No abstract

To the Editor We read with great interest the article by King et al 1 regarding the high prevalence of prolonged antibiotic usage in US adults with sinusitis, especially given the high costs associated with the management of sinusitis along with the potential for selecting antibiotic resistant organisms.Various organizations, in addition to the Infectious Diseases Society of America, have released statements regarding antibiotic usage for sinusitis. The American College of Emergency Physicians recommends to avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis. 2 The American Academy of Family Physicians recommends against routinely prescribing antibiotics for mild-to-moderate sinusitis unless symptoms last for 7 or more days or worsen after initial improvement. 3 As such, although initially grouped together for analyses, it would be interesting to see if the different specialties have different trends in treatment durations and compliance with guidelines.In addition, as the authors have noted, the choice of antibiotic as well as the duration of therapy for sinusitis represents a significant opportunity for implementing antimicrobial stewardship. 1 One potential avenue is through the use of an antibiotic stewardship team with various members such as clinicians, epidemiologists, nurses, and pharmacists. In particular, Veterans Health Administration hospitals have had success with the implementation of antibiotic stewardship programs. As of 2015, 89% of Veterans Health Administration hospitals had a defined stewardship team and 92% had a written stewardship policy, contributing to a 12% drop in antibiotic use between 2008 and 2015. 4 On an outpatient scale, Hingorani et al 5 noted that the use of active and passive interventions (ie, didactic teaching, guideline posters, electronically integrated clinical decision support tools, guideline adherence report cards, and continued reiteration of these concepts) were able to increase treatment guideline compliance for sinusitis from 57.58% to 90.90%. These interventions represent opportunities for managing and mitigating antibiotic resistance, especially given that the vast majority of sinusitis cases appear to be viral.We applaud the authors for acknowledging the importance of antibiotic stewardship and revealing what appears to be an alarming 36.4% (ie, azithromycin, cephalosporins, other) use of non-guideline-recommended therapies, 1 which raises another avenue for possible intervention. As the authors have noted, guideline appropriate antibiotic treatment regimens should not only focus on appropriate antibiotic choices in the correct patient population but should also address the minimum effective duration of therapy to provide appropriate highvalue care to patients.

Background: Hypertension is a significant risk factor for cardiovascular disease. According to the Centers for Disease Control and Prevention (CDC) half of all United States citizens with hypertension (HTN) do not have their blood pressure under control. As such, HTN remains a large public health challenge, especially in patients with other comorbidities such as diabetes or poor nutritional status. Our goal was to assess the correlation between various vitamin levels with both HTN and atherosclerotic cardiovascular disease (ASCVD) risk in diabetic patients in order to identify potential targets for intervention to further decrease ASCVD and HTN risk. Methods: We obtained data from the medical record data warehouse of a primary care outpatient clinic predominantly run by internal medicine residents within a large safety-net hospital from January to December 2015. Patients with a diagnosis of diabetes mellitus (both type 1 and 2) were identified and electronic medical records were reviewed. ASCVD risk scores were calculated using the American College of Cardiology ASCVD risk estimator. Linear and logistical regression analyses were performed using SPSS software to assess the correlation between Vitamin B12, Vitamin D, and folic acid levels with both HTN and ASCVD risk. Results: Our patient population was predominantly African American (93%, 1633 of 1750). ASCVD scores could be calculated for 883 patients (60% female) and 94% (829 of 883) of these patients had elevated ASCVD risk scores ≥7.5. 86% (760 of 883) of patients had a diagnosis of hypertension or were on anti-hypertensive treatment. However, analyses of Vitamin D (14%, 126 of 883), Vitamin B12 (31%, 273 of 883), and folic acid (18%, 159 of 883) levels did not reveal any statistically significant correlation with HTN or ASCVD risk, even when stratified for different levels of a1c, ASCVD, or categories of HTN. There was however, a non-statistically significant correlation between vitamin D deficiency and HTN across all a1c levels (a1c <7, r=0.767, p=0.08; a1c ≥7 & <10, r=0.703, p=0.11; a1c ≥7, r=0.543, p=0.09) Conclusion: Our mathematical model cannot be used to explain any statistically significant correlation between Vitamin D, Vitamin B12, or folic acid levels with HTN or ASCVD risk in diabetic patients despite the fact that some studies have noted a potential association. This may reflect an inherent difference in our population (predominantly African American) or may be due to the low baseline monitoring rates of these vitamins. Future aims include initiating a targeted educational intervention for residents in the continuity clinic to not only actively monitor these vitamin levels in high risk populations, but to also demonstrate that resident driven intervention is an effective way to modify both HTN and ASCVD risk factors. Further studies are necessary to elucidate the long term relationship between vitamin levels and CVD risk.

Background: The obesity epidemic is a significant health concern, affecting nearly a third of all United States citizens according to the 2013-2014 National Health and Nutrition Examination Survey. Obesity contributes to multiple metabolic and cardiovascular risk factors including diabetes mellitus, hypertension, and dyslipidemia. The atherosclerotic cardiovascular disease (ASCVD) risk calculator is a frequently used tool that aggregates various risk factors to assist physicians in detecting patients that may benefit from statin therapy and risk factor modification. However, this calculator does not directly factor in obesity, which has been found to be associated with multiple cardiovascular comorbidities. Our goal was to assess the correlation between body mass index (BMI) and ASCVD risk scores in order to identify potential targets for intervention to further decrease ASCVD risk. Methods: We obtained data from the medical record data warehouse of a primary care outpatient clinic predominantly run by internal medicine residents within a large safety-net hospital from January to December 2015. Patients with a diagnosis of dyslipidemia or hyperlipidemia were identified and electronic medical records were reviewed. ASCVD risk scores were calculated using the American College of Cardiology ASCVD risk estimator. Linear and logistical regression analyses were performed using SPSS software to assess the correlation between BMI and ASCVD risk. Results: The patient population was predominantly African American (92%, 1771 of 1919). Obesity (BMI ≥30) was present in 63% (1207 of 1919) of patients. ASCVD scores could be calculated for 914 patients and 90% (823 of 914) of these patients had ASCVD risk scores ≥7.5. However, only 84% (691 of 823) of these patients with elevated ASCVD scores were on a statin. Analyses did not reveal a correlation between BMI and ASCVD risk. However, elevated BMI (>25) conferred an increased odds ratio (O.R.) of having elevated ASCVD risk (>22.5% O.R. 1.58; p value 0.02) in comparison to normal or underweight BMI. Conclusion: Obesity rates appear to be higher in our patient population in comparison to national estimates but our mathematical model cannot be used to explain any correlation between BMI and ASCVD risk scores. Obesity did not confer an increased ASCVD risk in comparison to being overweight (BMI 25-29.9). However, both overweight and obese patients had a higher likelihood of having a significantly elevated ASCVD risk score. Future aims include initiating a targeted educational intervention for residents in the continuity clinic to ultimately demonstrate that resident driven intervention is an effective way to address obesity and modify ASCVD risk.