Effectiveness of a Universally Offered Chlamydia and Gonorrhea Screening Intervention in the Pediatric Emergency Department

PurposeAdolescents represent more than half of the newly diagnosed sexually transmitted infections in the U.S. annually. Emergency departments (EDs) may serve as an effective, nontraditional setting to screen for chlamydia/gonorrhea (CT/GC). The objective was to evaluate the effectiveness of a universally offered CT/GC screening program in two pediatric ED settings.MethodsThis was a prospective, delayed start pragmatic study conducted over 18 months in two EDs within the same academic institution among ED adolescents aged 14–21 years with any chief complaint. Using a tablet device, adolescents were confidentially informed of CT/GC screening recommendations and were offered screening. If patients agreed to CT/GC testing, a clinical decision support tool was triggered to inform the provider and order testing. The main and key secondary outcomes were the proportion of CT/GC testing and positive CT/GC test results in each respective ED.ResultsBoth EDs experienced modest but statistically significant increases in CT/GC testing post- versus pre-intervention (main: 11.5% vs. 7.9%; confidence interval [CI]: 2.9–4.2; p < .0001 and satellite: 3.8% vs. 2.6%; 95% CI: .7–1.7; p < .0001). Among those tested, the positivity rate at the main ED did not significantly change post- versus pre-intervention (24.1% vs. 23.2%; 95% CI: ?1.9 to 3.8; p = .71) but significantly decreased at the satellite ED (7.6% vs. 14.8%; 95% CI: ?12.2 to ?2.2; p = .01).ConclusionsA universally offered screening intervention increased the proportion of adolescents who were tested at both EDs and the detection rates for CT/GC at the main ED, but patient acceptance of screening was low.     

Adoption of Electronic Medical Record-Based Decision Support for Otitis Media in Children

ObjectiveSubstantial investment in electronic health records (EHRs) has provided an unprecedented opportunity to use clinical decision support (CDS) to increase guideline adherence. To inform efforts to maximize adoption, we characterized the adoption of an otitis media (OM) CDS system, the impact of performance feedback on adoption, and the effects of adoption on guideline adherence.ConclusionsPerformance feedback increased CDS adoption, but additional strategies are needed to integrate CDS into primary care workflows.     

Schistosoma mansoni Morbidity among School-Aged Children: A SCORE Project in Kenya

Schistosomiasis control programs aim to reduce morbidity but are evaluated by infection prevalence and intensity reduction. We present baseline cross-sectional data from a nested cohort study comparing indicators of morbidity for measuring program impact. Eight hundred twenty-two schoolchildren 7–8 years of age from Nyanza Province, Kenya, contributed stool for diagnosis of Schistosoma mansoni and soil-transmitted helminths (STH) and blood smears for malaria, and were evaluated for anemia, quality of life, exercise tolerance, anthropometry, and ultrasound abnormalities. Schistosoma mansoni, STH, and malaria infection prevalence were 69%, 25%, and 8%, respectively. Only anemia and S. mansoni infection (adjusted odds ratio [aOR] = 1.70; confidence interval [CI] = 1.03–2.80), and hepatomegaly and heavy S. mansoni infection (aOR = 2.21; CI = 1.19–4.11) were associated. Though anemia and hepatomegaly appeared most useful at baseline, additional morbidity indicators may be sensitive longitudinal measures to evaluate schistosomiasis program health impact.     

Geographic distribution of schistosomiasis and soil-transmitted helminths in Western Kenya: implications for anthelminthic mass treatment

A survey of 1,246 children 10-12 years old in 32 primary schools in Kenya near Lake Victoria was conducted to determine prevalence and distribution of schistosome and geohelminth infections. Stool and urine samples were collected and examined for eggs of Schistosoma mansoni, S. haematobium, and intestinal helminths. A questionnaire was used to obtain demographic information and to quantify exposure to surface waters. Houses, schools, and water sources were mapped using a geographic information system. The mean school prevalence of S. mansoni infection was 16.3% (range = 0-80%). Proximity to the lake (r = 0.89, P < 0.001) and contact with lake water were associated with infection, as were specific water-related activities including swimming, fishing, and collecting water. Sixty-three percent of students were infected with one or more other geohelminths and these infections were more homogenously distributed. The separate distributions of schistosome and geohelminth infections have important implications for combined mass-treatment programs.     

Cellular immune responses of schistosomiasis patients are altered by human immunodeficiency virus type 1 coinfection

In vitro studies suggest that CD4(+) cells with a T helper 2 (Th2) phenotype better support human immunodeficiency virus type 1 (HIV-1) replication than do cells of the Th1 phenotype. As a result, Th2-type immune responses may be substantially affected by HIV-1 coinfection. To test this hypothesis, a comparison was done of proliferation and cytokine production by peripheral blood mononuclear cells from patients with schistosomiasis who were positive or negative for HIV-1. Patients with schistosomiasis with HIV-1 coinfections had significantly lower interleukin (IL)-4 and IL-10 production than did HIV-1-negative individuals. In contrast, interferon-gamma production levels were similar between the 2 groups. Furthermore, in patients with HIV-1, a decrease in CD4(+) T cells was correlated with an increased Th1:Th2 cytokine production ratio. The effect of praziquantel treatment on proliferation and cytokine responses also differed between HIV-1 infection groups. Thus, HIV-1 infection affects immune response patterns of patients with schistosomiasis.     

Prevalence and psychosocial impact of lower urinary tract symptoms in patients with Duchenne muscular dystrophy

Patients with Duchenne muscular dystrophy (DMD) frequently report lower urinary tract symptoms at the outpatient rehabilitation clinic. The purpose of this study was to determine the prevalence of lower urinary tract symptoms in the Dutch male DMD population and their effect on quality of life. A postal questionnaire was sent to members of Dutch DMD patient organisations. 199 male patients with confirmed DMD and over the age of 3 years were included. 170/199 (85%) patients reported one or more lower urinary tract symptoms. Generally, post micturition dribble, straining and feeling of incomplete emptying were most frequently mentioned. 42% of patients (range 18–76%) experienced the symptoms as a problem. In 49/170 (29%) patients, it reduced quality of life. In conclusion, lower urinary tract symptoms in DMD patients are under reported and under diagnosed. However, the vast majority of male DMD patients with symptoms experience them as a problem, often reducing quality of life.     

Effects on blood lipids of a blood pressure-lowering diet: the Dietary Approaches to Stop Hypertension (DASH) Trial.

BACKGROUND: Effects of diet on blood lipids are best known in white men, and effects of type of carbohydrate on triacylglycerol concentrations are not well defined. OBJECTIVE: Our goal was to determine the effects of diet on plasma lipids, focusing on subgroups by sex, race, and baseline lipid concentrations. DESIGN: This was a randomized controlled outpatient feeding trial conducted in 4 field centers. The subjects were 436 participants of the Dietary Approaches to Stop Hypertension (DASH) Trial [mean age: 44.6 y; 60% African American; baseline total cholesterol: < or = 6.7 mmol/L (< or = 260 mg/dL)]. The intervention consisted of 8 wk of a control diet, a diet increased in fruit and vegetables, or a diet increased in fruit, vegetables, and low-fat dairy products and reduced in saturated fat, total fat, and cholesterol (DASH diet), during which time subjects remained weight stable. The main outcome measures were fasting total cholesterol, LDL cholesterol, HDL cholesterol, and triacylglycerol. RESULTS: Relative to the control diet, the DASH diet resulted in lower total (-0.35 mmol/L, or -13.7 mg/dL), LDL- (-0.28 mmol/L, or -10.7 mg/dL), and HDL- (-0.09 mmol/L, or -3.7 mg/dL) cholesterol concentrations (all P < 0.0001), without significant effects on triacylglycerol. The net reductions in total and LDL cholesterol in men were greater than those in women by 0.27 mmol/L, or 10.3 mg/dL (P = 0.052), and by 0.29 mmol/L, or 11.2 mg/dL (P < 0.02), respectively. Changes in lipids did not differ significantly by race or baseline lipid concentrations, except for HDL, which decreased more in participants with higher baseline HDL-cholesterol concentrations than in those with lower baseline HDL-cholesterol concentrations. The fruit and vegetable diet produced few significant lipid changes. CONCLUSIONS: The DASH diet is likely to reduce coronary heart disease risk. The possible opposing effect on coronary heart disease risk of HDL reduction needs further study.