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What is the best method of diagnosing onychomycosis?
Nail plate biopsy followed by periodic acid–Schiff staining is the most accurate method for diagnosing onychomycosis. The positive predictive value (PV+) of periodic acid–Schiff staining was equal to both potassium hydroxide (KOH) preparation and fungal culture, with a greater negative predictive value (PV–) due to superior sensitivity.
However, availability of periodic acid–Schiff staining may vary geographically, and the cost of the diagnostic tests is not addressed in this study. Thus, it makes clinical sense to start with the most accessible test, using periodic acid–Schiff staining if other methods are negative and clinical suspicion is high.
Nail plate biopsy followed by periodic acid–Schiff staining is the most accurate method for diagnosing onychomycosis. The positive predictive value (PV+) of periodic acid–Schiff staining was equal to both potassium hydroxide (KOH) preparation and fungal culture, with a greater negative predictive value (PV–) due to superior sensitivity.
However, availability of periodic acid–Schiff staining may vary geographically, and the cost of the diagnostic tests is not addressed in this study. Thus, it makes clinical sense to start with the most accessible test, using periodic acid–Schiff staining if other methods are negative and clinical suspicion is high.
Nail plate biopsy followed by periodic acid–Schiff staining is the most accurate method for diagnosing onychomycosis. The positive predictive value (PV+) of periodic acid–Schiff staining was equal to both potassium hydroxide (KOH) preparation and fungal culture, with a greater negative predictive value (PV–) due to superior sensitivity.
However, availability of periodic acid–Schiff staining may vary geographically, and the cost of the diagnostic tests is not addressed in this study. Thus, it makes clinical sense to start with the most accessible test, using periodic acid–Schiff staining if other methods are negative and clinical suspicion is high.
12-hour protocol safe for cocaine-associated chest pain
A 12-hour emergency department observation period is safe for patients with cocaine-associated chest pain, provided they have symptoms consistent with low-to-intermediate likelihood of unstable angina according to the Braunwald classification, and normal serial troponin I levels and cardiogram.
Patients with traditional cardiac risk factors should undergo cardiac stress testing within 2 weeks following the chest pain event, as atherosclerosis enhances the vasoconstrictive effects of cocaine. All patients should be referred for substance abuse counseling, as recurrent cocaine use was associated with subsequent nonfatal myocardial infarction (MI).
A 12-hour emergency department observation period is safe for patients with cocaine-associated chest pain, provided they have symptoms consistent with low-to-intermediate likelihood of unstable angina according to the Braunwald classification, and normal serial troponin I levels and cardiogram.
Patients with traditional cardiac risk factors should undergo cardiac stress testing within 2 weeks following the chest pain event, as atherosclerosis enhances the vasoconstrictive effects of cocaine. All patients should be referred for substance abuse counseling, as recurrent cocaine use was associated with subsequent nonfatal myocardial infarction (MI).
A 12-hour emergency department observation period is safe for patients with cocaine-associated chest pain, provided they have symptoms consistent with low-to-intermediate likelihood of unstable angina according to the Braunwald classification, and normal serial troponin I levels and cardiogram.
Patients with traditional cardiac risk factors should undergo cardiac stress testing within 2 weeks following the chest pain event, as atherosclerosis enhances the vasoconstrictive effects of cocaine. All patients should be referred for substance abuse counseling, as recurrent cocaine use was associated with subsequent nonfatal myocardial infarction (MI).
Is early cardioversion of atrial fibrillation, facilitated by transesophageal echocardiography, safe and effective?
BACKGROUND: Atrial fibrillation (AF) is the most common sustained arrhythmia and is an important contributor to cardiovascular morbidity and mortality. To prevent thromboembolism, physicians conventionally employ anticoagulant therapy for 3 to 4 weeks before an attempted cardioversion. Studies suggest that the duration of AF before cardioversion is a critical determinant of the reestablishment and maintenance of sinus rhythm. This study attempts to determine whether early transesophageal echocardiography (TEE), by ruling out a thrombus, can safely lead to more rapid cardioversion with improved outcomes.
POPULATION STUDIED: The subjects were 539 patients with AF recruited at 2 university hospitals over a 9-year period.
STUDY DESIGN AND VALIDITY: This was a prospective cohort study. Patients were excluded if estimated duration of AF was less than 2 days, if duration of AF was unknown, or if patients received long-term warfarin anticoagulation before admission. At admission, patients were given intravenous heparin and oral warfarin. Once therapeutic partial thromboplastin time was obtained, TEE was performed or supervised by 1 of 15 attending physicians, and all images were reviewed by at least 2 experienced practitioners to reach consensus for diagnosis of atrial thrombus. If no thrombus was detected, patients underwent chemical or direct-current cardioversion. However, if thrombus was demonstrated, cardioversion was deferred until follow-up TEE showed no thrombus after conventional warfarin treatment. For 1 month following cardioversion, patients continued to receive warfarin and were followed up for evidence of clinical thromboembolic events. Patients were followed up for 1 year to determine their health status. There are some methodologic concerns to this study. First, without randomization to a control group (anticoagulation 4 weeks preceding cardioversion), it is difficult to assess whether there is any direct effect of the early TEE strategy on the favorable outcomes reported. Second, the mode of cardioversion and use or choice of post-cardioversion antiarrhythmic medication were left to the discretion of the patient’s attending physician; this provides the opportunity for bias between patient groups. Third, objective surveillance data from 24-hour Holter monitoring was not used; thus, true incidence of AF recurrence was likely underestimated. Finally, though there were no complications attributed to the early cardioversion approach, safety was inferred by comparison with previously published studies rather than directly measured. This method could have underestimated asymptomatic thromboembolic events.
OUTCOMES MEASURED: The study compared the incidence of recurrent AF and prevalence of sinus rhythm at 1 year in those patients with clinically estimated initial AF of less than 3 weeks’ duration with those with initial AF greater than 3 weeks’ duration.
RESULTS: No significant differences were noted between the 2 studied groups on the basis of age, sex, left ventricular dysfunction, left atrial dimension, left/right atrial spontaneous echocardiographic contrast, or severity of mitral regurgitation. Patients who underwent cardioversion less than 3 weeks after the onset of AF had a lower likelihood of recurrence over the following year than did patients with more than 3 weeks of AF (41.1% vs 57.9%; P <.01). For every 6 patients who underwent cardioversion immediately rather than after 3 to 4 weeks of anticoagulation, there would be 1 less patient with recurrence of AF during the following year (number needed to treat [NNT]=6). At 1 year, the prevalence of sinus rhythm was also higher in the patients who received earlier cardioversion (65.8% vs 51.3%, P <.03; NNT=7). There were no complications attributed to early cardioversion.
Use of TEE to facilitate early cardioversion in patients with AF of less than 3 weeks’ duration appears to be an attractive alternative to conventional therapy. The conclusions of this study, combined with those from previous studies, may increase the use of TEE by cardiologists for patients with AF. However, the results from an ongoing randomized study directly comparing these 2 approaches will be useful in establishing whether this early strategy is indeed safer and more effective than convention.1
BACKGROUND: Atrial fibrillation (AF) is the most common sustained arrhythmia and is an important contributor to cardiovascular morbidity and mortality. To prevent thromboembolism, physicians conventionally employ anticoagulant therapy for 3 to 4 weeks before an attempted cardioversion. Studies suggest that the duration of AF before cardioversion is a critical determinant of the reestablishment and maintenance of sinus rhythm. This study attempts to determine whether early transesophageal echocardiography (TEE), by ruling out a thrombus, can safely lead to more rapid cardioversion with improved outcomes.
POPULATION STUDIED: The subjects were 539 patients with AF recruited at 2 university hospitals over a 9-year period.
STUDY DESIGN AND VALIDITY: This was a prospective cohort study. Patients were excluded if estimated duration of AF was less than 2 days, if duration of AF was unknown, or if patients received long-term warfarin anticoagulation before admission. At admission, patients were given intravenous heparin and oral warfarin. Once therapeutic partial thromboplastin time was obtained, TEE was performed or supervised by 1 of 15 attending physicians, and all images were reviewed by at least 2 experienced practitioners to reach consensus for diagnosis of atrial thrombus. If no thrombus was detected, patients underwent chemical or direct-current cardioversion. However, if thrombus was demonstrated, cardioversion was deferred until follow-up TEE showed no thrombus after conventional warfarin treatment. For 1 month following cardioversion, patients continued to receive warfarin and were followed up for evidence of clinical thromboembolic events. Patients were followed up for 1 year to determine their health status. There are some methodologic concerns to this study. First, without randomization to a control group (anticoagulation 4 weeks preceding cardioversion), it is difficult to assess whether there is any direct effect of the early TEE strategy on the favorable outcomes reported. Second, the mode of cardioversion and use or choice of post-cardioversion antiarrhythmic medication were left to the discretion of the patient’s attending physician; this provides the opportunity for bias between patient groups. Third, objective surveillance data from 24-hour Holter monitoring was not used; thus, true incidence of AF recurrence was likely underestimated. Finally, though there were no complications attributed to the early cardioversion approach, safety was inferred by comparison with previously published studies rather than directly measured. This method could have underestimated asymptomatic thromboembolic events.
OUTCOMES MEASURED: The study compared the incidence of recurrent AF and prevalence of sinus rhythm at 1 year in those patients with clinically estimated initial AF of less than 3 weeks’ duration with those with initial AF greater than 3 weeks’ duration.
RESULTS: No significant differences were noted between the 2 studied groups on the basis of age, sex, left ventricular dysfunction, left atrial dimension, left/right atrial spontaneous echocardiographic contrast, or severity of mitral regurgitation. Patients who underwent cardioversion less than 3 weeks after the onset of AF had a lower likelihood of recurrence over the following year than did patients with more than 3 weeks of AF (41.1% vs 57.9%; P <.01). For every 6 patients who underwent cardioversion immediately rather than after 3 to 4 weeks of anticoagulation, there would be 1 less patient with recurrence of AF during the following year (number needed to treat [NNT]=6). At 1 year, the prevalence of sinus rhythm was also higher in the patients who received earlier cardioversion (65.8% vs 51.3%, P <.03; NNT=7). There were no complications attributed to early cardioversion.
Use of TEE to facilitate early cardioversion in patients with AF of less than 3 weeks’ duration appears to be an attractive alternative to conventional therapy. The conclusions of this study, combined with those from previous studies, may increase the use of TEE by cardiologists for patients with AF. However, the results from an ongoing randomized study directly comparing these 2 approaches will be useful in establishing whether this early strategy is indeed safer and more effective than convention.1
BACKGROUND: Atrial fibrillation (AF) is the most common sustained arrhythmia and is an important contributor to cardiovascular morbidity and mortality. To prevent thromboembolism, physicians conventionally employ anticoagulant therapy for 3 to 4 weeks before an attempted cardioversion. Studies suggest that the duration of AF before cardioversion is a critical determinant of the reestablishment and maintenance of sinus rhythm. This study attempts to determine whether early transesophageal echocardiography (TEE), by ruling out a thrombus, can safely lead to more rapid cardioversion with improved outcomes.
POPULATION STUDIED: The subjects were 539 patients with AF recruited at 2 university hospitals over a 9-year period.
STUDY DESIGN AND VALIDITY: This was a prospective cohort study. Patients were excluded if estimated duration of AF was less than 2 days, if duration of AF was unknown, or if patients received long-term warfarin anticoagulation before admission. At admission, patients were given intravenous heparin and oral warfarin. Once therapeutic partial thromboplastin time was obtained, TEE was performed or supervised by 1 of 15 attending physicians, and all images were reviewed by at least 2 experienced practitioners to reach consensus for diagnosis of atrial thrombus. If no thrombus was detected, patients underwent chemical or direct-current cardioversion. However, if thrombus was demonstrated, cardioversion was deferred until follow-up TEE showed no thrombus after conventional warfarin treatment. For 1 month following cardioversion, patients continued to receive warfarin and were followed up for evidence of clinical thromboembolic events. Patients were followed up for 1 year to determine their health status. There are some methodologic concerns to this study. First, without randomization to a control group (anticoagulation 4 weeks preceding cardioversion), it is difficult to assess whether there is any direct effect of the early TEE strategy on the favorable outcomes reported. Second, the mode of cardioversion and use or choice of post-cardioversion antiarrhythmic medication were left to the discretion of the patient’s attending physician; this provides the opportunity for bias between patient groups. Third, objective surveillance data from 24-hour Holter monitoring was not used; thus, true incidence of AF recurrence was likely underestimated. Finally, though there were no complications attributed to the early cardioversion approach, safety was inferred by comparison with previously published studies rather than directly measured. This method could have underestimated asymptomatic thromboembolic events.
OUTCOMES MEASURED: The study compared the incidence of recurrent AF and prevalence of sinus rhythm at 1 year in those patients with clinically estimated initial AF of less than 3 weeks’ duration with those with initial AF greater than 3 weeks’ duration.
RESULTS: No significant differences were noted between the 2 studied groups on the basis of age, sex, left ventricular dysfunction, left atrial dimension, left/right atrial spontaneous echocardiographic contrast, or severity of mitral regurgitation. Patients who underwent cardioversion less than 3 weeks after the onset of AF had a lower likelihood of recurrence over the following year than did patients with more than 3 weeks of AF (41.1% vs 57.9%; P <.01). For every 6 patients who underwent cardioversion immediately rather than after 3 to 4 weeks of anticoagulation, there would be 1 less patient with recurrence of AF during the following year (number needed to treat [NNT]=6). At 1 year, the prevalence of sinus rhythm was also higher in the patients who received earlier cardioversion (65.8% vs 51.3%, P <.03; NNT=7). There were no complications attributed to early cardioversion.
Use of TEE to facilitate early cardioversion in patients with AF of less than 3 weeks’ duration appears to be an attractive alternative to conventional therapy. The conclusions of this study, combined with those from previous studies, may increase the use of TEE by cardiologists for patients with AF. However, the results from an ongoing randomized study directly comparing these 2 approaches will be useful in establishing whether this early strategy is indeed safer and more effective than convention.1
What is the long-term prognosis of patients with Lyme disease?
BACKGROUND: Lyme disease is the most common vector-borne illness diagnosed in the United States. Following a period of latent infection, long-term sequelae of untreated disease may involve the neurologic, cardiac, and musculoskeletal systems. Diagnosis is often difficult, as serologic testing is not standardized and patients with early disease may be antibody-negative. Vaccination confuses the issue by converting patients to seropositivity but protecting only 76% against symptomatic Lyme disease.1 Because it is primarily a clinical diagnosis, there are concerns about inadequate detection and treatment resulting in insidious progression of symptoms. Additionally, concern has been raised regarding possible long-term sequelae of the disease despite accepted treatment.
POPULATION STUDIED: Of the 8764 suspected cases of Lyme disease reported to the Connecticut Department of Public Health between 1984 and 1991, 1325 patients were randomly selected and 678 were included in this study. Of these, 52% were female, 34% were children, and 99% were white. The median age was 36 years. Patients were excluded if they reported that they had never had Lyme disease, did not speak English, or did not reside in Connecticut at the time of diagnosis.
STUDY DESIGN AND VALIDITY: This 2-part study consisted of a prospective longitudinal study and a case-control substudy to determine the frequency of long-term symptoms. In the longitudinal group, the median time from diagnosis was 51 months (range=15-135 months). A random subsample of 212 patients was selected from the longitudinal study. These patients were matched and compared with a person without Lyme disease of similar age and area of residence (control group). Patients and control subjects were interviewed by telephone using a standardized questionnaire to evaluate increased frequency of symptoms and increased difficulty in ability to perform activities. Adults also completed a study of general health and well-being (the Medical Outcomes Study Short Form-36 [SF-36]) and the Center for Epidemiologic Studies-Depression (CES-D) questionnaire. Parents were interviewed if the patient was a child.
OUTCOMES MEASURED: The primary outcome was a change in frequency of specifically identified symptoms and ability to perform certain typical daily activities. Patients were also screened for depression, and their health-related quality of life was evaluated.
RESULTS: Of patients with Lyme disease, 69% reported an increase in symptoms and difficulty with daily activities. Patients who did not meet the case definition for Lyme disease were significantly more likely to report joint or muscle pain (relative risk [RR]= 0.71; 95% CI, 0.57-0.88), numbness (RR=0.65; 95% CI, 0.48-0.88), fatigue (RR=0.66; 95% CI, 0.48-0.89), and headaches (RR=0.67; 95% CI, 0.47-0.96). Symptom reports were similar when patients were stratified by whether they had received antibiotic therapy, with the exception of joint or muscle aches, which were reported less often in the antibiotic-treated patients (RR=0.71; 95% CI, 0.6-0.9). Comparing patients with a diagnosis of Lyme disease with their matched control subjects, only joint or muscle pain (RR=1.4; 95% CI, 1.03-1.89) and difficulty formulating ideas (RR=2.96; 95% CI, 1.36-6.43) were reported more frequently. There were no statistically significant differences in the health and well-being (SF-36) and depression (CES-D) scores among the longitudinal and matched cohorts.
It appears that long-term outcomes are good in patients with Lyme disease when it is correctly diagnosed and treated. Long-term symptoms were more likely to be reported by patients who were given a diagnosis of Lyme disease but did not meet the CDC definition for diagnosis. It is uncertain whether these patients had an atypical presentation of Lyme disease or another chronic disease.
BACKGROUND: Lyme disease is the most common vector-borne illness diagnosed in the United States. Following a period of latent infection, long-term sequelae of untreated disease may involve the neurologic, cardiac, and musculoskeletal systems. Diagnosis is often difficult, as serologic testing is not standardized and patients with early disease may be antibody-negative. Vaccination confuses the issue by converting patients to seropositivity but protecting only 76% against symptomatic Lyme disease.1 Because it is primarily a clinical diagnosis, there are concerns about inadequate detection and treatment resulting in insidious progression of symptoms. Additionally, concern has been raised regarding possible long-term sequelae of the disease despite accepted treatment.
POPULATION STUDIED: Of the 8764 suspected cases of Lyme disease reported to the Connecticut Department of Public Health between 1984 and 1991, 1325 patients were randomly selected and 678 were included in this study. Of these, 52% were female, 34% were children, and 99% were white. The median age was 36 years. Patients were excluded if they reported that they had never had Lyme disease, did not speak English, or did not reside in Connecticut at the time of diagnosis.
STUDY DESIGN AND VALIDITY: This 2-part study consisted of a prospective longitudinal study and a case-control substudy to determine the frequency of long-term symptoms. In the longitudinal group, the median time from diagnosis was 51 months (range=15-135 months). A random subsample of 212 patients was selected from the longitudinal study. These patients were matched and compared with a person without Lyme disease of similar age and area of residence (control group). Patients and control subjects were interviewed by telephone using a standardized questionnaire to evaluate increased frequency of symptoms and increased difficulty in ability to perform activities. Adults also completed a study of general health and well-being (the Medical Outcomes Study Short Form-36 [SF-36]) and the Center for Epidemiologic Studies-Depression (CES-D) questionnaire. Parents were interviewed if the patient was a child.
OUTCOMES MEASURED: The primary outcome was a change in frequency of specifically identified symptoms and ability to perform certain typical daily activities. Patients were also screened for depression, and their health-related quality of life was evaluated.
RESULTS: Of patients with Lyme disease, 69% reported an increase in symptoms and difficulty with daily activities. Patients who did not meet the case definition for Lyme disease were significantly more likely to report joint or muscle pain (relative risk [RR]= 0.71; 95% CI, 0.57-0.88), numbness (RR=0.65; 95% CI, 0.48-0.88), fatigue (RR=0.66; 95% CI, 0.48-0.89), and headaches (RR=0.67; 95% CI, 0.47-0.96). Symptom reports were similar when patients were stratified by whether they had received antibiotic therapy, with the exception of joint or muscle aches, which were reported less often in the antibiotic-treated patients (RR=0.71; 95% CI, 0.6-0.9). Comparing patients with a diagnosis of Lyme disease with their matched control subjects, only joint or muscle pain (RR=1.4; 95% CI, 1.03-1.89) and difficulty formulating ideas (RR=2.96; 95% CI, 1.36-6.43) were reported more frequently. There were no statistically significant differences in the health and well-being (SF-36) and depression (CES-D) scores among the longitudinal and matched cohorts.
It appears that long-term outcomes are good in patients with Lyme disease when it is correctly diagnosed and treated. Long-term symptoms were more likely to be reported by patients who were given a diagnosis of Lyme disease but did not meet the CDC definition for diagnosis. It is uncertain whether these patients had an atypical presentation of Lyme disease or another chronic disease.
BACKGROUND: Lyme disease is the most common vector-borne illness diagnosed in the United States. Following a period of latent infection, long-term sequelae of untreated disease may involve the neurologic, cardiac, and musculoskeletal systems. Diagnosis is often difficult, as serologic testing is not standardized and patients with early disease may be antibody-negative. Vaccination confuses the issue by converting patients to seropositivity but protecting only 76% against symptomatic Lyme disease.1 Because it is primarily a clinical diagnosis, there are concerns about inadequate detection and treatment resulting in insidious progression of symptoms. Additionally, concern has been raised regarding possible long-term sequelae of the disease despite accepted treatment.
POPULATION STUDIED: Of the 8764 suspected cases of Lyme disease reported to the Connecticut Department of Public Health between 1984 and 1991, 1325 patients were randomly selected and 678 were included in this study. Of these, 52% were female, 34% were children, and 99% were white. The median age was 36 years. Patients were excluded if they reported that they had never had Lyme disease, did not speak English, or did not reside in Connecticut at the time of diagnosis.
STUDY DESIGN AND VALIDITY: This 2-part study consisted of a prospective longitudinal study and a case-control substudy to determine the frequency of long-term symptoms. In the longitudinal group, the median time from diagnosis was 51 months (range=15-135 months). A random subsample of 212 patients was selected from the longitudinal study. These patients were matched and compared with a person without Lyme disease of similar age and area of residence (control group). Patients and control subjects were interviewed by telephone using a standardized questionnaire to evaluate increased frequency of symptoms and increased difficulty in ability to perform activities. Adults also completed a study of general health and well-being (the Medical Outcomes Study Short Form-36 [SF-36]) and the Center for Epidemiologic Studies-Depression (CES-D) questionnaire. Parents were interviewed if the patient was a child.
OUTCOMES MEASURED: The primary outcome was a change in frequency of specifically identified symptoms and ability to perform certain typical daily activities. Patients were also screened for depression, and their health-related quality of life was evaluated.
RESULTS: Of patients with Lyme disease, 69% reported an increase in symptoms and difficulty with daily activities. Patients who did not meet the case definition for Lyme disease were significantly more likely to report joint or muscle pain (relative risk [RR]= 0.71; 95% CI, 0.57-0.88), numbness (RR=0.65; 95% CI, 0.48-0.88), fatigue (RR=0.66; 95% CI, 0.48-0.89), and headaches (RR=0.67; 95% CI, 0.47-0.96). Symptom reports were similar when patients were stratified by whether they had received antibiotic therapy, with the exception of joint or muscle aches, which were reported less often in the antibiotic-treated patients (RR=0.71; 95% CI, 0.6-0.9). Comparing patients with a diagnosis of Lyme disease with their matched control subjects, only joint or muscle pain (RR=1.4; 95% CI, 1.03-1.89) and difficulty formulating ideas (RR=2.96; 95% CI, 1.36-6.43) were reported more frequently. There were no statistically significant differences in the health and well-being (SF-36) and depression (CES-D) scores among the longitudinal and matched cohorts.
It appears that long-term outcomes are good in patients with Lyme disease when it is correctly diagnosed and treated. Long-term symptoms were more likely to be reported by patients who were given a diagnosis of Lyme disease but did not meet the CDC definition for diagnosis. It is uncertain whether these patients had an atypical presentation of Lyme disease or another chronic disease.