Eligible Visits Research Articles

Dynamics of viremia in primary HIV-1 infection in Africans: Insights from analyses of host and viral correlates

In HIV-1 infection, plasma viral load (VL) has dual implications for pathogenesis and public health. Based on well-known patterns of HIV-1 evolution and immune escape, we hypothesized that VL is an evolving quantitative trait that depends heavily on duration of infection (DOI), demographic features, human leukocyte antigen (HLA) genotypes and viral characteristics. Prospective data from 421 African seroconverters with at least four eligible visits did show relatively steady VL beyond 3 months of untreated infection, but host and viral factors independently associated with cross-sectional and longitudinal VL often varied by analytical approaches and sliding time windows. Specifically, the effects of age, HLA-B⁎53 and infecting HIV-1 subtypes (A1, C and others) on VL were either sporadic or highly sensitive to time windows. These observations were strengthened by the addition of 111 seroconverters with 2–3 eligible VL results, suggesting that DOI should be a critical parameter in epidemiological and clinical studies.

Emergency Department Revisits in Children With Gastroenteritis

The aim of the study was to determine whether intravenous fluid administration is independently associated with a reduction in unscheduled emergency department (ED) revisits within 7 days. We conducted a single-center, retrospective observational cohort study in a pediatric ED in Toronto, Canada. Participants were younger than 18 years, diagnosed as having gastroenteritis, and discharged home between July 2003 and June 2008. Multivariable regression models were used to determine the associations between the exposures (intravenous rehydration, triage severity score, age) and ED revisits and revisits with intravenous rehydration. Accuracy was assessed using bootstrap analysis. There were 22,125 potentially eligible visits; 3346 were included in our final cohort. A total of 497 children (15%) received intravenous rehydration and 543 (16%) had an unscheduled revisit. Regression analysis included 2874 children with complete data, and identified 5 independent predictors of an ED revisit: intravenous rehydration (odds ratio [OR] 1.76; 95% confidence interval [CI] 1.36-2.26); number of vomiting episodes (1.20; 95% CI 1.04-1.28/5 episode increase); days of diarrhea (OR 0.92; 95% CI 0.88-0.97/day increase); frequency of diarrhea (1.19; 95% CI 1.03-1.38/5 episode increase); and age (OR 0.94; 95% CI 0.91-0.98/year). Bootstrap methodology identified intravenous rehydration, age, number of vomiting episodes, days of diarrhea, and number of diarrheal stools a minimum of 500 of 1000 iterations. Intravenous rehydration is associated with unscheduled ED revisits after adjustment for clinical findings. Although children experiencing revisits were likely more unwell, our data do not support the provision of intravenous fluids to prevent unscheduled ED revisits in children with mild-to-moderate dehydration.

Pediatric Abdominal Radiograph Use, Constipation, and Significant Misdiagnoses

To determine the proportion of children diagnosed with constipation assigned a significant alternative diagnosis within 7 days (misdiagnosis), if there is an association between abdominal radiograph (AXR) performance and misdiagnosis, and features that might identify children with misdiagnoses. We conducted a retrospective cohort study of consecutive children <18 years who presented to a pediatric emergency department in Toronto, between 2008 and 2010. Children assigned an International Statistical Classification of Diseases and Related Health Problems 10th Revision code consistent with constipation were eligible. Misdiagnosis was defined as an alternative diagnosis during the subsequent 7 days that resulted in hospitalization or an outpatient procedure that included a surgical or radiologic intervention. Constipation severity was classified employing text word categorization and the Leech score. 3685 eligible visits were identified. Mean age was 6.6 ± 4.4 years. AXR was performed in 46% (1693/3685). Twenty misdiagnoses (0.5%; 95% CI 0.4, 0.8) were identified (appendicitis [7%], intussusception [2%, bowel obstruction [2%], other [9%]). AXR was performed more frequently in misdiagnosed children (75% vs 46%; P = .01). These children more often had abdominal pain (70% vs 49%; P = .04) and tenderness (60% vs 32%; P =.01). Children in both groups had similar amounts of stool on AXR (P = .38) and mean Leech scores (misdiagnosed = 7.9 ± 3.4; not misdiagnosed = 7.7 ± 2.9; P = .85). Misdiagnoses in children with constipation are more frequent in those in whom an AXR was performed and those with abdominal pain and tenderness. The performance of an AXR may indicate diagnostic uncertainty; in such cases, the presence of stool on AXR does not rule out an alternative diagnosis.

Climate Change Impacts of Ozone on Morbidity in Vulnerable Populations across the Life Stages in 2050, Mecklenburg County, North Carolina, USA

Background: Climate- and emissions-related changes in ozone concentrations will likely impact both morbidity and mortality; these changes may have greater effects on vulnerable populations such as children and older adults. Aims: 1) Estimate the climate- and emissions-related impacts on ozone-related cardiopulmonary morbidity burden from 2006-2011 to 2048-2050 in Mecklenburg County, North Carolina (NC), an urban county in Southeastern United States with over 900,000 residents. 2) Assess the sensitivity of results to alternate population growth and age structure scenarios. Methods: We obtained respiratory and cardiovascular emergency department (ED) visit data from Mecklenburg County for April-October 2006-2011 from the NC Disease Event Tracking and Epidemiologic Collection Tool surveillance system. We estimate baseline ozone-morbidity associations with a time-series model of merged daily ozone monitor data and ED visit counts. We generate projected ozone concentration grids (12km) for 2048-2050 with the Community Multi-scale Air Quality (CMAQ) chemistry transport model using the IPCC A1B emissions scenario and assuming emission changes from anthropogenic sources only . We use a health impact assessment framework to estimate the projected changes in ED visits and the influence of alternate demographic scenarios in 2050. Results: 39,515 eligible ED visits (19,812 cardiovascular, 19,703 respiratory) occurred during the 2006-2011 baseline study period, with mean daily count of 31.5 (SD 7.6). Daily maximum 8-hour average ozone concentrations ranged from 3 to 127 ppb, with median of 51 ppb; May-August 2050 ozone projections indicate decreasing ozone levels, with a median of 36 ppb and range of 18-62 ppb. Baseline associations, projected health impacts, and sensitivity to alternate demographic scenarios will be presented. Conclusions: Climate change, air quality regulation, and population dynamics will likely alter future demand for ED services. These projections can be used to inform local public health preparedness and support continued air pollution mitigation.

Emergency Department Physician Computed Tomography Utilization and Admission Rates

Emergency Department Physician Computed Tomography Utilization and Admission Rates

Emergency Physician Variation in Admissions for Common Chief Complaints

The emergency department (ED) represents an increasing source of hospital admissions, placing costly decisions in the hands of emergency physicians. Emergency physicians have been shown to vary dramatically in their admission rates, suggesting some providers may admit patients unnecessarily. It is unclear whether this variation in provider admission rates exists across all types of patient presentations. Determining the degree of admission rate variation for common chief complaints may help delineate clinical presentations that increase risk of inappropriate and costly hospital admissions. This retrospective study examined board certified/eligible emergency physicians practicing at an 850-bed tertiary level 1 trauma center with 85,000 annual care visits. Physicians worked equally in all areas of the ED. Patient characteristics and encounter data were obtained from an electronic medical record and physician order entry system from August 2008 to January 2012. Urgent care visits, patients younger than age 8, and trauma activations were excluded. Physicians were excluded if they worked less than 200 clinical hours, had less than 50 observations of a given chief complaint, or worked primarily in the pediatric ED. Admission rates were modeled using Emergency Severity Index, patient age, and time of presentation with logistic regression to adjust for differences in patient populations between physicians. Adjusted admission rates were modeled for the chief complaints of abdominal pain, shortness of breath, chest pain, and headache. Odds ratios were calculated to determine whether physicians with high admission rates (upper quartile) were consistent across chief complaints. There were 193,532 eligible ED visits, 57,213 of which resulted in admission. There were 48 emergency physicians who averaged 2,494 clinical hours and saw 3,949 patients during the study period. Each physician admitted an average of 1,168 patients. The adjusted overall admission rate was 23.5% (95%CI 22.9-24.3%) of ED visits, ranging from 17.4% (95%CI 16.2-18.6%) to 33.5% (95%CI 32.3-34.8%). The upper quartile of providers ordered 87% of admissions above the group average. There was large variation in admission rates between providers for all chief complaints. Shortness of breath had the highest admission rate among chief complaints, with 36.8% (range 17.1-53.0%) of visits resulting in admission. This was followed by abdominal pain (29.2%, 16.2-41.2%), chest pain (24.9%, 11.8-38.4%), and headache (15.3%, 5.4-26.7%). The odds ratio that high admitters for chest pain were high admitters for all patients was 34.0 (95%CI 5.84-197.8). High admission rates for shortness of breath (12.8, 95%CI 2.78-58.9) and abdominal pain (8.96, 95%CI 2.03-39.6) also predicted high overall admission rates. Odds ratios show high admitters of any one chief complaint were consistently high admitters for any one other chief complaint except headache. Large variation exists in provider admission rates for common chief complaints. A small group of providers appears to account for a significant volume of excess admissions in all chief complaints. Common factors may exist in this group that guide admission decisions. Chest pain and shortness of breath demonstrated the most variation among providers and appear to be good targets for interventions aimed at reducing unnecessary admissions.

Variation in use of all types of computed tomography by emergency physicians

Study ObjectivesVariation in computed tomography (CT) use between emergency medicine (EM) physicians may delineate appropriate or inappropriate use. We hypothesize that variation in all types of CT use exists between providers and their use in patients with common chief concerns. We determine EM physicians' variability in CT use of all types and whether high use in one area predicts use of other CT types. MethodsThis was a retrospective study of EM physicians practicing at an 800-bed tertiary level 1 trauma center over a 3.5-year period. Computed tomography rates by type and by patient chief concern were modeled for providers as a function of patient acuity, disposition, age, and time of day using logistic regression. ResultsOf 195 801 eligible visits, 44 724 visits resulted in at least 1 CT scan. The adjusted rate of CT ordering by providers was 23.8% of patient visits, ranging from 11.5% to 32.7% The upper quartile of providers was responsible for 78% of the CT scans ordered above the mean. There was a large variation in use of all types of CT and by chief concern. There was an 8-fold variation in use of CT abdomen in discharged patients. High head CT use by providers predicts high use in all other CT types. ConclusionWe demonstrate a dramatic variation in CT use among EM physicians in all types of CT and common chief concerns. Greater variation was present in patients who were discharged. Large deviation from the mean by a group of providers may suggest inappropriate use.

Initial Antibiotic Choice in the Treatment of Group A Streptococcal Pharyngitis and Return Visit Rates.

Our objectives were to describe the incidence of return visits for children with Group A Streptococcal (GAS) pharyngitis (ie, clinical treatment failure) and to assess whether initial treatment with amoxicillin or penicillin was associated with the rate of retreatment for GAS pharyngitis. This analysis was a retrospective cohort study of 5533 children 0-17 years from a multisite practice. Eligible visits (n = 6585) were associated with a positive test for GAS, receipt of antibiotics within 7 days, no allergies to penicillins or cephalosporins, and no codiagnoses requiring antibiotic treatment. Retreatment for GAS pharyngitis was defined as an index visit followed by another visit within 1-4 weeks. Five hundred episodes (250 treatment failures and 250 controls) were randomly selected for chart review to validate cases. Amoxicillin or penicillin was the initial antibiotic treatment at 76.1% of visits, and retreatment for GAS pharyngitis occurred after 5.8% of initial visits. Children initially prescribed amoxicillin or penicillin had higher odds of retreatment of GAS pharyngitis even after adjusting for age, sex, symptoms, and community-level covariates such as race, income, and education (odds ratio, 1.51; 95% confidence interval, 1.07-2.13). Retreatment for GAS pharyngitis was uncommon and associated with receipt of amoxicillin or penicillin, although the impact of GAS carriage is unknown. Recommendations for initial treatment of GAS pharyngitis should reflect both individual and societal considerations, including the potential impact on antibiotic resistance in the community.

Sodium challenge does not support an acute gastrointestinal–renal natriuretic signaling axis in humans

A gastrointestinal-renal natriuretic signaling axis has been proposed to regulate sodium excretion in response to acute sodium ingestion. Such an axis is thought to be regulated by a gastrointestinal sodium sensor coupled to the activation/release of a natriuretic signal and could have important clinical and scientific implications. Here we systematically tested for this putative axis and the potential involvement of the gastrointestinal-derived natriuretic prohormones prouroguanylin and proguanylin in 15 healthy volunteers. There was no difference in sodium excretion following equivalent oral or intravenous sodium loads during either high- or low-sodium diets. Furthermore, serum concentrations of prouroguanylin and proguanylin did not increase, did not differ following oral or intravenous sodium, and did not correlate with sodium excretion. Thus, our results do not support an acute gastrointestinal-renal natriuretic axis or a central role for prouroguanylin or proguanylin in humans. If such an axis does exist, it is not characterized by a significant difference in the pattern of sodium excretion following either an oral or intravenous sodium load.

The Effect of a Crowded Emergency Department on Admission Rates

Source: Michelson KA, Monuteaux MC, Stack AM, et al. Pediatric emergency department crowding is associated with a lower likelihood of hospital admission. Acad Emerg Med. 2012; 19(7): 816– 820; doi: 10.1111/j.1553-2712.2012.01390.xInvestigators from Children’s Hospital of Boston reviewed administrative data from pediatric emergency department (ED) visits between 2007 and 2010 to determine the effect of ED crowding on hospital admission and return ED visits. Every ED patient visit was eligible for inclusion except those with incomplete data or length of stay (LOS) >24 hours. For each eligible ED patient visit, investigators calculated an occupancy rate, defined as the ratio of the number of all patients in the ED at the time of presentation (including the waiting room) to total ED beds. An occupancy rate of 1 indicated there was 1 patient for every ED bed. Visits were then placed into quintiles by assigned occupancy rates.The primary outcomes of interest were hospital admission and return ED visits within 48 hours. Logistic regression models were used to calculate the odds of admission and return visits by comparing the 4 most crowded quintiles to the least crowded quintile, adjusting for potential confounders, such as triage severity score on arrival, hospital occupancy, and time of arrival. In a sub-analysis, investigators calculated hospital admission and return visits among patients who had diagnoses of asthma or gastroenteritis, since these 2 common conditions might be sensitive to the effects of ED crowding because they require a period of therapy and observation prior to making a disposition decision.Of 200,901 visits during the study period, 794 (0.4%) were excluded due to LOS >24 hours and 1,329 (0.7%) were excluded because of incomplete data. Of the remaining 198,778 visits, the overall admission rate was 17%. Patients in the 2 most crowded occupancy rate quintiles had a lower likelihood of admission compared to those in the least crowded quintile (adjusted odds ratios: 0.89; 95% CI, 0.85– 0.94; and 0.85; 95% CI, 0.81–0.89). Patients in the 4 most crowded quintiles were also significantly less likely to return to the ED within 48 hours than those in the least crowded quintile. There were no significant differences in the likelihood of hospital admission or return visits among patients with gastroenteritis or asthma across quintiles.The authors conclude that children evaluated in the study institution’s pediatric ED are less likely to be admitted when the ED is crowded.Dr Stevenson has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Crowding is known to contribute to delayed antibiotic administration to febrile neonates in the pediatric ED1 and adversely affects patient flow.2 ED crowding may also selectively strain hospital and ED resources during the winter season or during evening hours. Because criteria for hospital admission of pediatric patients are not well defined for many diagnoses, this study represents an important step toward understanding how crowding in the ED may affect provider decisions to hospitalize children.It is noteworthy that there were no differences in return visit or hospital admission rates for gastroenteritis or asthma patients with increasing crowding in the ED. However, although investigators controlled for important confounders such as acuity and hospital occupancy, there may be other relevant variables that were not accounted for, such as staffing changes or seasonal illness patterns. In addition, this urban referral center does not experience a significant number of patients who are boarded in the ED when the hospital is full. Therefore, the investigators’ findings may not be applicable to other settings with differing resources.Further evaluation of how crowding impacts disposition decisions is warranted. In the meantime, it may be prudent for pediatric practitioners to closely follow children discharged from the ED during times of high volume.The implications of this study are that providers’ decision-making (and therefore quality of care) might be affected by a very human factor – how busy they are. This is a crucial line of investigation, but we’re not sure that this study brings us much closer to a true understanding. As pointed out in the commentary above, there were several potential confounders that were not accounted for in the analyses, not to mention all the unknown confounders. Given this and other weaknesses in design of the study, and with odds ratios quite close to 1.0 (despite being statistically significant), we suspect that there weren’t any true differences in provider decision-making, at least related to the outcomes studied, related to ED crowding.

Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial

To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety. From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that used the same PHR. Intervention practices received access to a medications module prompting patients to review their documented medications and identify discrepancies, generating 'eJournals' that enabled rapid updating of medication lists during subsequent clinical visits. A sample of 267 patients who submitted medications eJournals was contacted by phone 3 weeks after an eligible visit and compared with a matched sample of 274 patients in control practices that received a different PHR-linked intervention. Two blinded physician adjudicators determined unexplained discrepancies between documented and patient-reported medication regimens. The primary outcome was proportion of medications per patient with unexplained discrepancies. Among 121,046 patients in eligible practices, 3979 participated in the main trial and 541 participated in the sub-study. The proportion of medications per patient with unexplained discrepancies was 42% in the intervention arm and 51% in the control arm (adjusted OR 0.71, 95% CI 0.54 to 0.94, p=0.01). The number of unexplained discrepancies per patient with potential for severe harm was 0.03 in the intervention arm and 0.08 in the control arm (adjusted RR 0.31, 95% CI 0.10 to 0.92, p=0.04). When used, concordance between documented and patient-reported medication regimens and reduction in potentially harmful medication discrepancies can be improved with a PHR medication review tool linked to the provider's medical record. This study was registered at ClinicalTrials.gov (NCT00251875).

Time‐series Analysis of Ondansetron Use in Pediatric Gastroenteritis

Emergency department use of ondansetron in children with gastroenteritis is increasing; however, its effect on clinical outcomes is unknown. We aimed to determine whether increasing ondansetron usage is associated with improved outcomes in children with gastroenteritis. A retrospective cohort study was conducted at The Hospital for Sick Children, Toronto, Canada. Eligible children included those younger than 18 years old with gastroenteritis who presented to an emergency department between 2003 and 2008. There were 22,125 potentially eligible visits; 20% were selected at random for chart review. The primary outcome measure, the intravenous rehydration rate, was evaluated using an interrupted time-series analysis with segmented logistic regression. Secondary outcomes included emergency department revisits, hospitalization, and length of stay. A total of 3508 patient visits were included in the final analysis. During the study period, there was a significant reduction in intravenous rehydration usage (27%-13%; P < 0.001) and an increase in ondansetron administration (1%-18%; P < 0.001). Time-series analysis demonstrated a level break (P = 0.03) following the introduction of ondansetron. The mean length of stay for children declined from 8.6 ± 3.4 to 5.9 ± 2.8 hours, P = 0.03. During the week following the index visit, there was a reduction in return visits (18%-13%; P = 0.008) and need for intravenous rehydration (7%-4%; P = 0.02). Ondansetron use has increased significantly and is associated with reductions in the use of intravenous rehydration, emergency department revisits, and length of stay. The selective use of ondansetron is associated with improved clinical outcomes.

Designing a smoking cessation intervention for the unique needs of homeless persons: a community-based randomized clinical trial

Although smoking prevalence remains strikingly high in homeless populations (~70% and three times the US national average), smoking cessation studies usually exclude homeless persons. Novel evidence-based interventions are needed for this high-risk subpopulation of smokers. To describe the aims and design of a first-ever smoking cessation clinical trial in the homeless population. The study was a two-group randomized community-based trial that enrolled participants (n = 430) residing across eight homeless shelters and transitional housing units in Minnesota. The study objective was to test the efficacy of motivational interviewing (MI) for enhancing adherence to nicotine replacement therapy (NRT; nicotine patch) and smoking cessation outcomes. Participants were randomized to one of the two groups: active (8 weeks of NRT + 6 sessions of MI) or control (NRT + standard care). Participants attended six in-person assessment sessions and eight retention visits at a location of their choice over 6 months. Nicotine patch in 2-week doses was administered at four visits over the first 8 weeks of the 26-week trial. The primary outcome was cotinine-verified 7-day point-prevalence abstinence at 6 months. Secondary outcomes included adherence to nicotine patch assessed through direct observation and patch counts. Other outcomes included the mediating and/or moderating effects of comorbid psychiatric and substance abuse disorders. Lessons learned from the community-based cessation randomized trial for improving recruitment and retention in a mobile and vulnerable population included: (1) the importance of engaging the perspectives of shelter leadership by forming and convening a Community Advisory Board; (2) locating the study at the shelters for more visibility and easier access for participants; (3) minimizing exclusion criteria to allow enrollment of participants with stable psychiatric comorbid conditions; (4) delaying the baseline visit from the eligibility visit by a week to protect against attrition; and (5) regular and persistent calls to remind participants of upcoming appointments using cell phones and shelter-specific channels of communication. The study's limitations include generalizability due to the sample drawn from a single Midwestern city in the United States. Since inclusion criteria encompassed willingness to use NRT patch, all participants were motivated and were ready to quit smoking at the time of enrollment in the study. Findings from the self-select group will be generalizable only to those motivated and ready to quit smoking. High incentives may limit the degree to which the intervention is replicable. Lessons learned reflect the need to engage communities in the design and implementation of community-based clinical trials with vulnerable populations.

Agreement among three examiners of colour Doppler imaging retrobulbar blood flow velocity measurements

To assess the agreement among three masked examiners on central retinal artery (CRA) and ophthalmic artery (OA) blood flow velocity measurements performed with colour Doppler imaging (CDI) in healthy volunteers. The study included 30 eyes of 15 healthy volunteers. Prior to the study, all examiners underwent intensive CDI training by an expert to facilitate uniformity in performing measurements according to a specific protocol. Following the eligibility visit, three masked examiners performed CDI measurements assessing the CRA and OA in both eyes of all subjects. All CDI images were analysed by a masked grader. Intraclass correlation coefficients (ICC) were calculated for peak systolic velocity (PSV) and end diastolic velocity (EDV) in the CRA and OA among the examiners. p-values < 0.05 were considered statistically significant. The study included seven men and eight women (mean age 30.9 ± 4.5 years). In right eyes, ICCs for PSV and EDV in the CRA ranged from 0.917 to 0.961 and from 0.937 to 0.980, respectively. ICCs for PSV and EDV in the OA ranged from 0.802 to 0.926 and from 0.611 to 0.891, respectively. In left eyes, all ICCs for PSV and EDV were >0.9, both in the CRA and the OA. All p-values calculated for ICCs were statistically significant. Expert training and execution of a specific protocol for CDI of ocular blood flow velocity measurements provide highly reproducible results in healthy volunteers. This is important for long-term studies assessing ocular hemodynamics, where multiple examiners may be involved.

A 12-week, Double-masked, Parallel-group Study of the Safety and Efficacy of Travoprost 0.004% Compared With Pilocarpine 1% in Chinese Patients With Primary Angle-closure and Primary Angle-closure Glaucoma

To examine the intraocular pressure-lowering efficacy and safety of travoprost 0.004% and pilocarpine 1% in Chinese patients with primary angle-closure (PAC) and primary angle-closure glaucoma (PACG) after laser iridotomy in China. Thirty patients with PAC or PACG after laser iridotomy were randomized into this double-masked, parallel-group study. Qualified patients had a mean intraocular pressure (IOP) between 21 and 35 mm Hg; inclusive at 9 AM at eligibility visit and previously undergone laser peripheral iridotomy at least 30 days before screening visit. Patients were treated with travoprost 0.004% once daily or pilocarpine 1% 4 times daily for 12 weeks after appropriate washout of glaucoma medications. Efficacy and safety evaluations were conducted at weeks 4, 8, and 12. IOP measurements were performed at 9 AM and 4 PM at baseline and week 12 visits, except at the weeks 4 and 8, when the IOP measurement was undertaken respectively at 9 AM or 4 PM only. The degree and distribution of peripheral anterior synechiae was evaluated by gonioscopy at baseline and week 12, respectively. Both the treatment groups showed statistically significant IOP reductions from baseline, except for the results of pilocarpine group at 4 PM in week 12. Travoprost demonstrated a statistically superior IOP reduction (7.6 mm Hg) compared with pilocarpine (1.9 mm Hg; P=0.04) at 4 PM over the 12-week period. There was no difference in peripheral anterior synechiae degree and distribution in week 12 from baseline for both treatment groups. No serious adverse event was found in both the groups. Travoprost 0.004% once daily provides effective IOP-lowering efficacy with significantly greater IOP reduction from baseline when compared with pilocarpine 1% 4 times daily at 4 PM over the 12-week period. Travoprost 0.004% once daily is safe and well tolerated in PAC or PACG patients.

Utilization and Yield of Chest Computed Tomographic Angiography Associated with Low Positive D-dimer Levels

BackgroundIt is unclear to what degree broadly applied D-dimer testing combined with a low threshold for imaging with even minimally positive results may be contributing to the utilization of chest computed tomographic angiography (CTA). Study ObjectivesTo determine what proportion of chest CTAs for suspected pulmonary embolism (PE) were performed in the setting of minimally elevated D-dimer levels, and to determine the prevalence of PE in those patients when stratified by clinical risk. MethodsRetrospective chart review of all patients who had chest CTA for the evaluation of suspected PE during the years 2002–2006 in a suburban community teaching hospital emergency department. ResultsThere were 1136 eligible patient visits, of which 353 (31.1%) were found to have D-dimer levels in the low positive range (0.5–0.99 μg/mL). Of these 353 patients, 9 (2.6%; 95% confidence interval [CI] 0.9–4.2%) were diagnosed with PE. There were also 109 patients (9.6%) who had normal D-dimer levels (<0.5 μg/mL). Two of these 109 (1.8%; 95% CI 0–4.2%) were diagnosed with PE. When stratified by the Pulmonary Embolism Rule-out Criteria, 99 of 353 patients with low positive D-dimer levels (28.0%; 95% CI 23.4–32.7%), and 14 of 109 with normal D-dimer levels (12.8%; 95% CI 6.6–19.1%) were classified as low risk, none of whom had PE. ConclusionsNearly one-third of all chest CTAs were done for patients with minimally elevated D-dimer levels, and another 9.6% for patients with normal D-dimer levels with very low yield. Further research to define clinical criteria identifying patients with minimal risk of PE despite low positive D-dimer levels represents an opportunity to improve both patient safety and utilization efficiency of chest CTA.

Quality Measures for the Care of Children With Otitis Media With Effusion

Current national efforts provide an opportunity to integrate performance measures into clinical practice and improve outcomes for children. The goal of this study was to explore issues in developing and testing measures of care for children with otitis media with effusion (OME). We assessed compliance with diagnostic, evaluation, and treatment measures for OME adapted from preliminary work of the Physician Consortium for Performance Improvement, using chart data in a convenience sample of practices from 2 primary care networks (Cincinnati Pediatric Research Group and the American Academy of Pediatrics Quality Improvement Innovation Network). Children aged 2 months to 12 years with at least 1 visit with a specified OME code during a 1-year period were included. Of 23 practices, 4 could not locate eligible visits. Nineteen practices submitted 378 abstractions (range: 3-37 per practice) with 15 identifying <30 eligible visits. Performance on diagnosis (33%) and hearing evaluation (29%) measures was low but high on measures of appropriate medication use (97% decongestant/antihistamine, 87% antibiotics, and 95% corticosteroids). Thirty-five percent of records documented antibiotic use concurrent with OME; only 16% of the 94 cases that cited reason for prescribing were appropriate. Using methods that consider appropriate clinical action, a more accurate rate for appropriate use of antibiotics was 68%. Coding, case finding, and evaluating appropriateness of treatment are some of the issues that will need to be considered to assess the care of children with OME. This study emphasizes the importance of testing proposed quality of care measures in "real-world" settings.

Adjunctive therapy with brinzolamide in patients on travoprost treatment

This study was aimed at evaluating the safety and efficacy of brinzolamide 1% suspension (Azopt 1%) and travoprost 0.004% (Travatan) combined therapy in patients with open-angle glaucoma or ocular hypertension who are in need of additional intraocular pressure lowering. This is a prospective, three-month, open-label, clinical study. Forty patients (80 eyes) with primary open-angle glaucoma or ocular hypertension on Travatan treatment and with unsatisfactory results in lowering intraocular pressure were included in the study. The qualifying intraocular pressure on previous treatment with Travatan (at least 6 weeks) was 22-36 mmHg in at least one eye at 8 a.m. intraocular pressure measurements at three eligibility visits. The patients received brinzolamide 1% twice a day in addition to travoprost 0.004% given once a day in the evening for 3 months. The follow-up examinations assessing the safety and efficacy of combined therapy of brinzolamide 1% and travoprost 0.004% were performed after 1 and 3 months. Adjunctive therapy with brinzolamide resulted in statistically significant reductions in intraocular pressure from the travoprost baseline at all visits. Treatment with brinzolamide/travoprost caused statistically significant sustained reduction in intraocular pressure with the reduction of 17.39% (p < 0.001) after 4 weeks and 20.08% (p < 0.001) after 12 weeks. The intraocular pressure change from the baseline ranged from -3.9 mmHg after 4 weeks to -4.48 mmHg after 12 weeks. The most frequently related adverse effect was abnormal taste and blurred vision. Brinzolamide 1% (b.i.d) used adjunctively with travoprost 0.004% (q.d.) lowers intraocular pressure significantly compared to travoprost alone. Both drugs were well tolerated and safe in the studied patients.

Lymphogranuloma Venereum Is Rare in Australian Community-Based Samples of Men Who Have Sex With Men

Lymphogranuloma venereum (LGV) typing was performed on chlamydia-positive samples obtained in Sydney, Australia, between 2005 and 2007, from community-based cohorts of predominantly asymptomatic HIV-infected and -uninfected men who have sex with men. The number of chlamydia tests and follow-up for each cohort were as follows: 2082 (90.2% of eligible visits) over 2005.1 person-years (PY) of follow-up in the HIV-uninfected cohort; and 521 (70.8% of eligible visits) over 320.2 PY of follow-up in the HIV-infected cohort. One case of rectal LGV in a symptomatic HIV-infected participant was identified among 64 Chlamydia trachomatis infections, giving an LGV incidence in the HIV-infected cohort of 0.3 per 100 PY, 95% Confidence Interval 0.008-1.7. Routine LGV typing of chlamydia infections in asymptomatic Australian men who have sex with men does not appear justified.

Bacterial Vaginosis Assessed by Gram Stain and Diminished Colonization Resistance to Incident Gonococcal, Chlamydial, and Trichomonal Genital Infection

We sought to assess the relationship between bacterial vaginosis (BV) assessed by Gram stain and incident trichomonal, gonococcal, and/or chlamydial genital infection. This longitudinal study included 3620 nonpregnant women aged 15-44 years who presented for routine care at 12 clinics in Birmingham, Alabama. Participants were assessed quarterly for 1 year. Vaginal smears were categorized by the Nugent Gram stain score (0-3, normal; 4-6, intermediate state; 7-10, BV). Pooled logistic regression was used to estimate the hazard ratios for the comparison of trichomonal, gonococcal, and chlamydial infection incidence in participants by Nugent score at the prior visit. Participants were censored at their first visit with a positive test result for trichomonal, gonococcal, and/or chlamydial infection. Of the 10,606 eligible visits, 37.96% were classified by BV and 13.3% by positive detection of trichomonal, gonococcal, and/or chlamydial infection. An intermediate state or BV at the prior visit was associated with a 1.5-2-fold increased risk for incident trichomonal, gonococcal, and/or chlamydial infection (adjusted hazard ratio [AHR] for intermediate state, 1.41 [95% confidence interval {CI}, 1.12-1.76]; AHR for BV, 1.73 [95% CI, 1.42-2.11]; P= .058 for trend). Estimates were similar for trichomonal-only, gonococcal-only, and chlamydial-only infection outcomes. BV microbiota as gauged by Gram stain is associated with a significantly elevated risk for acquisition of trichomonal, gonococcal, and/or chlamydial genital infection.