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ContextNational quality improvement initiatives implemented in the late 1990s were followed by substantial increases in opioid prescribing in the United States, but it is unknown whether opioid prescribing for treatment of pain in the emergency department has increased and whether differences in opioid prescribing by race/ethnicity have decreased.ObjectivesTo determine whether opioid prescribing in emergency departments has increased, whether non-Hispanic white patients are more likely to receive an opioid than other racial/ethnic groups, and whether differential prescribing by race/ethnicity has diminished since 2000.Design and SettingPain-related visits to US emergency departments were identified using reason-for-visit and physician diagnosis codes from 13 years (1993-2005) of the National Hospital Ambulatory Medical Care Survey.Main Outcome MeasurePrescription of an opioid analgesic.Results Pain-related visits accounted for 156 729 of 374 891 (42%) emergency department visits. Opioid prescribing for pain-related visits increased from 23% (95% confidence interval [CI], 21%-24%) in 1993 to 37% (95% CI, 34%-39%) in 2005 (P

ContextA frequent cause of human immunodeficiency virus (HIV)–related morbidity in sub-Saharan Africa is a commonly occurring, intensely pruritic skin rash. The resulting scars are disfiguring and stigmatizing. Despite the substantial prevalence of pruritic papular eruption (PPE) among HIV-infected Africans, the cause has been elusive.ObjectiveTo determine the etiology of PPE occurring in HIV-infected individuals.Design, Setting, and PatientsCross-sectional study of HIV-infected patients with active PPE from clinics in Uganda conducted from May 19 through June 6, 2003. Enrollment occurred in the month preceding May 19. Each participant was clinically examined by 2 dermatologists, had laboratory studies performed, was administered an epidemiologic questionnaire, and had a skin biopsy of a new lesion evaluated by a dermatopathologist.Main Outcome MeasuresHistological characteristics of new pruritic lesions. Other assessments included CD4 cell count, eosinophil count, and physician-assessed rash severity.ResultsOf 109 patients meeting inclusion criteria, 102 (93.6%) completed the study. The CD4 cell counts in this study population were generally low (median, 46/μL) and inversely related to increasing rash severity (median CD4 cell counts: 122 for mild, 41 for moderate, and 9 for severe; P

To the Editor: Dr Greenland and colleagues reported that both the Framingham Risk Score (FRS) and the coronary artery calcium score (CACS) were predictive of coronary artery disease. The authors also reported that across categories of FRS, CACS was predictive of risk among patients with an FRS higher than 10%, but not with an FRS less than 10%. Furthermore, the CACS was less predictive than the FRS (hazard ratio, 3.9 vs 14.3), and only added slightly to the area under the receiver operating characteristic (ROC) curve using FRS alone. We point out that the FRS has a wide confidence interval (5.1%-6.9%) depending on the number of initial measurements in this type of patient and so it is possible that no significant difference exists given the size of the ROC envelope for the FRS and the small numbers of events that occurred in the study. The original cohort for the FRS included a larger proportion of smokers (40%) than is currently present in the population, and it is likely that the performance of the FRS was better than that observed now due to risk-factor drift away from smoking and toward diabetes. Modification of the FRS by the addition of inflammatory markers (eg, high-sensitivity Creactive protein [hsCRP]) has been suggested as a way to improve performance, but this may be limited by large biological variation. While the combination of FRS and hsCRP levels might have been superior to the combination of FRS and CACS, the authors did not measure hsCRP levels. Finally, we suspect that this study did not include patients with diabetes, given the National Cholesterol Education Program guidelines. However, the FRS used in many countries does include diabetes as a variable. The high rate of arterial calcification in this group may further confound estimates of risk determined by CACS scores.