one week following diagnosis of acute cystitis is low. Initial encounter in a hospital setting showed higher rate of progression compared to outpatient office or telemedicine visits. Risk of empiric antibiotic therapy and antibiotic stewardship must be considered given low rate of positive cultures and overall risk of progression to sepsis. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e548 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniela Kaefer More articles by this author Jeffrey Chiang More articles by this author A. Lenore Ackerman More articles by this author Expand All Advertisement PDF DownloadLoading ...

Transepithelial photorefractive keratectomy on the same day of the initial consultation for the correction of myopia.

To examine the clinical outcomes, efficacy, safety, and predictability of transepithelial photorefractive keratectomy (Trans-PRK) operations performed on the day of the first screening visit in comparison with operations scheduled at a following appointment. Data of consecutive patients with myopia of various degrees, who underwent Trans-PRK, were retrospectively analyzed. Findings were compared between patients who underwent Trans-PRK on the same day of first consultation to patients that underwent surgery at subsequent visits, following initial consultation on a different day. The study included 599 eyes treated on the initial visit day and 1936 eyes treated on a subsequent visit. Mean final spherical equivalent was close to emmetropia in both groups (p = 0.183). Efficacy indices were 0.928 ± 0.192 in the initial-visit group and 0.945 ± 0.163 in the second-visit group (p = 0.152). Safety indices were 0.954 ± 0.156 and 0.955 ± 0.151 (p = 0.707), respectively. No differences between the groups were seen in uncorrected visual acuity (UDVA) of ⩾20/20, ⩾20/25, and ⩾20/32. Only the sub-analysis of patients reaching UDVA of 20/40 or better was slightly lower in the first-visit (95.5%) compared with the second-visit group (97.9%, p = 0.001). Results of attempted correction within ±0.50 D were: 63.3% and 69.0%, respectively (p = 0.009). Complications profiles in the two groups were comparable. Trans-PRK completed on the day of the first screening appointment demonstrated a similar safety outcome compared with subsequent-visits procedures, and slightly lower, yet comparable, results regarding efficacy and predictability.

Serious Diagnoses for Headaches After ED Discharge.

Headache is a common complaint among children presenting to the emergency department (ED) and can be due to serious neurologic and nonneurologic diagnoses (SNNDs). We sought to characterize the children discharged from the ED with headache found to have SNNDs at revisits. We performed a multicenter retrospective cohort study using data from 45 pediatric hospitals from October 1, 2015, to March 31, 2019. We included pediatric patients (≤18 years) discharged from the ED with a principal diagnosis of headache, excluding patients with concurrent or previous SNNDs or neurosurgeries. We identified rates and types of SNNDs diagnosed within 30 days of initial visit and compared these rates with those of control groups defined as patients with discharge diagnoses of cough, chest pain, abdominal pain, and soft tissue complaints. Of 121 621 included patients (57% female, median age 12.4 years, interquartile range: 8.8-15.4), 608 (0.5%, 95% confidence interval: 0.5%-0.5%) were diagnosed with SNNDs within 30 days. Most were diagnosed at the first revisit (80.8%); 37.5% were diagnosed within 7 days. The most common SNNDs were benign intracranial hypertension, cerebral edema and compression, and seizures. A greater proportion of patients with SNNDs underwent neuroimaging, blood, and cerebrospinal fluid testing compared with those without SNNDs (P < .001 for each). The proportion of SNNDs among patients diagnosed with headache (0.5%) was higher than for control cohorts (0.0%-0.1%) (P < .001 for each). A total 0.5% of pediatric patients discharged from the ED with headache were diagnosed with an SNND within 30 days. Further efforts to identify at-risk patients remain a challenge.

Double-blind randomized controlled trial on efficacy of cupulolith repositioning maneuver for treatment of apogeotropic horizontal canal benign paroxysmal positional vertigo

Backgrounds: Although various therapeutic maneuvers have been proposed, it is still unclear which maneuver is better to treat apogeotropic horizontal canal benign paroxysmal positional vertigo (HC-BPPV).Objectives: This study aimed to assess the therapeutic efficacy of the cupulolith repositioning maneuver (CuRM) in apogeotropic HC-BPPV in comparison with the therapeutic head-shaking maneuver and modified Lempert maneuver.Materials and Method: This is double-blind randomized prospective study. Forty-nine consecutive patients diagnosed with apogeotropic HC-BPPV were allocated randomly to CuRM (n = 18), therapeutic head-shaking (n = 16), or modified Lempert maneuver (n = 15). The presence of nystagmus and vertigo on positional testing were evaluated at 30 min, on 1 day, and 1 week after treatment.Results: There were no significant differences in any clinical characteristics between the three groups at randomization. After a single trial of therapeutic maneuvers on the initial visit day, the CuRM (38.9%) and therapeutic head shaking maneuver (12.5%) did not show differences compared to modified Lempert maneuver (33.3%). The therapeutic effects on the 2nd day and at 1 week after treatment also did not differ between the three groups.Conclusions: Although the CuRM is theoretically considered to be a better therapeutic method, the therapeutic efficacy of CuRM was not statistically different compared to the other two maneuvers.

Evaluation of the use of the Scale for the Assessment and Rating of Ataxia (SARA) in healthy volunteers and patients with schizophrenia

ObjectiveThe Scale for the Assessment and Rating of Ataxia (SARA) is a semi-quantitative assessment used to evaluate ataxia. The goal of these studies was to assess and evaluate the utility of this instrument in a Healthy Volunteer (HV) group and subjects with Schizophrenia (SCZ). MethodsTwo studies were completed to collect SARA data, in a HV group and in a stable SCZ group. 177 HVs (18–65 years) and 16 SCZs (18–58 years) provided written consent and were assessed using the SARA. Of 177 HV subjects, 88 had 2 SARA assessments (within 2 days of initial visit) while all 16 SCZ had 3 SARA assessments (within 14 days of initial visit). ResultsFor the HV group, the mean score ± Std for the SARA on visit-1 was 0.39 ± 0.72, and 0.34 ± 0.64 for visit-2. The Pearson correlation coefficient between visit-1 and visit-2 was 0.7486 and an ICC of 0.743. For the SCZ group, the mean score for the SARA was 0.63 ± 0.65 on visit-1, 0.84 ± 1.19 on visit-2, and 0.84 ± 0.94 on visit-3. The Pearson correlation coefficient between visit-1 and visit-2 was 0.6545, between visit-1 and visit-3 was 0.6635 and between visit-2 and visit-3 was 0.7613 and an ICC of 0.650. There was no significant difference in baseline SARA scores between the HV and SCZ group p = .063. A statistically significant positive association between age and total SARA scores was observed in HV (r = 0.345) and SCZ (r = 0.676). ConclusionsA strong association was observed in both the HV and SCZ groups in the reassessment of signs of ataxia using the SARA scale. Both groups demonstrated minimal signs of ataxia, with no statistically significant difference between the two groups in their visit-1 scores.

Syndromic Surveillance for Situation Awareness: Understanding Syndrome Performance

ObjectiveIn August 2017, a large influx of visitors was expected to view the total solar eclipse in Idaho. The Idaho Syndromic Surveillance program planned to enhance situation awareness during the event. In preparation, we sought to examine syndrome performance of several newly developed chief complaint and combination chief complaint and diagnosis code syndrome definitions to aid in interpretation of syndromic surveillance data during the event.IntroductionThe August 21, 2017 total solar eclipse in Idaho was anticipated to lead to a large influx of visitors in many communities, prompting a widespread effort to assure Idaho was prepared. To support these efforts, the Idaho Syndromic Surveillance program (ISSp) developed a plan to enhance situation awareness during the event by conducting syndromic surveillance using emergency department (ED) visit data contributed to the National Syndromic Surveillance Program’s BioSense platform by Idaho hospitals. ISSp sought input on anticipated threats from state and local emergency management and public health partners, and selected 8 syndromes for surveillance.Ideally, the first electronic message containing information on an emergency department visit is sent to ISSp within 24 hours of the visit and includes the chief complaint for the visit. Data on other variables, such as diagnosis codes, are updated by subsequent messages for several days after the visit. Chief complaint (CC) text and discharge diagnosis (DD) codes are the primary variables used for syndrome match; delay in reporting these variables adversely affects timely syndrome match of visits. Because our plan included development of new syndrome definitions and querying data within 24 hours of visits, earlier than ISSp had done previously for trend analysis, we sought to better understand syndrome performance.MethodsWe defined messages with completed CC and DD as the last message regarding a visit where term count increased from previous messages regarding that visit, indicating new information was added to the field. We retrospectively assessed the total number of ED visits and calculated the daily frequency of completed CC and DD by days since visit date for visits during June 1–July 31, 2017. Additionally, we calculated facility mean word count in CC fields by averaging the word count of parsed, complete CC fields for visits occurring June 1–July 31, 2017 for each facility.During July 10–24, 2017, we calculated the daily frequency of visits occurring in the previous 90 days for total ED visits and syndrome-matched visits for 8 selected syndromes (heat-related illness; cold exposure; influenza-like-illness; nausea, vomiting, and diarrhea; animal/bug bites and stings; drowning/submersion; alcohol/drug intoxication; and medication replacement). Syndrome-matched visits were defined as visits with CC or DD that match the syndrome definition. We calculated the percent of syndrome-matched visits by syndromes defined with CC or CC and DD combined (CCDD) over time. Syndromes with fewer than 5 matched visits were excluded from analysis.ResultsComplete CCs were received for 99.1% of visits and complete DDs were received for 89.8% of visits. Complete CCs were submitted for 58.2% of visits within 1 day of the visit, 88.9% of visits within 3 days, and 98.9% of visits within 7 days. In contrast, complete DDs were submitted for 24.3% of visits within 1 day, 38.7% of visits within 3 days, and 53.7% of visits within 7 days (Table 1).During the observation period, data submission from facilities representing approximately 33% of visits was interrupted for 5 (36%) of 14 days. Heat-related illness, cold exposure, and drowning/submersion, were excluded from syndrome-match analysis. During the 9 days of uninterrupted data submission, 100% syndrome-matched visits for syndromes defined by CC alone and 69.1% syndrome-matched visits for syndromes defined by CCDD were identified within 6–7 days of initial visit. Facilities with interrupted data submission contributed 75% of CC syndrome-matched visits and 33% of CCDD syndrome-matched visits. The facility mean word count in CC fields from these facilities was &gt;15 compared with 2–4 from other facilities.ConclusionsExamination of syndrome performance prior to a known event quantitated differences in timeliness of CC and DD completeness and syndrome match. CCs and DDs in visit messages were not complete within 24 hours of initial visit. CC completion was nearly 34 percentage points greater than DD completeness 1 day after initial visit and did not converge until ≥15 days after initial visit. Higher percentages of syndrome match within 6–7 days of initial visit were seen by CC alone than CCDD defined syndromes. Facilities using longer CCs contributed disproportionately to syndrome matching using CC, but not CCDD syndrome definitions. Syndromic surveillance system characteristics, including timeliness of CCs and DDs, length of CCs, and characteristics of facilities from which data transmission is interrupted should be considered when building syndrome definitions that will be used for surveillance within 7 days of emergency department visits and when interpreting syndromic surveillance findings.

P09.02 Reattendance rates in men presenting with symptoms of urethritis – can point of care testing for chlamydia and gonorrhoea improve outcomes?

Introduction Chlamydia and gonorrhoea are common causes of urethritis. Management is often based on an enhanced syndromic approach while awaiting results. This can necessitate prescribing to cover a range of potential pathogens, and uncertainty for patients. Point of care testing (POCT) for chlamydia and gonorrhoea in men with symptoms of urethritis could alter care pathways and reduce reattendance in these patients. The aim of this study was to measure reattendance rates in men presenting with symptoms of urethritis and develop a decision tree care pathway model in order to estimate potential benefits of replacing standard nucleic acid amplification testing with POCT. Methods All men with urethritis symptoms presenting over a three month period were identified using electronic patient records. Urethritis was defined as ≥5 pmnls/hpf on a Gram stained urethral smear. Reattendances within 30 days of initial clinic visit and reasons for reattendance were recorded for both microscopy-positive and negative groups. Review of literature was used to provide estimates of improved outcomes if the chlamydia/gonorrhoea POCT result was available prior to the clinical consultation. Results 431 men with urethritis symptoms were identified in a 3 month period. 192 had confirmed urethritis on initial microscopy. 31% of microscopy-positive men and 42% of microscopy-negative men reattended at least once within 30 days of initial visit. Common reasons for reattendance were early morning smear (20%), persistent symptoms (18%), results (16%) and gonorrhoea test of cure (9%). It was estimated that POCT could reduce microscopy by 25% and repeat reattendance following treatment by 75% through improved pathogen-directed treatment and the introduction of gonorrhoea POCT sample drop-off as a test of cure. Conclusion This service evaluation using decision tree care pathway modelling has identified high reattendance rates in men with urethritis symptoms which POCT has the potential to reduce substantially. Disclosure of interest statement PH has received funding from Cepheid directly and indirectly for lecturing on point of care testing and undertaking research on the cost effectiveness of their CT/NG assay. Has also received payment from Atlas Genetics for an article in the Parliamentary Review on the benefits of point of care technology in improving the cost effectiveness of sexual health services. Has also received an honorarium from Hologic for an education talk on STI diagnostics. NC, MC, FG, MC, JN, HW, no conflicts of interest declared.

P151 Reattendance rates in men presenting with symptoms of urethritis – should we be doing better?

<h3>Background</h3> Chlamydia and gonorrhoea are common causes of urethritis. Management is often based on an enhanced syndromic approach while awaiting results. This can necessitate prescribing to cover a range of potential pathogens, and result in uncertainty for patients. Point of care testing (POCT) for chlamydia and gonorrhoea in men with symptoms of urethritis could alter care pathways and reduce reattendance. <h3>Aims</h3> To measure reattendance rates in men presenting with symptoms of urethritis. To identify reasons for reattendance including those that could be mitigated by POCT. <h3>Methods</h3> All men with urethritis symptoms presenting over a three month period were identified using electronic patient records. Urethritis was defined as ≥5 pmnls/hpf on a Gram stained urethral smear. Reattendances within 30 days of initial clinic visit and reasons for reattendance were recorded for both microscopy-positive and negative groups. <h3>Results</h3> 431 men with urethritis symptoms were identified in a 3 month period. 192 had confirmed urethritis on initial microscopy. 31% of microscopy-positive men and 42% of microscopy-negative men reattended at least once within 30 days of initial visit. Common reasons for reattendance were early morning smear (20%), persistent symptoms (18%), results (16%) and gonorrhoea test of cure (9%). <h3>Discussion</h3> This service evaluation has identified high reattendance rates in men with urethritis symptoms. POCT could impact on reattendance rates in a number of ways. Pathogen-guided treatment may reduce antimicrobial failure and persistent symptoms. Same-day results could reduce results visits. Reassurance from negative same-day results may also have a role in reducing persistent symptoms.

Impact of imaging guidelines on X-ray use among American provider network chiropractors: interrupted time series analysis

Background contextOveruse and misuse of spine X-ray imaging for nonspecific back and neck pain persists among chiropractors. Distribution of educational materials among physicians results in small-to-modest improvements in appropriate care, such as ordering spine X-ray studies, but little is known about its impact among North American chiropractors. PurposeTo evaluate the impact of web-based dissemination of a diagnostic imaging guideline on the use of spine X-ray images among chiropractors. Study design/settingQuasi-experimental design that used interrupted time series to evaluate the effect of guidelines dissemination on spine X-ray imaging claims by chiropractors enlisted in managed care network in the United States. Patient sampleConsecutive adult patients consulting for complaints of spine disorders. Outcome measuresA change in level (the mean number of spine X-ray imaging claims per month immediately after the introduction of the guidelines), change in trend (any differences between preintervention and postintervention slopes), estimation of monthly average intervention effect after the intervention. MethodsThe imaging guideline was disseminated online in April 2008. Administrative claims data were extracted between January 2006 and December 2010. Segmented regression analysis with autoregressive error was used to estimate the impact of guideline recommendations on the rate of spine X-ray studies. Sensitivity analysis considered the effect of two additional quality improvement strategies, a policy change and an education intervention. ResultsTime series analysis revealed a significant change in the level of spine X-ray study ordering weeks after introduction of the guidelines (−0.01; 95% confidence interval=−0.01, –0.002; p=.01), but no change in trend of the regression lines. The monthly mean rate of spine X-ray studies within 5 days of initial visit per new patient exams decreased by 10 per 1000, a 5.26% relative decrease after guideline dissemination. Controlling for two quality improvement strategies did not change the results. ConclusionsWeb-based guideline dissemination was associated with an immediate reduction in spine X-ray imaging claims. Sensitivity analysis suggests our results are robust. This passive strategy is likely cost-effective in a chiropractic network setting.

Randomized clinical trial for geotropic horizontal canal benign paroxysmal positional vertigo

To determine the immediate and long-term therapeutic efficacies of barbecue rotation and Gufoni maneuvers, a randomized, prospective, and sham-controlled study was conducted in patients with the geotropic type of benign paroxysmal positional vertigo involving the horizontal semicircular canal (HC-BPPV). In 10 nationwide dizziness clinics in Korea, 170 consecutive patients (107 women, age range 11-97 years, mean age ± SD 61 ± 15 years, median = 61 years) with geotropic HC-BPPV were randomly assigned to barbecue rotation (n = 56), Gufoni (n = 64), or sham maneuver (n = 50). An immediate response was determined within 1 hour after a maximum of 2 trials of each maneuver on the visit day. We also assessed the cumulative results of each maneuver by following up the patients for 1 month. After a maximum of 2 maneuvers on the initial visit day, barbecue rotation (38 of 55 [69.1%]) and Gufoni (39 of 64 [60.9%]) maneuvers showed better responses than the sham maneuver (17 of 48 [35.4%]). The cumulative therapeutic effects were also better with barbecue rotation (p = 0.006) and Gufoni (p = 0.031) maneuvers than with the sham maneuver. However, therapeutic efficacies did not differ between the barbecue rotation and Gufoni groups in terms of both immediate (p = 0.46) and long-term (p = 0.10) outcomes. Using a prospective randomized trial, we demonstrated that barbecue rotation and Gufoni maneuvers are effective in treating geotropic HC-BPPV. This study provides Class I evidence that barbecue rotation and Gufoni maneuvers are effective in the treatment of geotropic HC-BPPV.

Randomized clinical trial for apogeotropic horizontal canal benign paroxysmal positional vertigo

To determine the immediate and long-term therapeutic efficacies of Gufoni and head-shaking maneuvers in apogeotropic type of benign paroxysmal positional vertigo involving the horizontal semicircular canal (HC-BPPV), a randomized, prospective, sham-controlled study was conducted. In 10 nationwide dizziness clinics in Korea, 157 consecutive patients (95 women, age range: 18-89 years, mean age ± SD = 59.9 ± 13.6) with apogeotropic HC-BPPV were randomized to Gufoni (n = 52), head-shaking (n = 54), or sham maneuver (n = 51). For Gufoni maneuver, patients underwent ipsilesional side-lying and upward head-turn for migration of the debris toward the vestibule. Immediate responses were determined within 1 hour after a maximum of 2 trials of each maneuver and in the following day. The patients also had weekly follow-ups for 1 month after the initial maneuver. After a maximum of 2 maneuvers on the initial visit day, Gufoni (38/52, 73.1%) and head-shaking (33/53, 62.3%) maneuvers showed better responses than the sham maneuver (17/49, 34.7%). The cumulative therapeutic effects were also better with Gufoni (p < 0.001) and head-shaking (p = 0.026) maneuvers compared with the sham maneuver. However, therapeutic efficacies did not differ between the Gufoni and head-shaking groups in terms of both immediate (p = 0.129) and long-term (p = 0.239) outcomes. Using a prospective randomized trial, we demonstrated that the Gufoni and head-shaking maneuvers are effective in treating apogeotropic HC-BPPV. This study provides Class II evidence that Gufoni and head-shaking maneuvers are effective in treating apogeotropic horizontal BPPV up to 1 month after initial treatment. NCT00810641.

Erythema multiforme, Stevens–Johnson syndrome and toxic epidermal necrolysis: Frozen‐section diagnosis

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) may be fatal. Although classified by body surface area skin detachment, initial stages of both may present with erythema multiforme (EM)-like lesions. To diagnose and predict disease activity adequately as early as possible for patients revealing EM-like lesions, we performed frozen-section diagnosis. Thirty-five patients clinically diagnosed as EM, SJS or TEN were biopsied to diagnose and predict disease progression within the initial-visit day. Half of a histological section taken from a lesion was snap-frozen and immediately cryostat-sectioned, acetone-fixed and stained with hematoxylin-eosin. Specimens were examined with light microscopy for presence of epidermal necrosis. A section from unaffected sites was also examined for 11 patients. Specimens were examined with light microscopy for presence of graft-versus-host reaction (GVHR)-like findings: apoptotic keratinocytes and satellite cell necrosis. Epidermal necrosis was seen in nine patients. Initial diagnosis of the nine was one of overlap SJS-TEN, four of SJS and four of EM, and final diagnosis of those was one of TEN, one of overlap SJS-TEN, four of SJS and three of EM. Dissociation between initial and final diagnosis was seen in three cases. GVHR-like findings in the epidermis were observed in two patients finally diagnosed as overlap SJS-TEN and TEN. Frozen sections are useful not only to make a diagnosis of erythema multiforme but to assess a potential to exhibit more aggressive clinical behaviors (SJS or TEN).