Point-of-care ultrasound (POCUS) is an imaging modality used to make expedient patient care decisions at bedside. Though its diagnostic utility has been extensively described, POCUS is not yet ...considered standard of care in inpatient settings. Data from emergency department settings suggest that POCUS may yield socioemotional benefits beyond its diagnostic utility; furthermore, elements of the POCUS experience are known to promote placebo effects. These elements likely contribute to a placebo-like "POCUS positive care effect" (PPCE) with socioemotional benefits for receptive patients. Our objective is to provide the first characterization of the PPCE and its facilitating factors in an inpatient setting. In this novel mixed-methods study, we recruited 30 adult patients admitted to internal medicine floors in an urban academic medical center, recorded observations during their routine POCUS encounters, and administered post-encounter surveys. We conducted complementary quantitative and qualitative analyses to define and assess the magnitude of the PPCE. We also aimed to identify factors associated with and facilitating receptiveness to the PPCE. The results indicated that POCUS improves patients' satisfaction with their hospital providers and care overall, as well as perceived care efficiency. Mutual engagement, strong therapeutic alliances, and interpreting POCUS images to provide reassurance are most closely associated with this PPCE. Patients who have lower anxiety levels, less severe illness, and received efficient care delivery during their hospitalizations are most receptive to the PPCE. We conclude that diagnostic POCUS has the potential to exert a positive care effect for hospitalized patients. This PPCE is associated with modifiable factors at the patient, provider, and environment levels. Together, our findings lay the groundwork for an optimized "therapeutic POCUS" that yields maximal socioemotional benefits for receptive patients.
Purpose:
This study contributes to the emerging literature on lesbian, gay, bisexual, transgendered, and queer (LGBTQ) health disparities and tobacco use by examining the motivations for smoking ...among the New York City (NYC) LGBTQ population. Approach: We used grounded theory and blended methods from 3 grounded theorists—Strauss, Corbin, and Charmaz—for data collection, coding, and analysis.
Setting:
NYC has extensive legislation to prevent smoking; however, the current smoking prevalence of homosexuals is double that of heterosexuals.
Participants:
Study participants were leaders from 23 NYC LGBTQ organizations. Leaders were chosen to establish a relationship with community and to ensure cultural sensitivity. Eligibility criteria required holding a leadership position in an organization serving the NYC LGBTQ community.
Methods:
Interviews were transcribed verbatim and uploaded into Dedoose for analysis. An initial code list was developed from the interview guide. Key themes were identified as the themes with the most number of quotes.
Results:
Three key themes emerged from our interviews: image, socializing, and stress. Smoking was reported to be a socialization aid and a maladaptive coping technique for stress arising from interactions of conflicting identities.
Conclusion:
Future smoking cessation interventions among the LGBTQ community should equip smokers with healthy coping mechanisms that address the stressors that arise from the intersections of smokers’ many identities.
COVID-19 in Hospitalized Adults With HIV Stoeckle, Kate; Johnston, Carrie D; Jannat-Khah, Deanna P ...
Open forum infectious diseases
7, Številka:
8
Journal Article
Recenzirano
Odprti dostop
The spread of SARS-CoV-2 and the COVID-19 pandemic have caused significant morbidity and mortality worldwide. The clinical characteristics and outcomes of hospitalized patients with SARS-CoV-2 and ...HIV co-infection remain uncertain.
We conducted a matched retrospective cohort study of adults hospitalized with a COVID-19 illness in New York City between March 3, 2020, and May 15, 2020. We matched 30 people with HIV (PWH) with 90 control group patients without HIV based on age, sex, and race/ethnicity. Using electronic health record data, we compared demographic characteristics, clinical characteristics, and clinical outcomes between PWH and control patients.
In our study, the median age (interquartile range) was 60.5 (56.6-70.0) years, 20% were female, 30% were black, 27% were white, and 24% were of Hispanic/Latino/ethnicity. There were no significant differences between PWH and control patients in presenting symptoms, duration of symptoms before hospitalization, laboratory markers, or radiographic findings on chest x-ray. More patients without HIV required a higher level of supplemental oxygen on presentation than PWH. There were no differences in the need for invasive mechanical ventilation during hospitalization, length of stay, or in-hospital mortality.
The clinical manifestations and outcomes of COVID-19 among patients with SARS-CoV-2 and HIV co-infection were not significantly different than patients without HIV co-infection. However, PWH were hospitalized with less severe hypoxemia, a finding that warrants further investigation.
Azithromycin and Childhood Mortality in Africa Keenan, Jeremy D; Arzika, Ahmed M; Lietman, Thomas M
The New England journal of medicine,
10/2018, Letnik:
379, Številka:
14
Journal Article
Objectives
This study aims to better understand and describe antibiotic prescribing practices and adherence to a procalcitonin (PCT)‐guided algorithm in patients undergoing serum PCT testing in adult ...hospitalized patients.
Methods
We performed an observational, retrospective study of 201 randomly selected patients who are aged ≥18 years, admitted to the general medicine floors or step‐down unit between 1 January 2017 and 31 December 2017, and had serum PCT testing. Physician adherence to a PCT‐guided algorithm was assessed through chart review.
Results
We found an overall adherence of 64.7%. Adherence was highest for PCT values above 0.25 ng/mL (82.8% for 0.25‐0.50 ng/mL and 83.6% for >0.50 ng/mL). Adherence was lower for PCT values less than 0.25 ng/mL (59% for <0.1 ng/mL and 38% for 0.1‐0.24 ng/mL). Serial testing was performed in 10% of patients.
Conclusions
Hospital‐based providers are more likely to overrule the algorithm and either initiate or continue antibiotics when guidelines encourage discontinuing antibiotics. These findings have important implications for antimicrobial stewardship and patient care and suggest that hospital‐based providers may benefit from targeted didactics regarding the interpretation of the serum PCT assay.
Objective
Concerns about severe acute respiratory syndrome coronavirus 2 (SARS–CoV‐2) infection may have led to changes or discontinuation of immunosuppressive medications among patients with ...systemic rheumatic disease. Our goal was to assess patients’ perspectives regarding medication modifications and deviations from planned uses during the height of the pandemic.
Methods
Adult patients of 13 rheumatologists at an academic center with physician‐diagnosed rheumatic disease and prescribed disease‐modifying medications were interviewed by telephone and asked open‐ended questions about the impact of SARS–CoV‐2 on their medications. Responses were analyzed using content and thematic analyses to generate categories that described patterns of medication modification.
Results
A total of 112 patients (mean age 50 years, 86% women, 34% non‐White race or Latino ethnicity) with diverse diagnoses (30% lupus, 26% rheumatoid arthritis, 44% other) who were taking various medications were enrolled. Patients reported clinically relevant issues that were iteratively reviewed to generate unique categories of medication modification: medications and increased or decreased risk of SARS–CoV‐2 infection; role of hydroxychloroquine; maintaining medication status quo; role of glucocorticoids; increasing or decreasing existing medications in relation to clinical disease activity; postponing infusions; and medication plan if infected by SARS–CoV‐2. Some modifications were suboptimal for disease control but were made to mitigate infection risk and to minimize potential harm when patients were unable to obtain laboratory tests and physical examinations due to cessation of in‐person office visits.
Conclusion
During the height of the pandemic, substantial medication modifications were made that, in some cases, were temporizing measures and deviations from planned regimens. Future studies will assess short‐ and long‐term sequelae of these medication modifications.
Dental visits represent an opportunity to identify and help patients quit smoking, yet dental settings remain an untapped venue for treatment of tobacco dependence. The purpose of this analysis was ...to assess factors that may influence patterns of tobacco-use-related practice among a national sample of dental providers.
We surveyed a representative sample of general dentists practicing in the United States (N = 1,802). Multivariable analysis was used to assess correlates of adherence to tobacco use treatment guidelines and to analyze factors that influence providers' willingness to offer tobacco cessation assistance if reimbursed for this service.
More than 90% of dental providers reported that they routinely ask patients about tobacco use, 76% counsel patients, and 45% routinely offer cessation assistance, defined as referring patients for cessation counseling, providing a cessation prescription, or both. Results from multivariable analysis indicated that cessation assistance was associated with having a practice with 1 or more hygienists, having a chart system that includes a tobacco use question, having received training on treating tobacco dependence, and having positive attitudes toward treating tobacco use. Providers who did not offer assistance but who reported that they would change their practice patterns if sufficiently reimbursed were more likely to be in a group practice, treat patients insured through Medicaid, and have positive attitudes toward treating tobacco dependence.
Findings indicate the potential benefit of increasing training opportunities and promoting system changes to increase involvement of dental providers in conducting tobacco use treatment. Reimbursement models should be tested to assess the effect on dental provider practice patterns.
Objective
To describe clinical features associated with cancer outcomes of patients with immune checkpoint inhibitor (ICI)‐associated arthritis.
Methods
Observational study of patients with ...ICI‐arthritis enrolled in a single‐center registry. Arthritis phenotype and activity, medications, and cancer status were recorded at every visit. We used descriptive statistic, and Kaplan‐Meier curves using two‐sided log‐rank test and Cox regression analysis were used to identify factors associated with cancer progression‐free survival (PFS).
Results
Forty‐two patients with ICI‐arthritis were followed for a median (interquartile range IQR) of 7.4 (1.7, 14.7) months. Fifty‐seven percent were female, 33% had melanoma, and 69% received anti–programmed death ligand 1 monotherapy. Median time from ICI initiation to arthritis onset was 2.8 (0.8, 11.2) months. Sixty‐two percent had a rheumatoid arthritis (RA)‐like small‐joint presentation; 27% of all patients were rheumatoid factor and/or cyclic citrullinated peptide positive. Median (IQR) Clinical Disease Activity Index (CDAI) on presentation was 15 (8, 24); 62% required systemic glucocorticoids, 55% required disease‐modifying antirheumatic drugs (DMARDs), and 69% had ongoing arthritis at 6 months. Arthritis led to ICI discontinuation in five patients. In univariate analysis, baseline CDAI, DMARD use, earlier arthritis onset, and longer duration of follow‐up were associated with shorter PFS. In multivariable Cox regression analysis controlling for DMARD use and time to arthritis onset, CDAI was a significant predictor of cancer progression (hazard ratio 1.09, 95% confidence interval CI 1.00‐1.19, P = 0.05)
Conclusion
ICI‐arthritis most commonly presents with an RA‐like phenotype. High disease activity, as measured by CDAI, may portend cancer progression.
We sought to identify features that distinguish osteoarthritis (OA) and rheumatoid arthritis (RA) hematoxylin and eosin (H&E)-stained synovial tissue samples.
We compared fourteen pathologist-scored ...histology features and computer vision-quantified cell density (147 OA and 60 RA patients) in H&E-stained synovial tissue samples from total knee replacement (TKR) explants. A random forest model was trained using disease state (OA vs RA) as a classifier and histology features and/or computer vision-quantified cell density as inputs.
Synovium from OA patients had increased mast cells and fibrosis (p < 0.001), while synovium from RA patients exhibited increased lymphocytic inflammation, lining hyperplasia, neutrophils, detritus, plasma cells, binucleate plasma cells, sub-lining giant cells, fibrin (all p < 0.001), Russell bodies (p = 0.019), and synovial lining giant cells (p = 0.003). Fourteen pathologist-scored features allowed for discrimination between OA and RA, producing a micro-averaged area under the receiver operating curve (micro-AUC) of 0.85±0.06. This discriminatory ability was comparable to that of computer vision cell density alone (micro-AUC = 0.87±0.04). Combining the pathologist scores with the cell density metric improved the discriminatory power of the model (micro-AUC = 0.92±0.06). The optimal cell density threshold to distinguish OA from RA synovium was 3400 cells/mm
, which yielded a sensitivity of 0.82 and specificity of 0.82.
H&E-stained images of TKR explant synovium can be correctly classified as OA or RA in 82% of samples. Cell density greater than 3400 cells/mm
and the presence of mast cells and fibrosis are the most important features for making this distinction.
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