Skin Disease in the Uninsured: Diagnoses, Management Decisions, and Referral Outcomes of an Urban Free Clinic.

An understanding of the burden of skin disease in the uninsured population is needed to address the unique barriers they face to access dermatologic care. We conducted a retrospective chart review of patients seen for skin conditions over three years at the New York City (NYC) Free Clinic, a weekly primary care clinic operated by the NYU School of Medicine and the Institute for Family Health. Main outcomes of this study were descriptive analyses of demographic characteristics, diagnoses, management strategies, and referral outcomes, as well as key factors influencing referral to a dermatologist and referral attendance. Diagnosis was a significant predictor of referral (p<.000). The referral attendance rate was 52.5%. Patients older than 50 years were more likely to attend their appointments than younger patients (p=.025). Gender, wait time, and travel distance had no significant association with non-attendance. While demand for dermatologic care by uninsured patients in NYC is high, referral non-attendance remains a substantial barrier to care.

National study of antibiotic use in emergency department visits for pneumonia, 1993 through 2008.

OBJECTIVES: The Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) developed guidelines for the management of community-acquired pneumonia (CAP); however, there are sparse data on actual rates of antibiotic use in the emergency department (ED) setting. METHODS: Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for ED visits during 1993 through 2008 for adults with a diagnosis of pneumonia. RESULTS: During the study period there were an estimated 23,252,000 pneumonia visits, representing 1.8% of all ED visits. The visit rate for pneumonia during this 16-year period may have increased (p trend = 0.055). Overall, 66% of adult patients with a primary diagnosis of pneumonia had documentation of an antibiotic administered while in the ED. There was an increase in antibiotic administration for adults with pneumonia from 1993 through 2008 (49% to 80%; p trend < 0.001). Specifically, there was an increase in use of macrolides from 1993 to 2006 (20% to 30%, p trend < 0.001) and a marked increase in use of quinolones from 0% to 39% from 1993 through 2008 (p trend < 0.001). Penicillin and cephalosporin use remained stable. Use of an antibiotic consistent with 2007 IDSA/ATS guidelines increased from 22% (95% confidence interval [CI] = 16% to 27%) of cases in 1993-1994 to 68% (95% CI = 63% to 73%) of cases in 2007-2008 (p trend < 0.001). CONCLUSIONS: ED visit rates for pneumonia increased slightly from 1993 through 2008. Although antibiotic administration in the ED has increased for adults with CAP, guideline-concordant antibiotics may not be consistently administered.

Herpes simplex following intra-articular sacroiliac corticosteroid injection.

Localized herpes simplex (HSV) type II following intra-articular corticosteroid injection is remarkable. We describe a 51-year-old woman with sacroiliitis following a fall. She was treated with an intra-articular injection of 80 mg methylprednisolone into her sacroiliac joint, followed 2 days later by a cluster of herpetiform vesicles adjacent to the injection site. Swab of punctured vesicles demonstrated HSV type II by polymerase chain reaction. One plausible explanation is HSV reactivation secondary to localized immunosuppression from corticosteroid injection.

Aging, nutritional status, and infection in the developing world.

The fast rate of increase in the number of older people in less-developed countries threatens to further strain the limited health resources of these countries. However, very little is known about their health status and the risk factors that contribute to it. In this article, we review the burden of infectious diseases in elderly people in less-developed countries, discuss the contribution of nutrition and immune response to morbidity and mortality, identify gaps in current knowledge, and suggest strategies to address this fast-growing public health problem.