Hueston Wj

Nasal Carriage of Staphylococcus aureus and Methicillin-Resistant S aureus in the United States, 2001–2002

PURPOSE Staphylococcus aureus is a common cause of invasive infections, yet most assessments of prevalence are based on health care–based samples. We computed population-based estimates of nasal carriage of S aureus and risk factors for carriage, as well as population-based estimates of nasal carriage of methicillin-resistant S aureus (MRSA). METHODS We used the National Health and Nutrition Examination Survey (NHANES) 2001–2002 to estimate carriage of S aureus and MRSA for the non-institutionalized US population including children and adults. RESULTS An estimated 86.9 million persons (32.40% of the population) were colonized with S aureus. The prevalence of MRSA among S aureus isolates was 2.58%, for an estimated population carriage of MRSA of 0.84% or 2.2 million persons. Among individuals with S aureus isolates, individuals aged 65 years or older had the highest MRSA prevalence (8.28%). Among all the racial/ethnic groups studied, Hispanics had the highest prevalence of colonization with S aureus but, when colonized, were less likely to have MRSA. CONCLUSIONS This first nationally representative assessment of carriage of S aureus indicates that nearly one third of the population is currently colonized by this organism. Although the prevalence of MRSA remains low, more than 2.2 million people carry this resistant organism; thus, vigilance in promoting appropriate microbial transmission protocols should remain a priority.

Subclinical hypothyroidism and the risk of hypercholesterolemia.

BACKGROUND Subclinical hypothyroidism, defined as a mild elevation in thyroid-stimulating hormone (TSH) levels in patients with normal serum thyroxine levels, has been associated with elevationed levels in serum cholesterol in some sample populations. These studies, however, have included referred patients and large numbers of patients with previously treated hyperthyroidism. The aim of this study was to assess whether subclinical hypothyroidism is associated with abnormal lipid levels in a population-based sample. METHODS Data from adults older than 40 years who did not previously have a diagnosis of hypothyroidism or who were taking thyroid replacement medication were analyzed from the National Health and Nutritional Examination Survey (NHANES) III. Subclinical hypothyroidism was defined as a TSH value of 6.7 to 14.9 mU/L and normal thyroxine (n = 215). Euthyroid control adults included participants with a TSH in a normal range between 0.36 and 6.7 mU/L (n = 8,013). Outcomes examined were serum cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglyceride levels in those who had subclinical hypothyroidism and in euthyroid controls. RESULTS Persons meeting the criteria for subclinical hypothyroidism had higher mean cholesterol levels (226 vs 217 mg/dL, P = .003) and rates of elevated cholesterol levels (74.2% vs 63.9%, P = 0.02) than the euthyroid control group, but there were no significant differences in low-density lipoprotein (LDL) or high-density lipoprotein (HDL) levels. When adjusted for age, race, sex, and the use of lipid-lowering drugs, however, subclinical hypothyroidism was not related to elevations in cholesterol levels (adjusted odds ratio [OR] = 1.06, 95% confidence interval [CI], 0.57–1.97), LDL levels (adjusted OR = 0.89; 95% CI, 0.59–1.35), or triglyceride levels (adjusted OR = 1.83; 95% CI, 0.87–3.85) or to a low HDL level (adjusted OR = 0.94; 95% CI, 0.36–2.48). CONCLUSIONS Subclinical hypothyroidism does not appear to be associated with abnormalities in serum cholesterol or triglyceride levels when adjusted for confounding variables in this population-based study.

Trends in Antimicrobial Prescribing for Bronchitis and Upper Respiratory Infections Among Adults and Children

OBJECTIVES This study examined antimicrobial prescribing patterns for adults and children with bronchitis or upper respiratory infections (URIs) before and after release of nationally disseminated pediatric practice recommendations. METHODS Data from the 1993, 1995, 1997, and 1999 National Ambulatory Medical Care Survey were used to evaluate prescriptions for antimicrobials for URIs and bronchitis. RESULTS From 1993 to 1999, the proportion of children receiving antimicrobials after visits for URIs and bronchitis decreased. However, the use of broad-spectrum antimicrobials rose from 10.6% of bronchitis visits to 40.5%. Prescriptions of antimicrobials for adults with URIs or bronchitis showed a decrease between 1993 and 1999. CONCLUSIONS Although antimicrobial prescribing for URIs and bronchitis has decreased for both children and adults, the prescribing of broad-spectrum antibiotics among children has shown a proportional rise.

Post-traumatic stress disorder screening test performance in civilian primary care

PURPOSE we determined the test performance characteristics of four brief post-traumatic stress disorder (PTSD) screening tests in a civilian primary care setting. METHODS this was a cross-sectional cohort study of adults attending a family medicine residency training clinic in the southeastern USA. Four hundred and eleven participants completed a structured telephone interview that followed an index clinic visit. Screening tests included: PTSD Symptom Checklist-Civilian Version (17 items), SPAN (four items), Breslaus scale (seven items) and Primary Care PTSD screen (PC-PTSD) (four items). A modified Clinician-Administered PTSD Scale was used to determine past month PTSD for comparison. Receiver operating characteristic analysis based on area under the curve (AUC) was used to assess diagnostic efficiency (>0.80 desired). Cut-off scores were selected to yield optimal sensitivity and specificity (>80%). RESULTS past month PTSD was substantial (women = 35.8% and men = 20.0%; P < 0.01). AUC values were PTSD Symptom Checklist (PCL) (0.897), SPAN (0.806), Breslaus scale (0.886) and PC-PTSD (0.885). Optimal cut-scores yielded the following sensitivities and specificities: PCL (80.0% and 80.7%; cut-off = 43), SPAN (75.9% and 71.6%; cut-off = 3), Breslaus scale (84.5% and 76.4%; cut-off = 4) and PC-PTSD (85.1% and 82.0%; cut-off = 3). Overall and gender-specific screening test performances were explored. CONCLUSIONS results confirm: (i) PTSD was common, especially among women; (ii) all four PTSD screening tests were diagnostically adequate; (iii) Two of four PTSD screening tests showed adequate sensitivity and specificity (>80%) and (iv) The PC-PTSD screening test (four items) appeared to be the best single screening test. There are few studies to establish the utility of PTSD screening tests within civilian primary care.

Colour of respiratory discharge and antibiotic use

The rise in antibiotic-resistant bacteria has focused attention on the selective pressure caused by widespread use of antibiotics for conditions in which antibiotics are not effective. In particular, patients seem confused about the normal presentation and course of an uncomplicated upper respiratory tract injection (URTI). Although discoloured nasal discharge is a normal self-limited phase of a viral URTI, and randomised placebo-controlled trials have shown no effect of antibiotics on purulent rhinitis or discoloured nasal discharge, patients are confused about the meaning of discoloured nasal discharge. Nearly 80% of adult patients believe antibiotics are effective for an URTI with discoloured nasal discharge. In this confusion about the normal presentation of respiratory infections being transmitted by the primary care physician to the patient? The purpose of our study was to examine primary care physicians’ understanding of the normal presentation and appropriate treatment regimens of URTIs, and acute bronchitis. Questionnaires were sent to 250 primary care physicians (general practitioners, family physicians, and general internists) in each of four states: Minnesota, South Carolina, Texas, and Oregon. The physicians were randomly selected from the American Medical Association’s Physician Masterfile. A total of 211 were returned and not able to be used because the physician either moved, died, or retired from practice. 214 completed questionnaires were returned and used for analysis. We assessed knowledge and current practices of treatment of URTIs with two scenarios representing the normal presentation of an uncomplicated URTI, varying only in the inclusion of discoloured nasal discharge. Similarly, knowledge and practice for acute bronchitis was based on two scenarios representing the normal presentation of acute bronchitis, varying only in the inclusion of purulent sputum. When the scenario presented an adult with symptoms of an URTI, physicians were more likely to diagnose sinusitis than an URTI when the nasal discharge was described as discoloured (table). Antibodies were prescribed seven times more frequently when the nasal discharge was discoloured. Even respondents who labelled both scenarios as an URTI were 5·6 times more likely to use an antibiotic when the nasal discharge was discoloured than when it was clear (28% vs 5%, p<0·001). In the second scenario which presented an adult with a cough following URTI symptoms, when the sputum was described as discoloured physicians were more likely to label the illness as bronchitis and prescribe antibiotics (table). Interestingly, physicians were more likely to use a bronchodilator for cough with clear sputum. In both the clear and purulent sputum scenarios, bronchodilators have been shown to have some asymptomatic benefit for patients with acute bronchitis regardless of sputum colour while antibiotics are of questionable effectiveness. This small study shows that physicians assign a great deal of predictive value to the colour of nasal discharge or sputum despite evidence that the appearance of these secretions alone is not predictive of bacterial infection or the effectiveness of antimicrobial therapy. Patients appear to have learned this interpretation of discoloured secretions from physicians and may bring expectations of receiving antibiotics for illnesses into the physician-patient encounter. These misperceptions may contribute to the inappropriate prescribing of antibiotics and may be a factor in the development of antibiotic-resistant strains of common pathogens.

Serum biomarkers for cardiovascular inflammation in subclinical hypothyroidism

Objective Cardiovascular disease has been reported to be more common in patients with elevated levels of TSH and with normal thyroxine levels, termed subclinical hypothyroidism (SCH). The aim of this study was to determine whether individuals with SCH were more likely than euthyroid controls to have elevations in inflammatory biomarkers that are associated with cardiac disease.

Glycemic Control in Medical Inpatients with Type 2 Diabetes Mellitus Receiving Sliding Scale Insulin Regimens versus Routine Diabetes Medications: A Multicenter Randomized Controlled Trial

PURPOSE Hospitalized patients with type 2 diabetes mellitus traditionally receive insulin on a sliding-scale regimen, but the benefits of this approach are unclear. The purpose of this study was to compare the effects of the sliding scale insulin regimen with those of routine diabetes medications on hyperglycemia, hypoglycemia and length of hospitalization in diabetic patients hospitalized for other conditions. METHODS This was a multicenter, randomized controlled trial conducted in family medicine inpatient services. One hundred fifty-three patients with type 2 diabetes mellitus hospitalized for other conditions were randomized to receive routine diabetes medications (control) or the combination of a standard sliding-scale insulin regimen and routine diabetes medications (intervention). The outcome measures included frequency of hyperglycemia and hypoglycemia (glycemic events), and length of hospitalization. RESULTS No differences were identified between treatment groups in the frequency of glycemic events. In the intervention group, 33.3% of patients developed hyperglycemia compared to 34.6% in the control group (P = .87). Six patients developed hypoglycemia in the intervention group, compared with 7 in the control group (P = .83). There was no difference in length of hospitalization (P = .86). Regardless of treatment assignment, patients receiving intermediate-acting insulin (OR, 2.8; 95% CI, 1.2–6.5), those with blood glucose values greater than 250 mg/dL at baseline (OR, 6.3; 95% CI, 2.3 – 17.2) and those receiving corticosteroids (OR, 9.1; 95% CI, 3.1 – 27.0) were more likely to have glycemic events. CONCLUSIONS The use of the sliding scale insulin regimen in combination with routine diabetes medications does not affect the rate of hyperglycemia, hypoglycemia or length of hospitalization in patients with type 2 diabetes mellitus hospitalized for other conditions.

Delayed Prenatal Care and the Risk of Low Birth Weight Delivery

To determine if the timing of prenatal care is associated with low birth weight delivery after adjusting for sociodemographic and behavioral risk factors, we performed a retrospective cross-sectional study of singleton births to white (2,945,595) or African-American (552,068) women in the United States in 1996. When adjusted for race, maternal age, educational level attained, and the use of alcohol and tobacco during pregnancy, women beginning care in the 2nd (adjusted RR = 0.85; 95% CI: 0.83–0.86) and 3rd trimesters (RR = 0.87; 95% CI: 0.84–0.91) had a reduced risk of low birth weight compared to women beginning care in the 1st trimester. Our findings suggest that no benefit exists for early initiation of prenatal care for reducing the risk of low birth weight. Findings related to differences in low birth weight among women who start prenatal care later are likely due to sociodemographic differences that may influence access to early care.

Availability of Antibiotics for Purchase Without a Prescription on the Internet

PURPOSE Reducing inappropriate use of antibiotics is key to many antibiotic resistance initiatives. Most initiatives, however, focus almost exclusively on controlling prescribing by health care clinicians and do not focus on patient self-medication. The purpose of this study was to examine antibiotics available to patients without a prescription, a phenomenon on the Internet. METHODS We conducted an Internet search using 2 major search engines (Google and Yahoo) with the key words “purchase antibiotics without a prescription” and “online (English only).” Vendors were compared according to the classes of antibiotics available, quantity, shipping locations, and shipping time. RESULTS We found 138 unique vendors selling antibiotics without a prescription. Of those vendors, 36.2% sold antibiotics without a prescription, and 63.8% provided an online prescription. Penicillins were available on 94.2% of the sites, macrolides on 96.4%, fluoroquinolones on 61.6%, and cephalosporins on 56.5%. Nearly all, 98.6%, ship to the United States. The mean delivery time was 8 days, with 46.1% expecting delivery in more than 7 days. Among those selling macrolides (n = 133), 93.3% would sell azithromycin in quantities consistent with more than a single course of medication. Compared with vendors that require a medical interview, vendors who sell antibiotics without a prescription were more likely to sell quantities in excess of a single course, and the antibiotics were more likely to take more than 7 days to reach the customer. CONCLUSIONS Antibiotics are freely available for purchase on the Internet without a prescription, a phenomenon that encourages self-medication and low quality of care.

The effectiveness of pretermbirth prevention educational programs for high-risk women: A meta-analysis

OBJECTIVE To evaluate whether preterm-birth prevention educational programs are effective at reducing neonatal mortality, low birth weight (LBW), and preterm delivery. DATA SOURCES A MEDLINE literature search of English-language studies was performed, supplemented by a bibliography search of original research and review articles to locate studies assessing preterm-birth prevention programs. METHOD OF STUDY SELECTION We identified 31 studies that reported results from trials evaluating preterm-birth prevention programs. From this group, only the six randomized controlled trials evaluating preterm-birth prevention education programs satisfied criteria of homogeneity to be included in a meta-analysis. One of these six studies was a subset of another study and was excluded except when reporting outcomes that were not included in the larger report. DATA EXTRACTION AND SYNTHESIS Two independent reviewers assessed study methodology and identified the following outcomes: LBW frequency, preterm birth frequency, neonatal survival, birth weight, gestational age at delivery, and preterm labor diagnosis rates. When data were combined using meta-analytic techniques, no significant benefits were found for preterm-birth education programs in preventing neonatal death (cumulative relative risk [RR] 1.00, 95% confidence interval [CI] 0.99-1.01), LBW rates (RR 0.99, 95% CI 0.88-1.11), or preterm delivery rates (RR 1.08, 95% CI 0.92-1.27). The only statistically significant effect of preterm birth education programs appears to be an increase in the frequency at which preterm labor is diagnosed (RR 1.71, 95% CI 1.41-2.08). CONCLUSION Preterm-birth prevention educational programs appear to have little benefit in reducing preterm birth and may result in an increased rate of diagnosis of preterm labor.