Renal Embolization and Urothelial Sclerotherapy for Recurrent Obstructive Urosepsis and

Intractable Haematuria from Upper Tract Urothelial Carcinoma.

Abstract
Management of intractable haematuria and obstructive urosepsis from upper tract urothelial
carcinoma can be problematic in patients not suitable for surgery, chemotherapy or radiotherapy.
Interventional radiology techniques provide alternative approaches in this setting, such as
complete kidney embolization to cease urine output, percutaneous nephrostomy, antegrade
injection of sclerotherapy agents and sterilisation of the upper collecting system. Related
approaches have been successfully employed to sclerose renal cysts, lymphoceles, chyluria and
intractable lower tract haemorrhage. No reports of percutaneous, antegrade sclerotherapy in the
upper urinary tract have previously been published. We present a case of recurrent haematuria
and obstructive urosepsis caused by invasive upper tract urothelial carcinoma in a non-operative
patient, which was treated with renal embolisation and percutaneous upper tract urothelial
sclerotherapy.

Iliac artery-uretero-colonic fistula presenting as severe gastrointestinal hemorrhage and

hematuria: a case report and review of the literature.
Abstract
Arterioenteric fistulas represent an infrequent but potentially fatal cause of gastrointestinal
hemorrhage. Patients often present in extremis from shock and sepsis. This mandates a rapid
diagnosis so that prompt, potentially life-saving interventions can be performed. We report the
case of a 35 year-old male who presented with hematuria and hematochezia secondary to an iliac
artery-uretero-colonic fistula that developed years following open common iliac artery aneurysm
repair. His condition rapidly progressed to hemorrhagic shock and he underwent successful
endovascular treatment with a covered stent graft as a bridge to definitive open surgery.
Subsequently, graft explantation, extra-anatomic arterial bypass, bowel resection and ureter
ligation was undertaken. A summary of the literature on iliac artery-enteric fistulas follows.
KEYWORDS:
aneurysm; arterioenteric fistula; gastrointestinal hemorrhage

Urinary Schistosomiasis in an Adolescent Refugee from Africa: An Uncommon Cause of

Hematuria and an Emerging Infectious Disease in Europe.
Abstract
We report a case of urinary schistosomiasis in an adolescent refugee from Gambia (arrived to
Italy illegally), who was brought to the Emergency Department of our hospital. The patient
complained of gross hematuria and, in the absence of clinical evidence of bacterial urinary
infection, was admitted to the pediatric ward, considering his provenience and social setting. An
appropriate collection and microscopic analysis of urine samples led to the detection of bilharzia.
Much attention should be paid to this emerging disease in Europe by physicians in order to
recognize and treat it timely, which could prevent future and higher costs for public health
systems and could reduce the potential risk of environmental spreading. In fact, there are some
areas in Italy where the parasite can find its intermediate host to complete its lifecycle.

[Incidence of admissions due to pneumonia in children under 24 months old before and
after the introduction of the 10-valent pneumococcal conjugate vaccine into the
National Immunization Program of Chile].
Abstract
INTRODUCTION:
Streptococcus pneumoniae is the leading cause of bacterial pneumonia in children, especially in
the hospitalized population. The 10-valent pneumococcal vaccine was included in the National
Immunization Program of Chile in 2011. This study aims to evaluate the incidence of pneumonia
in hospitalized children<24 months of age in the Luis Calvo Mackenna Hospital before and after
the introduction of the pneumococcal vaccine into the National Immunization Program.
PATIENTS AND METHODS:
Passive surveillance study. Patients<24 months with discharge diagnosis of bacterial pneumonia
from Luis Calvo Mackenna Hospital were studied between 2009 and 2013. Data were obtained
from the Luis Calvo Mackenna Hospital's Statistical Service. The incidence of pneumonia was
evaluated in the pre-vaccination period (2009-2010) and in the post-vaccination period (20122013).
RESULTS:
During the study period, an average of 4,321 discharges/year was observed in children<24
months (range: 3,587-4,702), with a significant decrease from pre- to post-vaccination vaccine
period (4,644 vs 4,013, P<.001). The average incidence of pneumonia ranged from 3.4/100,000
to 1.5/100,000 in the pre- and post-vaccine period, respectively (P=.009), with an annual mean of
157 cases of pneumonia in the pre- vaccine period, and 62 cases in the postvaccine period
(P<.001) and a decrease in incidence between the two periods of 56%.
CONCLUSION:
This study confirms information previously obtained in other countries, which show a decrease
in the incidence of pneumonia associated with the implementation of a pneumococcal vaccine at
the population level. Ongoing surveillance is required to evaluate if this effect is maintained over
time and expands to older populations.
Copyright 2015 Sociedad Chilena de Pediatra. Publicado por Elsevier Espaa, S.L.U. All
rights reserved.
KEYWORDS:
Incidence; Incidencia; Neumona; Pneumonia; Streptococcus pneumoniae; Vaccine; Vacuna

Five-year trends for ventilator-associated pneumonia: Correlation between microbiological

findings and antimicrobial drug consumption.
Abstract
The epidemiology of multidrug-resistant bacteria (MDRB) has changed significantly in
European healthcare settings, with a decrease in frequency of meticillin-resistant Staphylococcus
aureus and an increase in extended-spectrum -lactamase (ESBL)-producing Enterobacteriaceae.
Little is known about the effects of these changes on ventilator-associated pneumonia (VAP). A
retrospective 5-year trend analysis of ICU antibiotic consumption and resistance in bacteria
causing VAP was undertaken. Poisson regression analysis between complete microbiological
data and antibiotic consumption was performed. In total, 252 episodes of VAP in 184 patients
were identified between 2007 and 2011, from which 364 causal bacteria were isolated.
Enterobacteriaceae isolation rates increased significantly over this period [from 6.64 to 10.52
isolates/1000 patient-days; P=0.006], mostly due to an increase in AmpC-producing
Enterobacteriaceae (APE) (2.85-4.51 isolates/1000 patient-days; P=0.013), whereas the number
of episodes due to S. aureus and Pseudomonas aeruginosa remained stable. A positive association
was found between the increase in APE infections and an increase in past-year antibiotic
consumption: amoxicillin/clavulanic acid (P=0.003), ceftazidime and cefepime (P=0.007),
carbapenems (P=0.002), fluoroquinolones (P=0.012), macrolides (P=0.002) and imidazoles
(P=0.004). No such association was found for the emergence of resistance in P. aeruginosa.
These results indicate a change in the epidemiology of VAP, with Enterobacteriaceae exceeding
P. aeruginosa and S. aureus. Moreover, a positive correlation was observed between antibiotic
consumption and the incidence of potentially MDRB such as APE. No such correlation was
found for ESBL-producing Escherichia coli and antibiotic-resistant P. aeruginosa.
Copyright 2015 Elsevier B.V. and the International Society of Chemotherapy. All rights
reserved.
KEYWORDS:
Antibiotic resistance; Antibiotic usage; Intensive care unit; Ventilator-associated pneumonia

Immunomodulatory activity of pidotimod administered with standard antibiotic therapy in

children hospitalized for community-acquired pneumonia.
Abstract
BACKGROUND:
Several attempts to improve immune function in young children have been made and
encouraging results have been collected with pidotimod (PDT), a synthetic dipeptide molecule
that seems to have immunomodulatory activity on both innate and adaptive responses. Until now,
the effects of PDT on the immune system have only been studied in vivo after long-term
administration to evaluate whether its immunomodulatory activity might prevent the
development of infections. This study was planned to evaluate the immunomodulatory activity of
PDT administered together with standard antibiotic therapy in children hospitalized for
community-acquired pneumonia (CAP).
METHODS:
A total of 20 children hospitalized for community-acquired pneumonia (CAP) were randomized
at a 1:1 ratio to receive either standard antibiotics plus pidotimod (PDT) or standard antibiotics
alone to evaluate the immunomodulatory activity of PDT. Blood samples for the evaluation of
immunological parameters were drawn at the time of recruitment (T0) (i.e., before therapy
administration), at T3 and T5 (i.e., 3 and 5 days after the initiation of therapy) as well as at T21
(i.e., 7 days after the therapy ended).
RESULTS:
Following pneumococcal polysaccharide stimulation, the percentage of dendritic cells (DCs)
expressing activation and costimulatory molecules was significantly higher in children receiving
PDT plus antibiotics than in the controls. A significant increase in tumor necrosis factor- and/or
interleukin-12 secretion and expression of toll like receptor 2 was observed in PDT-treated
children compared with controls; this was followed by an increased release of proinflammatory
cytokines by monocytes. In the PDT-treated group, mRNA expression of antimicrobial peptides
and genes involved in the inflammatory response were also augmented in comparison with the
controls.
CONCLUSIONS:
These results demonstrate, for the first time, that PDT administered together with standard
antibiotics is associated with a favorable persistent immunomodulatory effect in children with
CAP.

Genetic Resistance to Malaria Is Associated With Greater Enhancement of

Immunoglobulin (Ig)M Than IgG Responses to a Broad Array of Plasmodium
falciparum Antigens.
Abstract
Background. People of the Fulani ethnic group are more resistant to malaria compared with
genetically distinct ethnic groups, such as the Dogon people, in West Africa, and studies suggest
that this resistance is mediated by enhanced antibody responses to Plasmodium falciparum
antigens. However, prior studies measured antibody responses to <0.1% of P falciparum proteins,
so whether the Fulani mount an enhanced and broadly reactive immunoglobulin (Ig)M and IgG
response to P falciparum remains unknown. In general, little is known about the extent to which
host genetics influence the overall antigen specificity of IgM and IgG responses to natural
infections. Methods. In a cross-sectional study in Mali, we collected plasma from
asymptomatic, age-matched Fulani (n = 24) and Dogon (n = 22) adults with or without
concurrent P falciparum infection. We probed plasma against a protein microarray containing
1087 P falciparum antigens and compared IgM and IgG profiles by ethnicity. Results. We
found that the breadth and magnitude of P falciparum-specific IgM and IgG responses were
significantly higher in the malaria-resistant Fulani versus the malaria-susceptible Dogon, and,
unexpectedly, P falciparum-specific IgM responses more strongly distinguished the 2 ethnic
groups. Conclusions. These findings point to an underappreciated role for IgM in protection
from malaria, and they suggest that host genetics may influence the antigen specificity of IgM
and IgG responses to infection.
KEYWORDS:
Dogon; Fulani; Plasmodium falciparum; antibodies; malaria

Clinical determinants of early parasitological response to ACTs in African patients with

uncomplicated falciparum malaria: a literature review and meta-analysis of individual
patient data.
Abstract
BACKGROUND:
Artemisinin-resistant Plasmodium falciparum has emerged in the Greater Mekong sub-region
and poses a major global public health threat. Slow parasite clearance is a key clinical
manifestation of reduced susceptibility to artemisinin. This study was designed to establish the
baseline values for clearance in patients from Sub-Saharan African countries with uncomplicated
malaria treated with artemisinin-based combination therapies (ACTs).
METHODS:
A literature review in PubMed was conducted in March 2013 to identify all prospective clinical
trials (uncontrolled trials, controlled trials and randomized controlled trials), including ACTs
conducted in Sub-Saharan Africa, between 1960 and 2012. Individual patient data from these
studies were shared with the WorldWide Antimalarial Resistance Network (WWARN) and
pooled using an a priori statistical analytical plan. Factors affecting early parasitological response
were investigated using logistic regression with study sites fitted as a random effect. The risk of
bias in included studies was evaluated based on study design, methodology and missing data.
RESULTS:
In total, 29,493 patients from 84 clinical trials were included in the analysis, treated with
artemether-lumefantrine (n=13,664), artesunate-amodiaquine (n=11,337) and
dihydroartemisinin-piperaquine (n=4,492). The overall parasite clearance rate was rapid. The
parasite positivity rate (PPR) decreased from 59.7 % (95 % CI: 54.5-64.9) on day 1 to 6.7 %
(95 % CI: 4.8-8.7) on day 2 and 0.9 % (95 % CI: 0.5-1.2) on day 3. The 95th percentile of
observed day 3 PPR was 5.3 %. Independent risk factors predictive of day 3 positivity were: high
baseline parasitaemia (adjusted odds ratio (AOR)=1.16 (95 % CI: 1.08-1.25); per 2-fold
increase in parasite density, P <0.001); fever (>37.5 C) (AOR=1.50 (95 % CI: 1.06-2.13), P=
0.022); severe anaemia (AOR=2.04 (95 % CI: 1.21-3.44), P=0.008); areas of low/moderate
transmission setting (AOR=2.71 (95 % CI: 1.38-5.36), P=0.004); and treatment with the loose
formulation of artesunate-amodiaquine (AOR=2.27 (95 % CI: 1.14-4.51), P=0.020, compared
to dihydroartemisinin-piperaquine).
CONCLUSIONS:
The three ACTs assessed in this analysis continue to achieve rapid early parasitological clearance
across the sites assessed in Sub-Saharan Africa. A threshold of 5 % day 3 parasite positivity from
a minimum sample size of 50 patients provides a more sensitive benchmark in Sub-Saharan
Africa compared to the current recommended threshold of 10 % to trigger further investigation
of artemisinin susceptibility.

Severe malaria in immigrant population: a retrospective review.

Abstract
Imported malaria continues to be an increasing medical challenge in the US. A significant
proportion of imported malaria occurs in foreign born immigrants visiting their native countries
and do not take prophylaxis for malaria mostly due to a misconception of being immune to
malaria. The purpose of this study is to review epidemiology, clinical presentation, rate of
prophylaxis and delineate the rate of severe malaria in a community hospital with largely
immigrant population. Retrospective chart review of forty patients diagnosed with malaria from
1997 to 2007 at a 673 bed teaching hospital in Newark, NJ, USA. Of the 40 cases included, 90%
were born in a malaria endemic area (MEA).The Majority (85%) acquired malaria while visiting
the African subcontinent. Overall prophylaxis rate was only 12%. Plasmodium falciparum was
the most common malaria species diagnosed. Severe malaria was diagnosed in 25% of the cases,
all in foreign born subjects visiting native countries where malaria is endemic. Malaria continues
to be a challenge in a population of immigrants visiting their country of origin. Low use of
prophylaxis is of major concern in immigrant population especially in light of high rates of
severe malaria. Primary care physicians play an important role in pre-travel advice to prevent the
complications of malaria.

Executive Function, Survival and Hospitalisation in Chronic Obstructive Pulmonary

Disease: A Longitudinal Analysis of the National Emphysema Treatment Trial (NETT).
Abstract
Background Cognitive dysfunction has been demonstrated in COPD, but studies are limited to
cross-sectional analyses or incompletely characterised populations. We examined longitudinal
changes in sensitive measures of executive function in a well-characterised population of patients
with severe COPD. Methods This study was performed on patients enrolled in the National
Emphysema Treatment Trial. To assess executive function, we analysed Trail Making (TM) A
and B times at enrolment in the trial (2128 patients), and at 12 (731 patients) and 24 months (593
patients) after enrolment, adjusted for surgery, marriage status, age, education, income,
depression, PaO2, PaCO2 and smoking. Associations with survival and hospitalizations were
examined using Cox regression and linear regression models. Measurements and Main Results
The average age of the patients was 66.4 years, and the average FEV1 was 23.9% of predicted.
At the time of enrolment, 38% had executive dysfunction. Compared with those who did not,
these patients were older, less educated, had higher oxygen use, higher PaC02, worse quality of
life as measured by the Saint George Respiratory Questionnaire, reduced well-being and lower
social function. There was no significant change over 2 years in Trail Making A or B times after
adjustment for co-variables. Changes in Trail Making B times were modestly associated with
survival, but changes in Trail Making B-A times were not. Changes in Trail Making scores were
not associated with frequency of hospitalisation. Lung function, PaO2, smoking, survival and
hospitalizations were not significantly different in those with executive dysfunction. Conclusions
In this large population of patients with severe emphysema and heavy cigarette smoking
exposure, there was no significant impairment or decline over 2 years in cognitive executive
function as measured by Trail Making tests. There was no association between executive
function and frequency of hospitalization, and a possible modest association with survival. It is

plausible that cerebrovascular co-morbidities explain previously described cognitive pathology

in COPD.

Comparing Clinical Outcomes in Upper versus Lower Lobe Endobronchial Valve

Treatment in Severe Emphysema.
Abstract
BACKGROUND:
Lung volume reduction surgery has been recommended for patients with upper lobe predominant
emphysema and was associated with less favorable outcomes in patients with non-upper lobe
predominant emphysema. The value of endobronchial valve (EBV) treatment in lower lobe
predominant emphysema has not been studied.
OBJECTIVES:
To confirm the equivalence of upper and lower lobe valve treatments in patients with
heterogeneous emphysema.
METHODS:
A retrospective analysis from the Endobronchial Valve for Emphysema Palliation Trial (VENT),
where patients with heterogeneous emphysema received Zephyr EBV (Pulmonx Corp.,
Redwood City, Calif., USA) or medical treatment, was performed. Patients with low interlobar
collateral ventilation and accurate placement of valves in the target lobes were identified. Safety
and efficacy were compared between patients who underwent upper versus lower lobe treatment.
RESULTS:

Of the 331 patients, 60 had low interlobar collateral ventilation and successful lobar exclusion
(45 patients with upper lobe treatment and 15 patients with lower lobe treatment). There was no
difference in baseline characteristics between the groups except for a higher destruction score
(70.3 vs. 60.7%; p = 0.0010) and a higher heterogeneity index (24 vs. 13%; p = 0.0005) for the
upper lobe cohort. At 180 days, both groups had improved clinically. There were no significant
differences in mean changes or responder rates of forced expiratory volume in 1 s (+23.8 vs.
+22.9%), the St. Georges Respiratory Questionnaire (-6.50 vs. -7.53 points), the 6-min walk test
(+24.1 vs. +44.0 m), target lobe volume reduction (-1,199 vs. -1,042 ml), or in the adverse event
rate between both cohorts.
CONCLUSION:
Patients with lower and upper lobe predominant emphysema benefit equally from EBV therapy
when interlobar collateral ventilation is low and lobar exclusion is achieved. Patients with lower
lobe disease did not have increased adverse events compared to patients with upper lobe
emphysema.

Subcutaneous emphysema and pneumomediastinum following cocaine inhalation: a case

report.
Abstract
INTRODUCTION:
Subcutaneous emphysema or pneumomediastinum can occur as a complication of illicit drug use
although this is rare. When occurring without a pneumothorax and spontaneously, it is usually
treated conservatively, but can have serious consequences.
CASE PRESENTATION:
Here, we present the case of an otherwise healthy 23-year-old Caucasian man who presented to
the Emergency Department at our institution and was found to have both subcutaneous
emphysema and pneumomediastinum as a result of cocaine use. His only presenting symptom
was mild chest pain and he had palpable subcutaneous crepitations. He underwent a series of
investigations including a chest radiograph and computed tomography as well as a barium
fluoroscopy study to rule out secondary pneumomediastinum, which can be fatal. There were no
other pulmonary features of illicit drug use, such as granulomas or fibrosis, seen on radiological
imaging. He was subsequently managed with a period of observation and supportive care.
CONCLUSION:
We report a rare case of subcutaneous emphysema and pneumomediastinum likely due to the
nasal insufflation of cocaine. We discuss the necessary investigations to rule out any serious

underlying pathology. These should be considered in patients who present with chest pain after
cocaine use.

Beta2-agonists for acute cough or a clinical diagnosis of acute bronchitis.

Abstract
BACKGROUND:
The diagnosis of acute bronchitis is made on clinical grounds and a variety of clinical
definitions have been used. There are no clearly effective treatments for the cough of acute
bronchitis. Beta2-agonists are often prescribed, perhaps because clinicians suspect many
patients also have reversible airflow restriction (as seen in asthma or chronic obstructive
pulmonary disease (COPD)) contributing to the symptoms.
OBJECTIVES:
To determine whether beta2-agonists improve acute bronchitis symptoms in people with no
underlying pulmonary disease (such as asthma, COPD or pulmonary fibrosis).
SEARCH METHODS:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2015, Issue 5,
MEDLINE (January 1966 to May 2015), EMBASE (1974 to May 2015), Web of Science (2011
to May 2015) and LILACS (1982 to May 2015).
SELECTION CRITERIA:

Randomised controlled trials (RCTs) which allocated people (adults, or children over two years
of age) with acute bronchitis or acute cough and without known pulmonary disease to beta2agonist versus placebo, no treatment or alternative treatment.
DATA COLLECTION AND ANALYSIS:
Three review authors independently selected outcomes and extracted data while blinded to study
results. Two review authors independently assessed each trial for risk of bias. We analysed trials
in children and adults separately.
MAIN RESULTS:
Two trials of moderate quality in children (n = 134) with no evidence of airflow restriction did
not find any benefits from oral beta2-agonists. Five trials in adults (n = 418) had mixed results
but overall summary statistics did not reveal any significant benefits from oral (three trials) nor
from inhaled (two trials) beta2-agonists. Three studies with low-quality evidence demonstrated
no significant differences in daily cough scores, nor in the percentage of adults still coughing
after seven days (control group 71%; risk ratio (RR) 0.86, 95% confidence interval (CI) 0.63 to
1.18; 220 participants). In one trial, subgroups with evidence of airflow limitation had lower
symptom scores if given beta2-agonists. The trials that noted quicker resolution of cough with
beta2-agonists were those with a higher proportion of people wheezing at baseline. Low-quality
evidence suggests that adults given beta2-agonists were more likely to report tremor, shakiness
or nervousness (RR 7.94, 95% CI 1.17 to 53.94; 211 participants; number needed to treat for an
additional harmful outcome (NNTH) 2).
AUTHORS' CONCLUSIONS:
There is no evidence to support the use of beta2-agonists in children with acute cough who do
not have evidence of airflow restriction. There is also little evidence that the routine use of beta2agonists is helpful for adults with acute cough. These agents may reduce symptoms, including
cough, in people with evidence of airflow restriction. However, this potential benefit is not well
supported by the available data and must be weighed against the adverse effects associated with
their use.

Influence of N-acetylcysteine on chronic bronchitis or COPD exacerbations: a metaanalysis.

Abstract
In order to clarify the possible role of N-acetylcysteine (NAC) in the treatment of patients with
chronic bronchitis and chronic obstructive pulmonary disease (COPD), we have carried out a
meta-analysis testing the available evidence that NAC treatment may be effective in preventing
exacerbations of chronic bronchitis or COPD and evaluating whether there is a substantial
difference between the responses induced by low (600mg per day) and high (>600mg per day)
doses of NAC.The results of the present meta-analysis (13 studies, 4155 COPD patients, NAC
n=1933; placebo or controls n=2222) showed that patients treated with NAC had significantly
and consistently fewer exacerbations of chronic bronchitis or COPD (relative risk 0.75, 95% CI
0.66-0.84; p<0.01), although this protective effect was more apparent in patients without
evidence of airway obstruction. However, high doses of NAC were also effective in patients
suffering from COPD diagnosed using spirometric criteria (relative risk 0.75, 95% CI 0.68-0.82;
p=0.04). NAC was well tolerated and the risk of adverse reactions was not dose-dependent (low
doses relative risk 0.93, 95% CI 0.89-0.97; p=0.40; high doses relative risk 1.11, 95% CI 0.891.39; p=0.58).The strong signal that comes from this meta-analysis leads us to state that if a
patient suffering from chronic bronchitis presents a documented airway obstruction, NAC should
be administered at a dose of 1200mg per day to prevent exacerbations, while if a patient suffers
from chronic bronchitis, but is without airway obstruction, a regular treatment of 600mg per day
seems to be sufficient.

Trends in Outpatient Visits with Benzodiazepines among US Adults With and Without
Bronchitis or Chronic Obstructive Pulmonary Disease from 1999 to 2010.
Abstract
Little is known about trends in prescriptions for benzodiazepines among patients with chronic
obstructive pulmonary disease (COPD). Our objective was to examine trends of office/outpatient
department visits with a mention of a benzodiazepine made by patients aged 40 years with
COPD in the United States. We used data from the National Ambulatory Medical Care Survey
and National Hospital Ambulatory Medical Care Survey from 1999-2010. From 1999 to 2010,
the estimated numbers of office/outpatient department visits with a benzodiazepine mentioned
increased from 20.7 million to 43.2 million among all patients, from 684,000 to 1.5 million
among patients with COPD, and from 20.0 million to 41.7 million among patients without
COPD. Using all 12-years of data, patients with COPD were more likely to have a visit with a
mention of a benzodiazepine than patients without COPD (adjusted prevalence ratio = 1.48, 95%
CI = 1.27-1.71).The unadjusted percentage of all office/outpatient department visits by patients
with COPD with a mention of a benzodiazepine increased from 4.6% during 1999-2002 to
10.2% during 2007-2010 (P trend < 0.001). After adjustment for age, sex, and race, the adjusted
prevalence ratio for 2007-2010 compared with 1999-2002 was 2.26 (95% confidence interval:
1.60-3.17). Since 1999, the number and percentage of office/outpatient department visits with a
mention of a benzodiazepine by patients with COPD and all patients may have increased in the
United States.
KEYWORDS:
COPD; United States; benzodiazepines; prescriptions; therapeutics; trends