Trachoma decline and widespread use of antimicrobial drugs.

Trachoma is disappearing in many parts of the world, even in the absence of specific control programs. Following mass antimicrobial drug treatments for trachoma in western Nepal, the prevalence of trachoma declined far more rapidly than could be attributed to the control program alone. Pharmacy surveys in the same region found that children received more antichlamydial drugs from sources outside the trachoma program than they did from the program itself. We demonstrate that high background antimicrobial drug use may be responsible for much of the observed decline in trachoma and discuss its potential role in eliminating this infectious disease.

Medical malpractice predictors and risk factors for ophthalmologists performing LASIK and photorefractive keratectomy surgery.

PURPOSE: To identify physician predictors in LASIK and photorefractive keratectomy (PRK) surgery that correlate with a higher risk for malpractice liability claims and lawsuits. DESIGN: Retrospective, longitudinal, cohort study. PARTICIPANTS AND METHODS: A comparison of physician demographic and practice pattern data of 100 consecutive Ophthalmic Mutual Insurance Company (OMIC) LASIK and PRK claims and lawsuits with demographic and practice pattern data for all active refractive surgeons insured by OMIC between 1996 to 2002 was made. Background information and data were obtained from OMIC underwriting applications, a physician practice pattern survey, and claims file records. Using an outcome of whether or not a physician had a history of a claim or lawsuit, logistic regression analyses were used separately for each predictor as well as controlling for refractive surgery volume. MAIN OUTCOME MEASURE: Malpractice claim or lawsuit for performance of PRK or LASIK surgery. RESULTS: Logistic regression analysis demonstrated that the most important predictor of filing a claim was surgical volume, with those performing more surgery having a greater risk of incurring a claim (odds ratio [OR] = 31.4 for >1000 surgeries/year versus 0-20 surgeries/year, 95% confidence interval [CI] = 7.9-125, P = 0.0001). Having one or more prior claim was the only other predictor examined that remained statistically significant after controlling for patient volume (OR = 6.4, 95% CI = 2.5-16.4, P = 0.0001). Physician gender, advertising use, preoperative time spent with patient, and comanagement seemed to be strong predictors in multivariate analyses when surgical volume was greater than 100 cases per year. CONCLUSION: The chances for incurring a malpractice claim or lawsuit for PRK or LASIK correlate significantly with higher surgical volume and a history of a claim or lawsuit. Additional risk factors that increase in importance with higher surgical volume include physician gender, advertising use, preoperative time spent with the patient, and comanagement with optometrists. These findings may be used in the future to help improve the quality of care for patients undergoing refractive surgery and to provide data for underwriting criteria and risk management protocols to manage proactively and perhaps reduce the risk for claims and lawsuits against refractive surgeons.

Does the diagnosis of trachoma adequately identify ocular chlamydial infection in trachoma-endemic areas?

We evaluated the validity of clinically determined active trachoma as a surrogate for chlamydial eye infection in 1059 children from the Egyptian arm of the Azithromycin in the Control of Trachoma study. Participants were determined to be "clinically active" if they had >or=5 follicles or intense inflammatory infiltration on the tarsal conjunctiva. Conjunctival swabs were tested using ligase chain reaction (LCR) to detect chlamydial DNA. Of clinically active children aged 1-10 years, 31% did not have infection, as determined by LCR. Conversely, 31% of infected children were not clinically active; 78% of clinically active children aged 1-5 years were infected, versus 17% of those aged 11-15 years. The proportion of clinically active children who were infected decreased from 67% before treatment to 10% 14 months after mass azithromycin treatment. Clinically active trachoma is not always a reliable marker of infection, particularly in teenagers and after treatment.

Pattern of antibiotic use in a trachoma-endemic region of Nepal: implications for mass azithromycin distribution.

PURPOSE: To investigate antibiotic utilization in a rural district of western Nepal that is currently receiving azithromycin as part of a trachoma program and is being monitored by the Centers for Disease Control and Prevention (CDC) for drug resistance. METHODS: Antibiotic purchase receipts were collected for 3 months from all medicine halls, pharmacies, and government sub-health posts in a sub-district of Western Nepal. Supplementary surveys of antibiotic sales were performed in different seasons. RESULTS: Macrolides account for 3.9% of total antibiotic use, far less than quinolones, penicillins, tetracyclines, and sulfonamides. CONCLUSIONS: If trachoma programs in Western Nepal generate transient macrolide resistance in pneumococcus and other bacteria, the epidemiological impact may not be great, as macrolides are not commonly used in the area.

Disappearance of trachoma from Western Nepal.

We assessed how much of the observed decline in the prevalence of trachoma in a district of Western Nepal was due to an antibiotic treatment program and how much to an underlying secular trend outside of the program. Although antibiotic treatments clearly have an effect at 6 months, we were unable to show that this effect persisted at 12 months; in fact, long-term gains may be due to a secular trend in the area.