A retrospective review of antibiotic use for acute respiratory infections in urgent-care patients.

Objective: We examined the use of antibiotics for acute respiratory infections in an urgent-care setting. Design: Retrospective database review. Setting: The study was conducted in 2 urgent-care clinics staffed by academic emergency physicians in San Diego, California. Patients: Visits for acute respiratory infections were identified based on presenting complaints. Methods: The primary outcome was a discharge prescription for an antibiotic. The patient and provider characteristics that predicted this outcome were analyzed using logistic regression. The variation in antibiotic prescriptions between providers was also analyzed. Results: In total, 15,160 visits were analyzed. The patient characteristics were not predictive of antibiotic treatment. Physicians were more likely than advanced practice practitioners to prescribe antibiotics (1.31; 95% confidence interval [CI], 1.21-1.42). For every year of seniority, a provider was 1.03 (95% CI, 1.02-1.03) more likely to prescribe an antibiotic. Although the providers saw similar patients, we detected significant variation in the antibiotic prescription rate between providers: the mean antibiotic prescription rate within the top quartile was 54.3% and the mean rate in the bottom quartile was 21.7%. Conclusions: The patient and provider characteristics we examined were either not predictive or were only weakly predictive of receiving an antibiotic prescription for acute respiratory infection. However, we detected a marked variation between providers in the rate of antibiotic prescription. Provider differences, not patient differences, drive variations in antibiotic prescriptions. Stewardship efforts may be more effective if directed at providers rather than patients.

Methohexital-Induced Seizure in a Patient Undergoing Conscious Sedation.

BACKGROUND: Methohexital is a short-acting barbiturate used for procedural sedation in the emergency department (ED). As with other sedatives, adverse effects with methohexital include excess sedation and hypotension, but this agent can also lower the seizure threshold. We report a patient who developed a generalized seizure after administration of methohexital. CASE REPORT: A 60-year-old man presented to the ED by ambulance with chest pain and shortness of breath. Paramedics had administered adenosine for supraventricular tachycardia without conversion before arrival to the ED. He had no history of seizures. His initial vital signs in the ED included heart rate of 189 beats/min with a supraventricular rhythm, blood pressure 137/108 mm Hg, respiration 22 breaths/min, and oxygen saturation of 98% on room air. It was decided to attempt synchronized electrical cardioversion, and methohexital 1 mg/kg (120 mg) was administered over 2 min for moderate sedation. Within 15 s of methohexital administration, the patient developed a generalized seizure that lasted for 90 s. After seizure termination, he was successfully cardioverted, returned to his previous baseline level of consciousness within 20 min, and discharged without further problems with a follow-up referral to neurology. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Methohexital is a short-acting barbiturate used for moderate sedation. Its adverse effects are unique in that it can lower the seizure threshold in some patients. Alternative agents for sedation should be considered in individuals with possible seizure disorders.

Role of Multiparametric Magnetic Resonance Imaging Prostate Specific Antigen Density and PI-RADS™ Score in Predicting Up Staging in Men on Active Surveillance.

INTRODUCTION: Using a combination of magnetic resonance imaging of the prostate and prostate specific antigen density, we determined which men on active surveillance are at risk for up staging and which men could avoid repeat biopsy while remaining on surveillance. METHODS: We reviewed the records of 110 men on active surveillance with Gleason 6 disease who underwent magnetic resonance imaging followed by UroNav fusion biopsy (Invivo, Gainesville, Florida). Using univariable and multivariable logistic regression analyses we examined the effect of age, race, prostate specific antigen, prostate specific antigen density, prostate volume, PI-RADS (Prostate Imaging Reporting and Data System) score, number and size of target lesions, and time on surveillance to determine the likelihood of up staging to Gleason 7 or greater disease. RESULTS: A total of 33 cases (30%) were up staged. On multivariable analysis prostate specific antigen density and PI-RADS score were significant predictors of up staging with adjusted odds ratios of 3.97 for prostate specific antigen density of 0.16 or more (CI 1.31-12.00, p <0.05), 13.8 for a PI-RADS 4 lesion (CI 2.3-81.3, p <0.01) and 25 for a PI-RADS 5 lesion (CI 3.8-163.5, p <0.01). When cross-tabulating these factors, men with a PI-RADS score of 3 or greater with a prostate specific antigen density of 0.16 ng/ml/cc or more had a 61.2% chance of up staging. Conversely, in men with PI-RADS score 3 or less and prostate specific antigen density less than 0.15, no up staging was seen. CONCLUSIONS: A combination of PI-RADS score and prostate specific antigen density predicts patients at risk for up staging at surveillance biopsy. Conversely, this combination may help determine which men may safely forgo biopsy.