Evaluation and Treatment of Nausea and Vomiting in Adults.

Nausea and vomiting are common symptoms that can reduce quality of life and indicate life-threatening illness. Acute nausea and vomiting last up to 7 days. In the absence of alarm symptoms, they are typically treated symptomatically and without an extensive evaluation. Typical causes include gastroenteritis or other viral syndromes, foodborne illness, acute migraine headaches, vestibular disturbances, early pregnancy, and adverse effects of medication. Chronic nausea and vomiting last 4 weeks or longer and have a broad differential diagnosis. Causes can be gastrointestinal, infectious, metabolic, neurologic, psychiatric, or related to medications and toxins. A careful history of related factors is essential to guide the initial evaluation and narrow the differential diagnosis. These factors include associated symptoms, timing of onset and duration of symptoms, exacerbating or relieving factors, alarm symptoms, medication and substance use, relationship with recent food ingestion, and comorbidities. Nonpharmacologic management options include fluid and electrolyte replacement; small, frequent meals; and avoidance of trigger foods. Antiemetic drugs effectively reduce symptoms of acute nausea and vomiting, but chronic symptoms are often more challenging to treat. When a specific etiology is not identified, a serotonin antagonist or dopamine antagonist can be used. However, medications may also target the suspected cause of symptoms and the neurotransmitters involved in central and peripheral pathways of nausea and vomiting. Pharmacologic therapy should be used for the shortest time necessary to control symptoms.

Safety of the Trauma Quality Improvement Program Guideline for Venous Thromboembolism Prophylaxis in Traumatic Brain Injury.

BACKGROUND: The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) provides a guideline for when to initiate pharmacologic venous thromboembolism (VTE) prophylaxis in traumatic brain injury (TBI) patients. We hypothesized that implementation of the guideline would not result in progression in intracranial hemorrhage. METHODS: The TBI TQIP guideline was implemented at a Level I Trauma Center. Patients with a stable Computerized tomography (CT) of the brain were started on chemical prophylaxis per the Modified Berne-Norwood Criteria. CT scans before and after initiation of treatment were retrospectively reviewed by one board-certified radiologist to determine if there was progression of hemorrhage. Patients without a follow-up CT scan were evaluated for progression of bleed/neurologic deterioration by review of physician notes, nursing documentation, and Glasgow coma scale (GCS). RESULTS: From July 2017 to December 2020, 12,922 patients were admitted to the trauma service. A total of 552 of these patients had TBI and 269 met inclusion criteria. 55 patients had at least one CT of the brain after initiation of prophylaxis. None of these 55 patients had progression of hemorrhage. 214 patients did not have a CT of the brain after prophylaxis. Chart review showed that none of these patients had a clinical decline. Overall, there was no progression of hemorrhage in the 269 patients that met inclusion criteria. DISCUSSION: Initiation of the TQIP TBI VTE prophylaxis guideline was found to be safe with no progression of intracranial hemorrhage.

Approaches for optimizing venous thromboembolism prevention in injured patients: Findings from the consensus conference to implement optimal venous thromboembolism prophylaxis in trauma.

ABSTRACT: Venous thromboembolism (VTE) is a major issue in trauma patients. Without prophylaxis, the rate of deep venous thrombosis approaches 60% and even with chemoprophylaxis may be nearly 30%. Advances in VTE reduction are imperative to reduce the burden of this issue in the trauma population. Novel approaches in VTE prevention may include new medications, dosing regimens, and extending prophylaxis to the postdischarge phase of care. Standard dosing regimens of low-molecular-weight heparin are insufficient in trauma, shifting our focus toward alternative dosing strategies to improve prophylaxis. Mixed data suggest that anti-Xa-guided dosage, weight-based dosing, and thromboelastography are among these potential strategies. The concern for VTE in trauma does not end upon discharge, however. The risk for VTE in this population extends well beyond hospitalization. Variable extended thromboprophylaxis regimens using aspirin, low-molecular-weight heparin, and direct oral anticoagulants have been suggested to mitigate this prolonged VTE risk, but the ideal approach for outpatient VTE prevention is still unclear. As part of the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma, a multidisciplinary array of participants, including physicians from multiple specialties, pharmacists, nurses, advanced practice providers, and patients met to attack these issues. This paper aims to review the current literature on novel approaches for optimizing VTE prevention in injured patients and identify research gaps that should be investigated to improve VTE rates in trauma.

Telehealth in Geriatrics.

Telehealth is commonly used in the care of geriatric patients; however, it requires special considerations for effective implementation. Although available evidence suggests that this model of care is useful and feasible, interventions should be carefully designed with the unique needs of geriatric patients in mind. Further, more research is needed to determine the most effective telehealth interventions in this population, which will assist in determining cost-effectiveness and reimbursement policies.

Prospective randomized trial of metal versus resorbable plates in surgical stabilization of rib fractures.

BACKGROUND: Surgical stabilization of rib fractures has gained popularity as both metal and resorbable plates have been approved for fracture repair. Is there a difference between metal and resorbable plate rib fixation regarding rib fracture alignment, control of pain, and quality-of-life (QOL) scores (Rand SF-36 survey)? METHODS: Eligible patients (pts) included 18 years or older with one or more of the following: flail chest, one or more bicortical displaced fractures (3-10), nondisplaced fractures with failure of medical management. Patients were randomized to either metal or resorbable plate fixation. Primary outcome was fracture alignment. Secondary outcomes were pain scores, opioid use, and QOL scores. RESULTS: Thirty pts were randomized (15 metal/15 resorbable). Total ribs plated 167 (88 metal/79 resorbable). Patients with rib displacement at day of discharge (DOD) metal 0/14 (one pt died, not from plating) versus resorbable 9/15 or 60% ( p = 0.001). Ribs displaced at DOD metal 0/88 versus resorbable 22/79 or 28% ( p < 0.001), 48% in posterior location. Patients with increased rib displacement 3 months to 6 months: metal, 0/11 versus resorbable, 3/9 or 33% ( p = 0.043). Ribs with increased displacement 3 months to 6 months metal 0 of 67 versus resorbable 6 of 49 or 12.2% ( p < 0.004). Pain scores and narcotic use at postoperative Days 1, 2, 3, DOD, 2 weeks, 3 months and 6 months showed no statistically significant difference between groups. QOL scores were also similar at 3 months and 6 months. Trauma recidivism in outpatient period resulted in fracture of resorbable plates in two pts requiring a second surgery. CONCLUSION: Metal plates provided better initial alignment with no displacement over time. Clinical outcomes were similar regarding pain, narcotic use, and QOL scores. Routine use of resorbable plates for posterior rib fractures is not warranted. Lateral repairs were technically most feasible for using resorbable plates but still resulted in significant displacement. Resorbable plates may not maintain rib alignment when exposed to subsequent injury. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Comprehensive Initiative to Decrease Trauma Venous Thromboembolism.

BACKGROUND: Our trauma center was a high outlier for pulmonary embolism on a 2017 American College of Surgeons Trauma Quality Improvement Program (TQIP) report. The odds ratio for developing a pulmonary embolus was 1.76 and was in the 10th decile (worst results). Of the patients who received chemoprophylaxis, only 69% of patients received the "gold standard" low-molecular-weight heparin. OBJECTIVE: The purpose of this study was to describe and evaluate a multicomponent performance improvement project to prevent pulmonary embolus incidence. METHODS: This descriptive study was a before-and-after time-series analysis of adult trauma patients. Ongoing data validation, concurrent monitoring, and analysis on incidence of venous thrombolytic events identified barriers to evidence-based chemoprophylaxis administration. RESULTS: There were a total of 4,711 trauma patients in the analysis. Compared with preintervention (fall 2017), the fall 2019 TQIP report indicated the pulmonary embolus odds ratio dropped to 0.56, lowering the benchmark decile from 10 (worst) to 1 (best). The proportion of patients receiving no chemoprophylaxis decreased to 23% and was lower than all hospitals (32%). The rate of low-molecular-weight heparin use increased to 80% for patients receiving chemoprophylaxis, and unfractionated heparin use plummeted to 14%. The proportion of patients with no chemoprophylaxis in the severe traumatic brain injury cohort fell to 21%. CONCLUSIONS: The high pulmonary embolus rate was driven by inaccurate data, infrequent monitoring, suboptimal ordering, and administration of chemoprophylaxis. A sustained decrease in the pulmonary embolus incidence was achieved through collaboration, updated guidelines, expanded education, concurrent validation, monitoring, and frequent reporting.

The health care utilization model: Application to dental care use for Black and Hispanic children.

OBJECTIVES: To explore the pathway associated with dental service use among Hispanic and non-Hispanic Black children, applying Andersen's model of health care service utilization. METHODS: Samples of Hispanic (n = 5,055) and non-Hispanic (NH) Black (n = 2,695) children aged 2-17 years from the 2016 National Survey of Children's Health (NSCH) were included in this study. We used structural equation modeling (SEM) to examine the path of the relationship between dental care visits and the three groups of characteristics in Andersen's behavioral model. RESULTS: In the models for Hispanic and non-Hispanic Black children, parents' educational attainment directly and positively affected income and having insurance. Also, insurance (Hispanic children: ß = 0.17, P ≤ 0.01; NH Black children: ß = 0.25, P ≤ 0.01) and age of the child (Hispanic children: ß = 0.14, P ≤ 0.01; NH Black: ß = 0.21, P ≤ 0.01) directly and positively affected dental care use. However, there was no direct effect of the need factor on dental care use in either model. CONCLUSIONS: Children may receive dental services that eliminate acute dental problems, probably as a result of the ACA and CHIP coverage. The patterns of findings suggest the need for policy changes to improve pediatric dental coverage and promote professional recommendations for effective dental hygiene.

IMPACT survey: IMpaired fecundity in Physicians and Association with Clinical Time.

OBJECTIVE: Studies suggest female physicians experience higher rates of infertility than the general population. The overall objective of this study was to determine the rate of impaired fecundity in a sample of female emergency physicians and compare it to the Centers for Disease Control and Prevention (CDC) National Survey of Family Growth (NSFG) data. Impaired fecundity is defined as physical difficulty in getting pregnant or carrying a pregnancy to live birth. METHODS: We performed a cross-sectional survey of female emergency physicians to determine the rate of impaired fecundity. Survey questions were adapted from the NSFG to allow comparison to the general population. Statistical comparisons were made using contingency tables (with chi-square and tau-c assessments), 1-sample t tests, and independent samples t tests, as appropriate. RESULTS: A total of 2072 women completed the survey with a mean (SD) current age of 38.9 (7.2) years. Data were analyzed for women of childbearing years (15-44 years old as defined by the CDC; n = 1705 [82% total responses]). The rate of impaired fecundity in emergency physicians was 24.9% as compared to the NSFG cohort (12.1%; P < 0.001). Female emergency physicians with impaired fecundity reported working 9.8 overall more clinical hours (95% CI 2.5-17) and 4.5 more night hours (95% CI 0.8-8.2) than those with normal fecundity. CONCLUSION: Female emergency physicians have increased rates of impaired fecundity when compared with a general population cohort. Clinical workload and night shifts are greater in female emergency physicians with impaired fecundity. Research is needed to elucidate work-related impaired fecundity risk factors.

Multimodal Analgesia and Decreased Opioid Use in Adult Trauma Patients.

BACKGROUND: There is an opioid epidemic in the United States. With the increased concern of over-prescribing opioids, physicians are seeking alternative pain management strategies. The purpose of this study is to review the impact of instituting a multimodal analgesia (MMA) guideline on decreasing opioid use in trauma patients at a Level 1 trauma center. METHODS: In 2017, an MMA guideline was developed and included anti-inflammatories, muscle relaxants, neuropathic agents, and local analgesics in addition to opioids. Staff were educated and the guideline was implemented. A retrospective review of medications prescribed to patients admitted from 2016 through 2018 was performed. Patients admitted in 2016 served as the control group (before MMA). In 2018, all patients received multimodal pain therapy as standard practice, and served as the comparison group. RESULTS: A total of 10 340 patients were admitted to the trauma service from 2016 through 2018. There were 3013 and 3249 patients for review in 2016 and 2018, respectively. Total morphine milligram equivalents were 2 402 329 and 1 975 935 in 2016 and 2018, respectively, a 17.7% decrease (P < .001). Concurrently, there was a statistically significant increase in the use of multimodal pain medications. A secondary endpoint was studied to evaluate for changes in acute kidney injury; there was not a statistically significant increase (0.56% versus 0.68%, P = .55). DISCUSSION: Implementation of an MMA guideline significantly reduced opioid use in trauma patients. The use of nonopioid MMA medications increased without an increased incidence of acute kidney injury.

'Simple and easy:' providers' and latinos' perceptions of the fecal immunochemical test (FIT) for colorectal cancer screening.

Objective: Colorectal cancer (CRC) screening efforts have effectively reduced CRC morbidity and mortality, yet screening remains relatively low among Latinos. The study's purpose was to document the awareness/knowledge of Fecal Immunochemical Test (FIT) among Latinos, gain better understanding of patient and health care provider perceptions about FIT, and explore the feasibility of adoption/uptake.Design/Methods: The study was guided by qualitative, ethnography design and methods. Eight focus groups (FG) with patients who self-identified as Hispanic/Latino between 50-75 years of age and key informant interviews with providers (N = 10) were conducted followed by a brief demographic questionnaire.Results: Awareness levels varied based on prior screening experiences among patients and providers. Both patients and providers believed the FIT is simple and easy to use; although, a minority of patients expressed doubts about the efficacy of the FIT when compared to colonoscopy.Conclusions: Despite the increasing acceptance of the FIT among the health care community, a significant lag time still exists among our study's populations. Study findings speak to novelty of the FIT test among underserved populations and the health disparity gap between health innovations/discoveries. Increased awareness and education efforts about the efficacy coupled with information about its accessibility, ease, and user instructions may increase the adoption of FIT.

How much green does it take to be orange? Determining the cost associated with trauma center readiness.

BACKGROUND: Readiness costs are real expenses incurred by trauma centers to maintain essential infrastructure to provide emergent services on a 24/7 basis. Although the components for readiness are well described in the American College of Surgeons' Resources for Optimal Care of the Injured Patient, the cost associated with each component is not well defined. We hypothesized that meeting the requirements of the 2014 Resources for Optimal Care of the Injured Patient would result in significant costs for trauma centers. METHODS: The state trauma commission in conjunction with trauma medical directors, program managers, and financial officers of each trauma center standardized definitions for each component of trauma center readiness cost and developed a survey tool for reporting. Readiness costs were grouped into four categories: administrative/program support staff, clinical medical staff, in-house operating room, and education/outreach. To verify consistent cost reporting, a financial auditor analyzed all data. Trauma center outliers were further evaluated to validate variances. All level I/level II trauma centers (n = 16) completed the survey on 2016 data. RESULTS: Average annual readiness cost is US $10,078,506 for a level I trauma center and US $4,925,103 for level IIs. Clinical medical staff was the costliest component representing 55% of costs for level Is and 64% for level IIs. Although education/outreach is mandated, levels I and II trauma centers only spend approximately US $100,000 annually on this category (1%-2%), demonstrating a lack of resources. CONCLUSION: This study defines the cost associated with each component of readiness as defined in the Resources for Optimal Care of the Injured Patient manual. Average readiness cost for a level I trauma center is US $10,078,506 and US $4,925,103 for a level II. The significant cost of trauma center readiness highlights the need for additional trauma center funding to meet the requirements set forth by the American College of Surgeons. LEVEL OF EVIDENCE: Economic and value-based evaluations, level III.

Evaluation of the Georgia trauma system using the American College of Surgeons Needs Based Assessment of Trauma Systems tool.

BACKGROUND: The American College of Surgeons Needs Based Assessment of Trauma Systems (NBATS) tool was developed to help determine the optimal regional distribution of designated trauma centers (DTC). The objectives of our current study were to compare the current distribution of DTCs in Georgia with the recommended allocation as calculated by the NBATS tool and to see if the NBATS tool identified similar areas of need as defined by our previous analysis using the International Classification of Diseases, Ninth Revision, Clinical Modification Injury Severity Score (ICISS). METHODS: Population counts were acquired from US Census publications. Transportation times were estimated using digitized roadmaps and patient zip codes. The number of severely injured patients was obtained from the Georgia Discharge Data System for 2010 to 2014. Severely injured patients were identified using two measures: ICISS<0.85 and Injury Severity Score >15. RESULTS: The Georgia trauma system includes 19 level I, II, or III adult DTCs. The NBATS guidelines recommend 21; however, the distribution differs from what exists in the state. The existing DTCs exactly matched the NBATS recommended number of level I, II, or III DTCs in 2 of 10 trauma service areas (TSAs), exceeded the number recommended in 3 of 10 TSAs, and was below the number recommended in 5 of 10 TSAs. Densely populated, or urban, areas tend to be associated with a higher number of existing centers compared with the NBATS recommendation. Other less densely populated TSAs are characterized by large rural expanses with a single urban core where a DTC is located. The identified areas of need were similar to the ones identified in the previous gap analysis of the state using the ICISS methodology. DISCUSSION: The tool appears to underestimate the number of centers needed in extensive and densely populated areas, but recommends additional centers in geographically expansive rural areas. The tool signifies a preliminary step in assessing the need for state-wide inpatient trauma center services. LEVEL OF EVIDENCE: Economic, level IV.

Descriptive Analysis of Venous Thromboembolism in Georgia Trauma Centers Compared with National Trauma Centers Participating in the Trauma Quality Improvement Program.

This study was designed to compare the incidence of venous thromboembolism (VTE) in Georgia trauma centers with other national trauma centers participating in the Trauma Quality Improvement Program (TQIP). The use of chemoprophylaxis and characteristics of patients who developed VTE were also examined. We conducted a retrospective observational study of 325,703 trauma admissions to 245 trauma centers from 2013 to 2014. Patient demographics, rate of VTE, as well as the use, type, and timing of chemoprophylaxis were compared between patients admitted to Georgia and non-Georgia trauma centers. The rate of VTE in Georgia trauma centers was 1.9 per cent compared with 2.1 per cent in other national trauma centers. Overall, 49.6 per cent of Georgia patients and 45.5 per cent of patients in other trauma centers had documented chemoprophylaxis. Low molecular weight heparin was the most commonly used medication. Most patients who developed VTE did so despite receiving prophylaxis. The rate of VTE despite prophylaxis was 3.2 per cent in Georgia and 3.1 per cent in non-Georgia trauma centers. Mortality associated with VTE was higher in Georgia trauma centers compared with national TQIP benchmarks. The incidence of VTE and use of chemoprophylaxis within Georgia trauma centers were similar to national TQIP data. Interestingly, most patients who developed VTE in both populations received VTE prophylaxis. Further research is needed to develop best-practice guidelines for prevention, early detection, and treatment in high-risk populations.

Human Papillomavirus Vaccination Training Experience Among Family Medicine Residents and Faculty.

BACKGROUND AND OBJECTIVES: Residency training is a pivotal time to establish skills for career-long practices, particularly for challenging skills such as human papillomavirus (HPV) vaccine recommendation. Training experience and preferences related to delivering HPV vaccine recommendations were examined for family medicine (FM) residents and faculty. METHODS: Residents (n=28) and faculty (n=19) were identified through a national FM residency directory and recruited from training programs in Florida. Participants completed a phone interview assessing key aspects of HPV vaccine recommendation training. Interviews were audio recorded, transcribed verbatim, and analyzed using content analysis. A brief follow-up survey assessing training, practices, and demographics was emailed after the interview. RESULTS: Residents' training experience with HPV vaccine recommendation varied from none to extensive, and was often self-directed. Variation in training was seen between and within programs. Faculty often noted HPV vaccination training was not standardized and residents lacked instruction about effective communication. Most programs relied on preceptors for training residents but training from preceptors varied widely and was often not standardized within the program. CONCLUSIONS: This study identified a lack of consistent and standardized training for delivering HPV vaccine recommendations. A training curriculum that uses multiple modalities and reflects resident and faculty preferences is needed.

Successful Incorporation of Performance Based Payments for Trauma Center Readiness Costs into the Georgia Trauma System.

As quality and outcomes have moved to the fore front of medicine in this era of healthcare reform, a state trauma system Performance Based Payments (PBP) program has been incorporated into trauma center readiness funding. The purpose of this study was to evaluate the impact of a PBP on trauma center revenue. From 2010 to 2016, a percentage of readiness costs funding to trauma centers was placed in a PBP and withheld until the PBP criteria were completed. To introduce the concept, only three performance criteria and 10 per cent of readiness costs funding were tied to PBP in 2010. The PBP has evolved over the last several years to now include specific criteria by level of designation with an increase to 50 per cent of readiness costs funding being tied to PBP criteria. Final PBP distribution to trauma centers was based on the number of performance criteria completed. During 2016, the PBP criteria for Level I and II trauma centers included participation in official state meetings/conference calls, required attendance to American College of Surgeons state chapter meetings, Trauma Quality Improvement Program, registry reports, and surgeon participation in Peer Review Committee and trauma alert response times. Over the seven-year study period, $36,261,469 was available for readiness funds with $11,534,512 eligible for the PBP. Only $636,383 (6%) was withheld from trauma centers. A performance-based program was successfully incorporated into trauma center readiness funding, supporting state performance measures without adversely affecting the trauma center revenue. Future PBP criteria may be aligned to designation standards and clinical quality performance metrics.

A Decade Evaluation of a State Trauma System: Has Access to Inpatient Trauma Care at Designated Trauma Centers Improved?

Recently, the trauma center component of the Georgia trauma system was evaluated demonstrating a 10 per cent probability of increased survival for severely injured patients treated at designated trauma centers (DTCs) versus nontrauma centers. The purpose of this study was to determine the effectiveness of a state trauma system to provide access to inpatient trauma care at DTCs for its residents. We reviewed 371,786 patients from the state's discharge database and identified 255,657 treated at either a DTC or a nontrauma center between 2003 and 2012. Injury severity was assigned using the International Classification Injury Severity Score method. Injury was categorized as mild, moderate, or severe. Patients were also categorized by age and injury type. Access improved over time in all severity levels, age groups, and injury types. Although elderly had the largest improvement in access, still only 70 per cent were treated at a DTC. During the study period, increases were noted for all age groups, injury severity levels, and types of injury. A closer examination of the injured elderly population is needed to determine the cause of lower utilization by this age group. Overall, the state's trauma system continues to mature by providing patients with increased access to treatment at DTCs.

Chlamydia trachomatis genotypes in a cross-sectional study of urogenital samples from remote Northern and Central Australia.

OBJECTIVES: The objective was to determine the frequency of trachoma genotypes of Chlamydia trachomatis-positive urogenital tract (UGT) specimens from remote areas of the Australian Northern Territory (NT). SETTING: The setting was analysis of remnants of C. trachomatis positive primarily UGT specimens obtained in the course of clinical practice. The specimens were obtained from two pathology service providers. PARTICIPANTS: From 3356 C. trachomatis specimens collected during May 2012-April 2013, 439 were selected for genotyping, with a focus on specimens from postpubescent patients, in remote Aboriginal communities where ocular trachoma is potentially present. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was the proportion of successfully genotyped UGT specimens that were trachoma genotypes. The secondary outcome measures were the distribution of genotypes, and the frequencies of different classes of specimens able to be genotyped. RESULTS: Zero of 217 successfully genotyped UGT specimens yielded trachoma genotypes (95% CI for frequency=0-0.017). For UGT specimens, the genotypes were E (41%), F (22%), D (21%) and K (7%), with J, H and G and mixed genotypes each at 1-4%. Four of the five genotyped eye swabs yielded trachoma genotype Ba, and the other genotype J. Two hundred twenty-two specimens (50.6%) were successfully genotyped. Urine specimens were less likely to be typable than vaginal swabs (p<0.0001). CONCLUSIONS: Unlike in some other studies, in the remote NT, trachoma genotypes of C. trachomatis were not found circulating in UGT specimens from 2012 to 2013. Therefore, C. trachomatis genotypes in UGT specimens from young children can be informative as to whether the organism has been acquired through sexual contact. We suggest inclusion of C. trachomatis genotyping in guidelines examining the source of sexually transmitted infections in young children in areas where trachoma genotypes may continue to circulate, and continued surveillance of UGT C. trachomatis genotypes.

Elements of Access: The Effects of Food Outlet Proximity, Transportation, and Realized Access on Fresh Fruit and Vegetable Consumption in Food Deserts.

This study surveys 900 supplemental nutrition assistance program recipient or eligible households and 300 supplemental nutrition assistance program ineligible households in local food deserts to identify the effects of different dimensions of access on fresh fruit and vegetables (FFV) consumption. While proximity and access to one's own car were not significant predictors of FFV consumption, realized access to nonsupermarket outlets did have a positive effect on fresh vegetable consumption. Among food insecure respondents, limited car access had a negative effect on FFV consumption. This research underlines the importance of focusing on dimensions of access other than proximity when considering interventions designed to improve nutrition and health outcomes in food deserts.

Individualized vancomycin dosing in obese patients: a two-sample measurement approach improves target attainment.

STUDY OBJECTIVE: To compare the likelihood of vancomycin target trough concentration attainment based on infectious diagnosis and/or minimum inhibitory concentration for the organism by using a two-sample approach versus the prior institutional standard of a trough-only approach in obese patients receiving vancomycin. DESIGN: Preintervention and postintervention study. SETTING: Community acute care hospital. PATIENTS: One hundred fifty hospitalized adults with a body mass index (BMI) of 30 kg/m(2) or greater and treated with vancomycin for at least 48 hours between July 2013 and March 2014 were evaluated to compare the frequency of steady-state therapeutic trough concentration attainment between two approaches: a trough-only dosing method (preintervention group [75 patients]) and a dosing strategy measuring two vancomycin serum concentrations during the elimination phase (peak and trough) to calculate pharmacokinetic parameters and individualize the maintenance regimen (postintervention group [75 patients]). Data for the preintervention group were retrospectively retrieved from a 4-month period for patients admitted between July and October 2013, prior to implementation of the two-point vancomycin dosing protocol. Initial vancomycin empiric dose selection for both groups utilized the same population-based pharmacokinetic equations. MEASUREMENTS AND MAIN RESULTS: Median (5th-95th percentile) age, weight, and BMI were 59 (34-80) years, 105 (79.8-164) kg, and 34.5 (30.0-55.1) kg/m(2) , respectively, for all patients. The percentages of initial therapeutic trough concentrations achieved in the preintervention and postintervention groups were 32.0% and 42.7%, respectively (p=0.117). For patients with a second trough measurement, 31.0% in the preintervention group and 65.2% in the postintervention group were within the therapeutic range (p=0.024). CONCLUSION: Measurement of two serum vancomycin concentrations significantly improves subsequent target trough concentration attainment in the obese population.