Article

Emergency provider documentation of sexual health risk factors and its association with HIV testing: A retrospective cohort study

Correspondence / American Journal of Emergency Medicine 37 (2019) 13621393 1365

than are patients with other allergies (i.e., neither is a significant risk factor). There is no cross-reactivity between different classes of contrast medium. For example, a prior reaction to gadolinium- based contrast medium does not predict a future reaction to io- dinated contrast medium, or vice versa, more than any other un- related allergy.”

[[14-15]]

Emergency medicine and radiology providers could benefit from ad- ditional awareness of ACR recommendations for managing administra- tion of iodinated contrast media in the presence of a documented iodine or seafood allergy. Despite numerous evidence and recommendations from national organizations, the myth of iodine allergy and IV contrast still persists to a considerable degree.

Prior presentations

None.

Funding sources/disclosures

None.

Acknowledgments

None.

Christopher S. Sampson, MD? Kara B. Goddard, PharmD Starr-Mar’ee C. Bedy, PharmD Julie A.W. Stilley, PhD

University of Missouri-Columbia, Department of Emergency Medicine,

United States of America

?Corresponding author.

E-mail address: [email protected]

29 November 2018

https://doi.org/10.1016/j.ajem.2018.12.011

References

  1. National Institutes for Health Office of Dietary Supplements. Iodine fact sheet for health professionals. Available from https://ods.od.nih.gov/factsheets/Iodine- HealthProfessional/, Accessed date: 23 October 2018.
  2. Brenner DJ, Hall EJ. Computed tomography-an increasing source of radiation expo- sure. N Engl J Med 2007;357:2277-84.
  3. Larson DB, Johnson LW, Schnell BM, et al. National trends in CT use in the emergency

    department: 1995-2007. Radiology 2010;258(1):164-73.

    Pradubpongsa P, Dhana N, Jongjarearnprasert K, et al. Adverse reactions to iodinated contrast media: prevalence, risk factors and outcome-the results of a 3-year period. Asian Pac J Allergy Immunol 2013;31(4):299-306.

  4. Schabelman E, Wiitting M. The relationship of radiocontrast, iodine, and seafood al-

    Emergency provider documentation of sexual health risk factors and its association with HIV testing: A retrospective cohort study

    Emergency departments (ED) are targeted areas for diagnosing human immunodeficiency virus [1]. There is a paucity of data, however, characterizing emergency provider (EP) sexual history docu- mentation (SHD) practices and its association with HIV testing [2-4]. In this regard, we conducted a retrospective cohort study of patients 18 years and older seen at an ED of a level 1 trauma center in Cleveland, Ohio from January 1, 2016 to December 31, 2016. Inclusion criteria were patients’ first index visit in 2016 for those patients with billing codes for either a sexually transmitted infection (STI) diagnosis or STI laboratory testing. Patients were excluded from the study if they were transferred from an outside hospital, admitted, left against medical advice, previ- ously diagnosed with HIV, or pregnant at the time of the visit. Data gath- ered included demographics and laboratory tests, as well as free text from each patient chart. SHD consisted of 7 components based on the CDC’s recommendations for STI screening, which include questions about partners, prevention of pregnancy, protection, type of sexual practices, past history of STIs, and patient’s sexual orientation [5]. We further included whether patients had a history of intravenous drug use (IVDU) to incorporate an additional known risk factor for HIV trans- mission [6,7]. In this study, a score of 1 point was given for each of the seven aspects. This study was approved by the university hospitals Cleveland Medical Center Institutional Review Board.

    Descriptive statistics and Pearson’s chi-square tests were used to de- scribe demographic characteristics, SHD, and HIV testing, as well to as- sess the association between both HIV testing and HIV diagnosis within 1 year of index visit. The association among total SHD score and likelihood of HIV testing was assessed with a logistic regression model. This association was adjusted for patient age, race, gender, num- ber of providers seen at the index visit, and total SHD score, which was a shifted continuous variable ranging from 1 to 8 (instead of 0-7) to allow for assessment of the log-linear relationship with the dependent vari- able. Two sensitivity analyses were conducted with SHD coded as ordi- nal categorical (0,1- 3,4+) and binary categorical (0 = no, 1+ = yes). A significance level of 5% determined statistical significance. Statistical analyses were conducted using Jamovi Project (Version 0.9.2.12).

    We identified 1450 initial patient visits in 2016. Patients were pri- marily black (90%), female (77%), with a median age of 27 years (IQR, 22-35) of which only 101 (7%) were tested for HIV and 841 (58%) free text notes had SHD (Table 1). When sexual history was documented, it rarely consisted of N3 of the 7 aspects (17%). The most frequently doc- umented aspect of the sexual history were ‘partners’ (40%), IVDU (27%), and ‘protection’ (20%) (Fig. 1). In the unadjusted analysis, the only

    Table 1

    Patient demographics and index visit characteristics.

    lergies: a medical myth exposed. J Emerg Med Nov 2010;39(5):701-7.

    Nilsson R, Ehrenberg L, Fedorcsak I. Formation of potential antigens from radio- graphic contrast media. Acta Radiol 1987;28:473-7.

  5. Stejkal V, Nilson R, Grepe A. Immunologic basis for adverse reactions to radiographic contrast media. Acta Radiol 1990;31:605-12.
  6. Can DH, Walker AC. Contrast media reactions: experimental evidence against the al- lergy theory. Br J Radiol 1984;57:469-73.
  7. Daul CB, Morgan JE, Lehrer SB. hypersensitivity reactions to Crustacea and mollusks. Clin Rev Allergy 1993;1(1):201-22.
  8. Shehadi WH. Adverse reactions to intravascularly administered contrast media. AJR 1975;24:145-52.
  9. Van Ketel WG, van den Berg WHHW. Sensitization to povidone-iodine. Dermatol Clin 1990;8:107-9.
  10. Waran KD, Munsick RA. Anaphylaxis from povidone-iodine (letter). Lancet 1995; 345:1506.
  11. Beaty AD, Lieberman PL, Slavin RG. Seafood allergy and radiocontrast media: are physicians propagating a myth? Am J Med 2008;121(2):158 e151-154.
  12. ACR Manual on Contrast Media (Version 10.3); 2018.
  13. Boehm I. Seafood allergy and radiocontrast media: are physicians propagating a myth? Am J Med 2008;121(8):e19.

    Variable

    Count 1450

    Age, years 27 (22-35)

    Female 1121 (77%)

    Race/ethnicity

    Black 1311 (90%)

    Caucasian 111 (8%)

    Other 28 (2%)

    Number of providers seen at ED index visit 3 (1-4)

    STI laboratory testing 1429 (99%)

    STI discharge diagnosis 508 (35%)

    HIV testing 101 (5%)

    Reported are either median (Q1 – Q3) or count (%); STI = sexually transmitted infection; HIV = human immunodeficiency virus; ED = emergency department. a Patients who re- ceived laboratory testing for an STI at the ED index visit; b Patients discharged from the ED index visit with a diagnosis of an STI. c Patients who received laboratory testing for HIV at the ED index visit.

    1366 Correspondence / American Journal of Emergency Medicine 37 (2019) 13621393

    Fig. 1. Frequency of sexual history documented by sexual health risk factor.

    variable significantly associated with SHD was gender (68.6% male vs 54.5% Female gender p b 0.01). The 35% of patients (n = 508) with a dis- charge diagnosis of an STI were more likely to have SHD (64.1%) com- pared to those without a similar discharge diagnosis (54.2%) (p b 0.01). In our adjusted analysis, SHD was not a significant predictor of HIV testing (aOR, 1.39; 95% CI, 0.86-2.17; p = 0.14), though age (aOR,

    1.03; 95% CI, 1.02-1. 05, p b 0.01), male gender (aOR, 4.01; 95% CI,

    2.58-6.24; p b 0.01), and Caucasian vs. Black race (aOR, 4.25; 95% CI, 2.50-7.24; p b 0.01) were significant predictors. In the two sensitivity analyses, SHD (coded as an ordinal and binary variable) remained a non-significant predictor of ordering an HIV test, though age, gender, and race remained significant predictors.

    Patients were followed for one year after the index visit to assess fre- quency of STIs and HIV diagnosis. 627 (43%) and 44 (3%) patients had an additional STI diagnosis and a new HIV diagnosis, respectively, in the chart at their next visit.

    This study was limited by its reliance on EMR documentation as sur- rogate for risk factor assessment, as well as a significant proportion of female patients, which may not be applicable to other settings [8]. How- ever, pertinent risk factors should be documented in patient charts. The strength of this study is its direct focus on SHD and significantly larger sample size compared to other studies [2-4], as well as the first charac- terization of the types of sexual health risk factors documented by EP in the ED setting.

    In conclusion, SHD for patients presenting with concern for STIs in the ED remains suboptimal and was not associated with HIV testing, though 43% and 3% of patients presented within one year with an STI and HIV diagnosis, respectively. Targeted efforts to educate EP on as- sessment of sexual health risk factors for patients presenting with STI- related chief complaints may represent an opportunity to identify those at high-risk for undiagnosed HIV infection earlier rather than later.

    Sources of support

    HIV Medical Association Medical Student Research Award.

    Declarations of interest

    JY and JN received funding from the AIDS Funding Collaborative of Cleveland for the 2017-2018 academic year to start and HIV/syphilis screening program in the Department of Emergency Medicine at Uni- versity Hospitals Cleveland Medical Center, Cleveland, OH.

    Author contributions

    JN, AN, BG, JY conceived the study. JN, JC, JC were responsible for data collection. JN, AN provided statistical advice on study design and ana- lyzed the data. JN drafted the manuscript, and all authors contributed substantially to its revision. JN takes responsibility for the paper as a whole.

    Joshua D. Niforatos, MTS Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America Corresponding author at: 9500 Euclid Avenue, Na/21, Cleveland, OH

    44195, United States of America.

    E-mail addresses: [email protected]

    Amy S. Nowacki, PhD Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States of America Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland,

    OH, United States of America

    Jacqueline Cavendish

    University Hospitals Cleveland Medical Center, Cleveland, OH, United States of

    America

    Barbara M. Gripshover, MD John T. Carey Special Immunology Unit, Department of Medicine, Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States of America

    Justin A. Yax, MPH Department of Emergency Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States of America

    5 December 2018

    https://doi.org/10.1016/j.ajem.2018.12.016

    References

    Anderson ES, White DAE. Public health conditions for successful broad-scale integra- tion of HIV and HCV screening in emergency departments. Am J Public Health 2018; 108:591-2. https://doi.org/10.2105/AJPH.2018.304364.

  14. Jenkins WD, LeVault KR. Sexual History taking in the emergency department – more specificity required. J Emerg Med 2015;48:143-51. https://doi.org/10.1016/j. jemermed.2014.06.051.

    Correspondence / American Journal of Emergency Medicine 37 (2019) 13621393 1367

    Schechter SB, Romo DL, Cohall AT, Neu NM. Approach to human immunodeficiency virus/sexually transmitted infection testing for men at an urban urgent care center. Sex Transm Dis 2017;44:255. https://doi.org/10.1097/OLQ.0000000000000571.

  15. Goyal M, McCutcheon M, Hayes K, Mollen C. Sexual history documentation in adoles- cent emergency department patients. Pediatrics 2011;128:86-91. https://doi.org/10. 1542/peds.2010-1775.
  16. Clinical Prevention Guidance. STD treatment guidelines, (2018). https://www.cdc. gov/std/tg2015/clinical.htm; 2015, Accessed date: 6 December 2018.
  17. Haukoos JS, Lyons MS, Lindsell CJ, Hopkins E, Bender B, Rothman RE, et al. Derivation and validation of the Denver human immunodeficiency virus (HIV) risk score for targeted HIV screening. Am J Epidemiol 2012;175:838-46. https://doi.org/10.1093/ aje/kwr389.
  18. Hsieh Y-H, Haukoos JS, Rothman RE. Validation of an abbreviated version of the Den- ver HIV risk score for prediction of HIV infection in an urban emergency department. Am J Emerg Med 2014;32:775-9. https://doi.org/10.1016/j.ajem.2014.02.043.
  19. Pearson WS, Peterman TA, Gift TL. An increase in Sexually transmitted infections seen in US emergency departments. Prev Med 2017;100:143-4. https://doi.org/10.1016/j. ypmed.2017.04.028.

    Airtraq(R) is superior to the Macintosh laryngoscope for tracheal intubation: Systematic review with trial sequential analysis

    The Airtraq(R) laryngoscope (Prodol Ltd., Vizcaya, Spain) is a one-time-use video-guided laryngoscope for tracheal intubation of patients with either normal or Difficult airways [1]. Compared with the conventional laryngoscope, the efficacy of the Airtraq for tracheal intubation has been reported to be inconsistent in adults [2,3]. Here, we performed a systematic review and meta-analysis of several RCTs to compare the usefulness of the Airtraq versus the Macintosh laryngo- scope for tracheal intubation in an adult population.

    We conducted this meta-analysis according to the recommenda- tions of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [4]. We only included a study in the analysis if it was a prospective randomized trial or it compared the Airtraq and the Macintosh laryngoscope in adults. A comprehensive lit- erature search was performed using PubMed, Cochrane Central Register of Controlled Trials, EMBASE, and Scopus (Table 1).

    Data extracted from the eligible studies included the success rate (success on the first attempt), the intubation time, and the assessment of glottic visualization using the Cormack-Lehane classification (2 ver- sus >=3). We also conducted trial sequential analysis (TSA) [5]. In sub- group analysis, we separated these parameters to assess the influence of the airway condition (normal versus difficult) and laryngoscopist skill (novice versus experienced). We performed all statistical analyses with Review Manager (ver. 5.2, Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). We combined all data from the individual trials and used DerSimonian and Laird random effects models for our calculations. Pooled effect estimates for the binary variables of success rate and glottic visualization are shown as RR with the 95% CI. Pooled differences in intubation time between the two devices are expressed as the Weighted mean difference with 95% CI. To determine the percentage of variability due to heterogeneity rather than that due to sampling error, we used the Cochran Q and I2 statistics to test for homogeneity of the effect size across all trials [6].

    Twenty-nine articles describing 31 trials met the inclusion criteria. The Airtraq was used to intubate 1211 patients and the Macintosh la- ryngoscope was used to intubated 1203 patients. The rate of successful tracheal intubation with the Airtraq in the present meta-analysis of these 31 trials was significantly higher than that with the Macintosh la- ryngoscope (RR = 1.07, 95% CI, 1.03-1.11, P = 0.001, Cochrane’s Q = 108.6, I2 = 72%). TSA corrected the 95% CI to 1.02-1.11. The Z curve met the TSA monitoring boundary for benefit, and the accrued sample size (n = 2414) satisfied the previously estimated RIS (n = 1298). Intu- bation time with the Airtraq was significantly shorter than that with the Macintosh laryngoscope (WMD = -9.66, 95% CI 1-13.7 to -5.26, P b 0.0001, Cochrane’s Q = 1070.1, I2 = 97%). TSA resulted in correction of the 95% CI to -14.9 to -4.45. The Z curve crossed over the boundary of futility, and TSA further showed the accrued information size (n = 2192) to be 72.9% of the previously estimated RIS (n = 3003). Assess- ment of glottic visualization in 17 of the 31 trials examined showed that the Airtraq provided better glottic visualization than the Macintosh

    Table 1

    Characteristics of included studies

    No.

    Author

    Year

    Number of patients (ATQ/Mac)

    ASA status

    Status of airway

    Laryngoscopists

    1

    Maharaj CH

    2006

    60 (30/30)

    I-III

    Normal

    Novice

    2

    Maharaj CH

    2007

    40 (20/20)

    I-III

    MILS

    Experienced

    3

    Maharaj CH

    2008

    40 (20/20)

    I-III

    Predict difficult airway

    Experienced

    4

    Ndoko SK

    2008

    106 (53/53)

    I-III

    morbidly obese patients

    Experienced

    5

    Hirabayashi Y

    2009

    200 (100/100)

    N/A

    Normal

    Novice

    6

    Hirabayashi Y

    2009

    20 (10/10)

    N/A

    Normal

    Novice

    7

    Wang WH

    2009

    40 (20/20)

    I-II

    Normal

    Experienced

    8

    Gaszynski T

    2009

    68 (36/32)

    N/A

    Mobidly obese patients

    Experienced

    9

    Dhonneur G

    2009

    212 (106/106)

    III

    Mobidly obese patients

    Experienced

    10

    Chalkeidis O

    2010

    63 (35/28)

    I-III

    Normal

    Experienced

    11

    Park SJ

    2010

    74 (37/37)

    I-II

    Normal

    Novice

    12

    Koh JC

    2010

    50 (25/25)

    I-II

    MILS

    Experienced

    13

    di Marco PD

    2011

    108 (54/54)

    I-III

    Normal

    Novice

    14

    de Oliveira GS

    2011

    30 (15/15)

    I-II

    Normal

    Novice

    15

    McElwain J

    2011

    60 (29/31)

    I-III

    MILS

    Experienced

    16

    Ferrando C

    2011

    120 (60/60)

    I-III

    Normal

    Novice

    17

    Nishiyama T

    2011

    38 (18/20)

    I-II

    Normal

    Experienced

    18

    Puchner W

    2011

    40 (20/20)

    I-II

    Normal

    Experienced

    19

    Mont Gst

    2012

    100 (50/50)

    N/A

    Normal or predict difficult airway

    Experienced

    20

    Amor M

    2013

    120 (60/60)

    I

    MILS

    Experienced

    21

    Bhandari G

    2013

    80 (40/40)

    I

    Normal

    Experienced

    22

    Bensghir M

    2013

    70 (35/35)

    I-II

    Difficult, thyroid surgery

    Experienced

    23

    Zhao H

    2014

    149 (74/75)

    I-II

    Normal

    Novice

    24

    Saracoglu KT

    2014

    62 (31/31)

    I-II

    Normal

    Experienced

    25

    Ranieri Jr. D

    2014

    132 (68/64)

    III

    Mobidly obese patients

    Experienced

    26

    Colak A

    2015

    100 (50/50)

    I-III

    Normal

    Experienced

    27

    Vijayakumar V

    2016

    90 (45/45)

    I-II

    MILS

    Experienced

    28

    Al-Ghamdi AA

    2016

    43 (21/22)

    I-II

    Normal

    Experienced

    29

    Castillo-Monzon CG

    2017

    46 (23/23)

    III

    Morbidly obese patients

    Experienced

    ATQ: Airtraq, Mac: Macintosh laryngoscope, MILS: manual in-line neck stabilization, ASA: American Society of Anesthesiologist, N/A: not available.

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