Trends in Chlamydia and Gonorrhea Testing and Positivity Rates in a Safety Net Hospital in Georgia: 2014 to 2017.

BACKGROUND: Sexually transmitted infections (STIs) in the United States continue to increase at an alarming rate. Since 2015, reported cases of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC), the 2 most prevalent reportable STIs, have increased by 19% and 56%, respectively. Characterizing testing patterns could elucidate how CT/GC care and positivity have evolved over time in a high-risk urban setting and illustrate how patients use the health care system for their STI needs. METHODS: Using electronic medical record data from a large safety net hospital in Georgia, patient demographics and clinical characteristics were extracted for all nucleic acid amplification tests ordered from 2014 to 2017 (n = 124,793). Descriptive statistics were performed to understand testing patterns and assess positivity rates. RESULTS: Annual nucleic acid amplification test volume grew by 12.0% from 2014 to 2017. Obstetrics/gynecology consistently accounted for half of all tests ordered; volume in emergency medicine grew by 45.2% (n = 4108 in 2014 to n = 5963 in 2017), whereas primary care volume fell by -4.3% (n = 4186 in 2014 to n = 4005 in 2017). The largest number of positive results was detected among 15- to 24-year-olds. The positivity of CT was higher among females, and GC among males. The percent positivity of CT remained stable (range, 6.4%-7.0%). The percent positivity of GC increased from 2.7% to 4.3% over time. CONCLUSIONS: Testing volume in emergency medicine has increased at a faster rate than other specialties; point-of-care testing could ensure more accurate treatment and improve antibiotic stewardship. The rates of CT/GC were high among adolescents and young adults. Tailored approaches are needed to lower barriers to care for this vulnerable population.

Perfecting the Gastrointestinal Physical Exam: Findings and Their Utility and Examination Pearls.

The physical examination of the patient is the cornerstone of the practice of medicine, and the skills to complete a thorough abdominal examination are critical in the care of patients. When performed correctly, the abdominal examination can be revealing when it comes to the overall health of the patient as well as acute pathology. The examination of the abdomen has the potential to minimize further testing or radiation and serves as a key diagnostic tool. In this article, we will discuss each portion of the abdominal examination in detail as well as pathologic findings, abdomen-specific signs, special patient populations, and clinical pearls.

Finding the Gaps in Retesting for Chlamydia and Gonorrhea: Differences Across High-Volume Testing Departments in an Urban Health Care Setting.

BACKGROUND: The Centers of Disease Control and Prevention guidelines recommend that all patients be retested 3 months after a positive chlamydia (CT) or gonorrhea (GC) result. However, retest rates are generally low, and only a quarter of patients return to clinic for retesting. This analysis explored retesting patterns in a high sexually transmitted infection (STI)/human immunodeficiency virus (HIV)-risk setting to illuminate gaps in adherence to guideline recommendations. METHODS: Retrospective chart data from a large urban safety-net institution were analyzed descriptively. Patients who received a positive CT/GC test from January to February 2017 were followed up for at least 4 months to assess if retesting occurred within approximately 3 months. RESULTS: Our sample of 207 patients was primarily non-Hispanic Black (92.8%), younger than 25 years (63.3%) and women (60.4%). Over half had been initially diagnosed with CT, one-third with GC, and one-tenth with both CT and GC. Eighty-nine (43.0%) patients were retested during the observed period; mean time between tests was 2.7 months. Retesting was most common in infectious diseases/HIV primary care (73.6%) and obstetrics/gynecology (44.9%). Patients who were first diagnosed in emergency medicine were significantly less likely to be retested. Retested patients included a large number of HIV-positive men (31 of 89 total) and pregnant women (23 of 54 women). CONCLUSIONS: Forty-three percent of patients were retested within approximately 3 months of their initial positive CT/GC diagnosis, exceeding previously published rates. Nonetheless, in light of the growing STI epidemic, health care systems should prioritize retesting across high-volume testing specialties, rethink retesting models, and facilitate referrals to ensure that patients receive guideline-recommended, comprehensive STI care.

Who Is Practicing Expedited Partner Therapy and Why? Insights From Providers Working in Specialties With High Volumes of Sexually Transmitted Infections.

BACKGROUND: Expedited partner therapy (EPT), the practice of prescribing antibiotics for sexual partners of patients, is underutilized in Georgia. This qualitative study in a large urban institution aimed to (1) characterize the clinical specialties that predominantly treat sexually transmitted infections (STIs), (2) identify perceived barriers to EPT, and (3) describe strategies to advance routine EPT use. METHODS: Providers in obstetrics/gynecology (OB/GYN), infectious disease (ID), and emergency medicine (EM) were interviewed using a structured discussion guide. Transcripts were double-coded and iteratively analyzed using qualitative content analysis. Barriers and strategies were summarized and supported with quotes from providers (n = 23). RESULTS: Perceived EPT barriers overlapped across OB/GYN, ID, and EM, yet the settings were diverse in their patient populations, resources, and concerns. Providers in OB/GYN were the only ones practicing EPT, yet there was a lack of standardization. Providers in ID noted that an EPT prescription from an ID provider could inadvertently disclose the HIV status of a patient to a sexual partner, posing an ethical dilemma. Providers in EM exhibited readiness for EPT, although routine empiric treatment for index patients in EM (estimated at 90%) gave some providers pause in prescribing for partners: "I do not know what I'm treating." Point-of-care testing could increase providers' confidence in prescribing EPT, yet some worried it could contribute to overutilization of the emergency department as a sexually transmitted infection clinic. All settings prioritized setting-specific training and protocols. CONCLUSIONS: Providers in OB/GYN, ID, and EM report unique hurdles, specific to their settings and patient populations; tailored EPT implementation strategies, particularly provider training, are urgently needed to improve patient/partner outcomes.

Eclampsia.

Audience: Emergency medicine residents and medical students on emergency medicine rotations. Introduction: Eclampsia is an uncommon but important life-threatening obstetrical emergency, complicating 1.5-10 deliveries per 10,000 pregnancies in resource-rich countries.1 If not recognized and treated promptly, there is risk of significant morbidity or death to both mother and baby. Clinically, eclampsia is defined by new-onset seizures or coma in women with preeclampsia.2 Preeclampsia is defined by maternal hypertension after 20 weeks gestation with or without signs of end organ dysfunction, and, like eclampsia, can develop in the postpartum period.1 Eclampsia manifests as new onset generalized tonicclonic seizures. Eclamptic seizures are usually preceded by neurologic symptoms such as severe or atypical headache, visual disturbances, and non-neurologic symptoms such as severe abdominal pain or proteinuria.1 Emergent treatment involves prompt administration of (intravenous) IV magnesium sulfate.2,3,4 Adjuncts include securing the airway if necessary and administration of IV antihypertensive medications. Like preeclampsia, definitive management is by prompt delivery of the fetus if the mother is still pregnant.1 If untreated, maternal mortality is as high as 14%.1 Women who develop eclampsia are at increased risk of obstetric complications in subsequent pregnancies and at higher risk for cardiovascular disease and metabolic disease later in life. Educational Objectives: At the end of this oral boards session, examinees will: 1) Demonstrate ability to obtain a complete medical history including a detailed obstetric history. 2) Demonstrate the ability to perform a detailed physical examination in a postpartum female patient who presents with a seizure. 3) Investigate the broad differential diagnoses which include electrolyte imbalances, brain tumor, meningitis or encephalitis, hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and eclampsia. 4) List the appropriate laboratory and imaging studies to differentiate eclampsia from other diagnoses (complete blood count, comprehensive metabolic panel, magnesium level, pregnancy testing, urinalysis, and computed tomography [CT] scan of the head). 5) Identify a postpartum eclampsia patient and manage appropriately (administer IV magnesium therapy, administer IV antihypertensive therapy, emergent consultation with an obstetrician). 6) Provide appropriate disposition to the intensive care unit after consulting with an obstetrician. Educational Methods: This was envisioned as an oral board testing case due to the multiple aspects which require emergency care. Residents are expected to assess the seriousness of the patient's condition, elicit critical details from her recent medical history, and synthesize that data in order to treat a medically complex patient. Oral board testing is able to incorporate each of these aspects together and provide the resident with a dynamic learning environment.Oral board testing is a way to assess the resident's ability to rapidly obtain and interpret multiple sources of information simultaneously. By utilizing a case that requires pharmaceutical therapy, the clinical competency committee is able to obtain additional milestones which are sometimes difficult to test in the emergency department itself.Learners were assessed using online evaluation tools available, ie, Google forms. Critical actions were subsequently tied to Emergency Medicine Milestones and the results were compiled and used for resident evaluations and clinical competency. Residents were given verbal feedback immediately after the examination, and they were provided with the scores of their online evaluation after all results were compiled. Research Methods: Learners and instructors provided written feedback after the case was administered to assess for strengths and weaknesses of the case, and modifications were then made to better address concerns. Learners answered written multiple-choice questions on high-level concepts, ie, critical actions, at least one month after this exam was completed. Results: Learners found this a challenging, but enjoyable, way to refresh their knowledge and skills regarding preeclampsia, and this was a highly rated part of their mock oral board examination. Overall, residents rated the session 4.3 (1-5 Likert scale, 5 being Excellent) after the oral board review session was completed. Comments from residents included "haven't seen post-partum preeclampsia in residency" and "challenging to remember magnesium dosing." Discussion: Residents and medical students were evaluated using this method and both enjoyed the activity as a novel way to study as well as exercise their medical knowledge. The content was both highly relevant to the practice of emergency medicine and the format was an effective way to deliver the information to the learners. The case is a good model to evaluate for the high stakes testing of both the written and oral board examinations, but also a way to assess residents' abilities to treat preeclamptic and eclamptic patients in the emergency department. Topics: Eclampsia, preeclampsia, seizures, end-organ damage, hypertensive emergency, altered mental status, neurologic emergency, obstetric emergency.