1
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Kershaw C, Lurie JD, Brackett C, Loukas E, Smith K, Mullins S, Gooley C, Borrows M, Bardach S, Perry A, Carpenter-Song E, Landsman HS, Pierotti D, Bergeron E, McMahon E, Finn C. Improving care for individuals with serious infections who inject drugs. Ther Adv Infect Dis 2022; 9:20499361221142476. [PMID: 36600726 PMCID: PMC9806364 DOI: 10.1177/20499361221142476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 11/14/2022] [Indexed: 12/28/2022] Open
Abstract
Background Hospitalizations for serious infections requiring long-term intravenous (IV) antimicrobials related to injection drug use have risen sharply over the last decade. At our rural tertiary care center, opportunities for treatment of underlying substance use disorders were often missed during these hospital admissions. Once medically stable, home IV antimicrobial therapy has not traditionally been offered to this patient population due to theoretical concerns about misuse of long-term IV catheters, leading to discharges with suboptimal treatment regimens, lengthy hospital stays, or care that is incongruent with patient goals and preferences. Methods A multidisciplinary group of clinicians and patients set out to redesign and improve care for this patient population through a health care innovation process, with a focus on increasing the proportion of patients who may be discharged on home IV therapy. Baseline assessment of current experience was established through retrospective chart review and extensive stakeholder analysis. The innovation process was based in design thinking and facilitated by a health care delivery improvement incubator. Results The components of the resulting intervention included early identification of hospitalized people who inject drugs with serious infections, a proactive psychiatry consultation service for addiction management for all patients, a multidisciplinary care conference to support decision making around treatment options for infection and substance use, and care coordination/navigation in the outpatient setting with a substance use peer recovery coach and infectious disease nurse for patients discharged on home IV antimicrobials. Patients discharged on home IV therapy followed routine outpatient parenteral antimicrobial therapy (OPAT) protocols and treatment protocols for addiction with their chosen provider. Conclusion An intervention developed through a design-thinking-based health care redesign process improved patient-centered care for people with serious infections who inject drugs.
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Affiliation(s)
| | - Jon D Lurie
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA; Dartmouth College Geisel School of Medicine, Hanover, NH, USA,The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH,
USA
| | - Charles Brackett
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA,Dartmouth College Geisel School of Medicine,
Hanover, NH, USA
| | - Elias Loukas
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA,Dartmouth College Geisel School of Medicine,
Hanover, NH, USA
| | - Katie Smith
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA
| | - Sarah Mullins
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA
| | | | | | - Shoshana Bardach
- The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH,
USA
| | - Amanda Perry
- The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH,
USA
| | | | - H. Samuel Landsman
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA,Dartmouth College Geisel School of Medicine,
Hanover, NH, USA
| | - Danielle Pierotti
- Visiting Nurse and Hospice for Vermont and New
Hampshire, White River Junction, VT, USA,Christine Finn is also affiliated to Dartmouth
College Geisel School of Medicine, Hanover, NH, USA
| | - Ericka Bergeron
- Visiting Nurse and Hospice for Vermont and New
Hampshire, White River Junction, VT, USA,Christine Finn is also affiliated to Dartmouth
College Geisel School of Medicine, Hanover, NH, USA
| | - Erin McMahon
- Visiting Nurse and Hospice for Vermont and New
Hampshire, White River Junction, VT, USA,Christine Finn is also affiliated to Dartmouth
College Geisel School of Medicine, Hanover, NH, USA
| | - Christine Finn
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA,Dartmouth College Geisel School of Medicine,
Hanover, NH, USA
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2
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Zimmer AJ, Barsoumian AE, Hsu J, Walker J, Summers NA, Derber C, Allen BL, Ressner R, Kershaw C, Luther V. 2363. Clinician Educators within Infectious Diseases Society of America (IDSA): Who We Are, What We Do, and What We Need to Succeed. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
To best support, its membership, the IDSA Medical Education Community of Practice (Med Ed CoP) must know the spectrum of educational duties, common challenges, and needs among its clinician educators (CE). Further, benchmark data for medical education is lacking, including average time to perform duties, salary support, and other resources. Therefore, we conducted a survey to help identify opportunities for institutions and IDSA to support Infectious Disease (ID) CE.
Methods
We conducted an anonymous electronic mixed-methods survey of ID CE faculty in the United States. The survey link was distributed through the IDSA Med Ed CoP and Program Director discussion forums and receptions at IDWeek 2021.
Results
Approximately 90/552 (16%) participants completed a majority of the survey. Respondents were evenly distributed by gender and geographic region. A majority of respondents were Caucasian, aged 30 – 49 years, and at the Assistant or Associate Professor level (Table 1). Overall breakdown of allocated duties is as follows; median education full-time equivalent (FTE) was 0.25, clinical FTE=0.50, administrative FTE=0.16, and research FTE=0 (Table 1). Faculty most commonly taught medical students (95%), physician residents (92%), and fellows (88%) and held positions within ID fellowship programs (69%) and medical schools (50%, Table 2). CE's common challenges included competing responsibilities (69%), lack of medical education mentorship (51%), and inexperience in medical education publication (67%). In addition, 77% reported burnout in the past year, frequently due to an increased pandemic-related workload. CEs would like to see opportunities for IDSA grants, advocacy for salary support, and increased opportunities to publish within IDSA journals. CEs report finding reward in their educational work related to: teaching the next generation, developing relationships with learners and colleagues, and promoting others’ success.
Conclusion
In our study, ID CEs identified common challenges including educational work often requiring more time than allocated FTE, lack of mentors, publishing educational activities, recognition of CE work for promotion, and burnout. Additionally, ID CEs identified practical strategies in which their institutions and IDSA can offer support.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | | | | | | | - Nathan A Summers
- University of Tennessee Health Science Center , Memphis, Tennessee
| | | | | | - Roseanne Ressner
- Walter Reed National Military Medical Center , Bethesda, Maryland
| | | | - Vera Luther
- Wake Forest School of Medicine , Winston Salem, North Carolina
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3
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Thakarar K, Kohut MR, Stoddard H, Burris D, Sikka MK, Solomon DA, Kershaw C, Eaton E, Chessa F, Hutchinson R, Fairfield K, Friedmann P, Thomas J. 993. “ I feel like they’re actually listening to me”: A Pilot Study of Hospital Discharge-Decision Making for Patients with Injection Drug Use-Associated Infections. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Conversation guides have the potential to transform care for patients hospitalized with injection drug use (IDU)-associated infections. This study’s objectives were to 1) pilot a structured conversation guide for hospital discharge decision making in patients with IDU-associated infections 2) investigate the guide’s feasibility and acceptability and 3) examine patient and provider experiences, patient outcomes, and lessons learned.
Methods
We developed a conversation guide and conducted semi-structured interviews with physicians and patients at a tertiary care center in Maine. We interviewed physicians after each piloted the guide with two patients. We interviewed patients less than one week after the conversation and again after 4-6 weeks. Two analysts indexed transcriptions and used the framework method to identify and organize relevant information. We conducted retrospective chart review to corroborate and contextualize qualitative data.
Results
Eight patients and four infectious disease physicians piloted the conversation guide. All patients (N=8) completed antimicrobial treatment and 88% were discharged on medication for opioid use disorder (Table 1). All providers and most patients stated that the conversation guide was important for incorporating patient preferences and antimicrobial treatment options. Patients appreciated more autonomy and their voices being included in their care. Providers felt the guide facilitated their understanding of patient values. Values and preferences between patients and providers were aligned. Participants identified the length of the guide, discussion of pain management, and addressing post-discharge needs such as housing as areas for improvement (Table 2).
Conclusion
The use of a conversation guide to inform hospital discharge decision making for patients with IDU-associated infections incorporates patient preferences and values into treatment decisions. While we identified areas for improvement, overall patients and providers believed that this novel conversation guide helped to improve patient care and autonomy.
Disclosures
Kinna Thakarar, DO, MPH, Maine Medical Center: Board Member|NIH: Grant/Research Support|University of New England: Board Member Monica K. Sikka, MD, F2G: Site research investigator Ellen Eaton, MD, MSPH, Gilead: Grant/Research Support.
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Affiliation(s)
- Kinna Thakarar
- Maine Medical Center/Tufts University School of Medicine , South Portland, Maine
| | | | - Henry Stoddard
- Maine Medical Center Research Institute , Portland, Maine
| | | | | | - Daniel A Solomon
- Brigham and Women's Hospital / Harvard Medical School , Boston, MA
| | | | - Ellen Eaton
- University of Alabama at Birmingham , Birmingham, Alabama
| | | | | | | | | | - J Thomas
- Tufts University School of Medicine , Boston, Massachusetts
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4
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Melrose R, Kershaw C, Jones E. 672 ASSESSMENT OF THERAPEUTIC RESPONSE TO MELATONIN IN PARKINSON’S DISEASE PATIENTS WITH SLEEP DISORDERS, A QI PROJECT. Age Ageing 2022. [DOI: 10.1093/ageing/afac034.672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Holistic care of patients with Parkinson’s Disease (PD) addresses motor and non-motor features. With prevalence of around two-thirds of patients, sleep disorders; including REM Sleep behaviour Disorder (RBD); can have significant negative impact on quality of life. The naturally occurring neuro-hormone, melatonin plays a role in circadian rhythm; a process disrupted in PD. In 2017, NICE suggested to ‘consider clonazepam or melatonin to treat RBD.’ Melatonin has a more favourable side effect profile than clonazepam. This QI project qualitatively evaluates a geographical subset of PD patients treated with melatonin, assessing the clinical effect of treatment and whether this medication is being used optimally. PDSA methodology identified potential for introducing a sleep scale to allow more Objective future assessment.
Methods
A departmental database identified all current and deceased patients treated with melatonin since 2015. The electronic patient record of a total of 26 patients were reviewed. Data on indication, dosing, response (subjectively categorised as no effect, mild, moderate, or good impact) alongside demographics were collected.
Results
Analysis revealed poor sleep as the most common indication for melatonin. Melatonin was well tolerated with no reported side effects. Results showed benefit in 95% of patients with an initial dose of 2 mg. Dosing was reviewed in 81% of patients at next clinic appointment. For those patients who did not have ‘good’ effect dose was increased in 62% of patients.
Conclusion
The subjective nature of sleep assessment makes assessing therapeutic benefit challenging however data suggests melatonin does improve sleep, a finding consistent with current limited research. Implementation of a sleep scale questionnaire for patients commencing melatonin will allow Objective analysis by the multidisciplinary team of medication effect and aid dose titration. Ongoing review is required to assess effect due to the infrequency of included patients and protracted therapeutic response period.
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AlSalman A, Worby CP, Considine E, Zijoo R, Kershaw C. 599. Dalbavancin Utilization in Rural Healthcare Setting: A Single Center Three Years’ Experience. Open Forum Infect Dis 2020. [PMCID: PMC7777039 DOI: 10.1093/ofid/ofaa439.793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Dalbavancin is a second generation lipoglycopeptide, approved by the Food and Drug Administration (FDA) for treatment of acute bacterial skin and skin structure infections (ABSSSI). The weekly dosing of Dalbavancin has encouraged its off-label use to treat other severe infections, especially in patients deemed to be poor candidates for intravenous antimicrobial therapy through a long-term intravenous catheter. Methods Single center retrospective chart review of 33 patients who were planned to receive Dalbavancin between March 2015 and March 2019 at a rural medical center in New Hampshire. We reviewed demographics, indications, microbiological, intravenous drug use status and compliance data. Results Dalbavancin therapy was planned for 25/33 patients (75.75%) specifically due to safety concerns around use of a peripherally inserted central catheter (PICC) in Persons Who Inject Drugs (PWID). All 25 patients (75.75%) were actively injecting at the time of the infection with 16/33 patients (48.48%) receiving or newly enrolled in medication assisted treatment. The planned duration of therapy was not completed in 15/33 patients (45.45%) and all were PWID. 11/33 patients (33.3%) were lost to follow up. Additionally, 6 patients experienced insurance coverage issues or difficulty having peripheral access placed. The average driving distance between home and infusion suite was 47 miles. Methicillin Resistant Staphylococcus aureus (19/33) and Methicillin Susceptible Staphylococcus aureus (8/33) were the most commonly treated organisms and the average pathogen-directed therapy duration prior to starting Dalbavancin was 15 days. Conclusion Despite recent data suggesting that Dalbavancin therapy for PWID has good compliance rates in urban settings, our experience suggests that the same principle might not be true in rural settings as the non-compliance and loss to follow up rates were very high. Disclosures All Authors: No reported disclosures
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Affiliation(s)
- Ahmad AlSalman
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Craig P Worby
- Mary Hitchcock Memoral Hospital, Lebanon, New Hampshire
| | | | - Ritika Zijoo
- Dartmouth hitchcock Medical Center, Canaan, New Hampshire
| | - Colleen Kershaw
- Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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6
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Kershaw C, Williams M, Kilaru S, Zash R, Kalenga K, Masole F, Shapiro R, Barak T. Audit of Early Mortality among Patients Admitted to the General Medical Ward at a District Hospital in Botswana. Ann Glob Health 2019; 85:22. [PMID: 30873803 PMCID: PMC6997521 DOI: 10.5334/aogh.1354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Mortality among adult general medical admissions has been reported to be high across sub-Saharan Africa, yet there is a paucity of literature on causes of general medical inpatient mortality and quality-related factors that may contribute to the high incidence of deaths. Based on a prior study at our hospital as well as our clinical experience, death early in the hospitalization is common among patients admitted to the adult medical wards. OBJECTIVE Quantify early inpatient mortality and identify factors contributing to early in-hospital mortality of medical patients in a resource-limited hospital setting in Botswana. METHODS Twenty-seven cases of patients who died within 48 hours of admission to the general medical wards at Scottish Livingstone Hospital in Molepolole, Botswana from December 1, 2015-April 25, 2016 were retrospectively reviewed through a modified root cause analysis. FINDINGS Early in-hospital mortality was most frequently attributed to septic shock, identified in 20 (74%) of 27 cases. The most common care management problems were delay in administration of antibiotics (15, 56%), inappropriate fluid management (15, 56%), and deficient coordination of care (15, 56%). The most common contributing factors were inadequate provider knowledge and skills in 25 cases (93%), high complexity of presenting condition in 20 (74%), and inadequate communication between team members in 18 (67%). CONCLUSIONS Poor patient outcomes in low-and middle-income countries like Botswana are often attributed to resource limitations. Our findings suggest that while early in-hospital mortality in such settings is associated with severe presenting conditions like septic shock, primary contributors to lack of better outcomes may be healthcare-provider and system-factors rather than lack of diagnostic and therapeutic resources. Low-cost interventions to improve knowledge, skills and communication through a focus on provider education and process improvement may provide the key to reducing early in-hospital mortality and improving hospitalization outcomes in this setting.
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Affiliation(s)
- Colleen Kershaw
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, US
- Botswana-Harvard AIDS Institute Partnership, Gaborone, BW
| | - Margaret Williams
- The Ohio State University Wexner Medical Center, Columbus, OH, US
- Botswana-Harvard AIDS Institute Partnership, Gaborone, BW
| | - Saikiran Kilaru
- New York University School of Medicine, NY, US
- Botswana-Harvard AIDS Institute Partnership, Gaborone, BW
| | - Rebecca Zash
- Beth Israel Deaconess Medical Center, Boston, MA, US
- Botswana-Harvard AIDS Institute Partnership, Gaborone, BW
| | | | | | - Roger Shapiro
- Beth Israel Deaconess Medical Center, Boston, MA, US
- Harvard T.H. Chan School of Public Health, Boston, MA, US
- Botswana-Harvard AIDS Institute Partnership, Gaborone, BW
| | - Tomer Barak
- Beth Israel Deaconess Medical Center, Boston, MA, US
- Botswana-Harvard AIDS Institute Partnership, Gaborone, BW
- Scottish Livingstone Hospital, Molepolole, BW
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7
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Kershaw C, Stead W, Rowley CF. 1327. Educational Intervention to Improve Communication With Patients Who Have Opioid Use Disorder. Open Forum Infect Dis 2018. [PMCID: PMC6253198 DOI: 10.1093/ofid/ofy210.1160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Infectious complications of opioid use disorder (OUD) have increased significantly in the last decade. Patients with OUD encounter stigma from healthcare providers, and providers find interactions with patients with OUD to be very challenging. At our teaching institution, anecdotal experience and objective data suggested clinician discomfort with communicating with OUD patients, as well as a “hidden curriculum” of stigma and bias around care of this group. We attempted to characterize this problematic learning environment and created an intervention focusing on reduction of bias and stigma and improved communication with OUD patients. Methods General internal medicine faculty and residents completed a preintervention survey to measure knowledge and attitudes about OUD, as well the institutional learning environment related to this issue. A workshop on communication, bias, and stigma in OUD was then administered to 78 faculty and residents. Immediately after participation, they completed a postintervention survey assessing concepts addressed in the session. Results The preintervention survey of 99 faculty and residents showed that 47% felt patients with OUD were difficult to work with. Faculty were more likely than residents to agree there was a negative hidden curriculum around OUD (70% vs. 43%, P < 0.001). This included witnessing other physicians using stigmatizing language (80%), minimizing time with OUD patients (49%), and choosing not to involve medical students with OUD patients (34%). Fifty participants completed the postsurvey. Respondents identified a mean of 86% of stigmatizing words within patient scenarios, which improved from 60% before the intervention (P < 0.0001). Conclusion Clinicians reported negative attitudes and difficulty caring for patients with OUD. The majority identified a negative hidden curriculum around this disease, including stigmatizing language and avoidance of engagement with OUD patients. A workshop on communication, stigma, and bias improved scores on knowledge of stigmatizing language. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Colleen Kershaw
- Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Wendy Stead
- Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher F Rowley
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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8
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Porter LB, Kozakewich E, Clouser R, Kershaw C, Hale AJ. Occam's razor need not apply: Advanced HIV infection presenting with five simultaneous opportunistic infections and central nervous system lymphoma. IDCases 2018; 13:e00437. [PMID: 30128292 PMCID: PMC6097275 DOI: 10.1016/j.idcr.2018.e00437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/06/2018] [Accepted: 08/06/2018] [Indexed: 12/12/2022] Open
Abstract
Patients with Human Immunodeficiency Virus (HIV) infection and Acquired Immunodeficiency Syndrome (AIDS) are at risk for multiple infectious and oncologic complications. In such cases, Occam's razor need not apply: multiple infections and malignancies are often present concurrently upon presentation to care. A patient off anti-retroviral therapy (ART) for several years developed advanced HIV infection (CD4 count 19 cells/uL) and presented with five simultaneous opportunistic infections including Pneumocystis jiroveci pneumonia (PJP), cytomegalovirus (CMV) retinitis, Mycobacterium avium complex (MAC) bloodstream infection, chronic hepatitis B virus (HBV), and Epstein-Barr virus (EBV) viremia. Simultaneously, he was found to have primary central nervous system (CNS) B-cell lymphoma. Treatment decisions for such patients are often complex, as ideal therapy for one disease may directly counter or interact with therapy for another. For instance, methotrexate for primary CNS lymphoma and trimethoprim/sulfamethoxazole for PJP is a strictly contraindicated medication combination. It is important to understand not just the management of any single opportunistic disease in patients with advanced HIV, but how to balance management for patients with a variety of concurrent processes. In an era when HIV care is becoming increasingly simplified, patients presenting with advanced infection highlight the lack of data on how best to manage patients with multiple concurrent disease processes. Significant further research is needed to clarify ideal comparative therapy.
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Affiliation(s)
| | | | - Ryan Clouser
- The University of Vermont Medical Center, Larner College of Medicine at the University of Vermont, Burlington, VT, United States
| | - Colleen Kershaw
- Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Andrew J. Hale
- The University of Vermont Medical Center, Larner College of Medicine at the University of Vermont, Burlington, VT, United States
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9
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Kershaw C, Taylor JL, Horowitz G, Brockmeyer D, Libman H, Kriegel G, Ngo L. Use of an electronic medical record reminder improves HIV screening. BMC Health Serv Res 2018; 18:14. [PMID: 29316919 PMCID: PMC5761195 DOI: 10.1186/s12913-017-2824-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 12/28/2017] [Indexed: 11/10/2022] Open
Abstract
Background More than 1 in 7 patients with human immunodeficiency virus (HIV) infection in the United States are unaware of their serostatus despite recommendations of US agencies that all adults through age 65 be screened for HIV at least once. To facilitate universal screening, an electronic medical record (EMR) reminder was created for our primary care practice. Screening rates before and after implementation were assessed to determine the impact of the reminder on screening rates. Methods A retrospective cohort analysis was performed for patients age 18–65 with visits between January 1, 2012-October 30, 2014. EMR databases were examined for HIV testing and selected patient characteristics. We evaluated the probability of HIV screening in unscreened patients before and after the reminder and used a multivariable generalized linear model to test the association between likelihood of HIV testing and specific patient characteristics. Results Prior to the reminder, the probability of receiving an HIV test for previously unscreened patients was 15.3%. This increased to 30.7% after the reminder (RR 2.02, CI 1.95–2.09, p < 0.0001). The impact was most significant in patients age 45–65. White race, English as primary language, and higher median household income were associated with lower likelihoods of screening both before and after implementation (RR 0.68, CI 0.65–0.72; RR 0.74, CI 0.67–0.82; RR 0.84, CI 0.80–0.88, respectively). Conclusions The EMR reminder increased rates of HIV screening twofold in our practice. It was most effective in increasing screening rates in older patients. Patients who were white, English-speaking, and had higher incomes were less likely to be screened for HIV both before and after the reminder.
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Affiliation(s)
- Colleen Kershaw
- Department of Medicine, Beth Israel Deaconess Medical Center, 110 Francis Street, Suite GB, Boston, MA, 02215, USA.
| | - Jessica L Taylor
- Department of Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown 2, Boston, MA, 02118, USA
| | - Gary Horowitz
- Department of Pathology, Tufts Medical Center, Biewend Building 3, 800 Washington St, Boston, MA, 02111, USA
| | - Diane Brockmeyer
- Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Howard Libman
- Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Gila Kriegel
- Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Long Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
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Kershaw C, Williams M, Kilaru S, Barak T. ISQUA17-3128ASSESSMENT OF EARLY MORTALITY IN PATIENTS ADMITTED TO THE GENERAL MEDICAL WARD AT A DISTRICT HOSPITAL IN BOTSWANA. Int J Qual Health Care 2017. [DOI: 10.1093/intqhc/mzx125.35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Dias J, Kershaw C, Raymakers R, Power R. Thomas Frederick Stoyle. West J Med 2010. [DOI: 10.1136/bmj.c4129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hewamadduma CAA, Kirby J, Kershaw C, Martindale J, Dalton A, McDermott CJ, Shaw PJ. HSP60 is a rare cause of hereditary spastic paraparesis, but may act as a genetic modifier. Neurology 2008; 70:1717-8. [PMID: 18458233 DOI: 10.1212/01.wnl.0000311395.31081.70] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- C A A Hewamadduma
- Academic Neurology Unit, Medical School, Beech Hill Road, University of Sheffield, S10 2RX, UK.
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13
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Affiliation(s)
- J Kirby
- Academic Neurology Unit, University of Sheffield, School of Medicine and Biomedical Sciences, Sheffield, UK.
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14
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Kershaw C, Pelaez A, Guidot DM. 415 GRANULOCYTE-MACROPHAGE COLONY-STIMULATING FACTOR TREATMENT DECREASES SEPSIS-MEDIATED ACUTE LUNG INJURY IN ETHANOL-FED RATS. J Investig Med 2005. [DOI: 10.2310/6650.2005.00006.414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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15
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Lumb R, Davies K, Dawson D, Gibb R, Gottlieb T, Kershaw C, Kociuba K, Nimmo G, Sangster N, Worthington M, Bastian I. Multicenter evaluation of the Abbott LCx Mycobacterium tuberculosis ligase chain reaction assay. J Clin Microbiol 1999; 37:3102-7. [PMID: 10488161 PMCID: PMC85503 DOI: 10.1128/jcm.37.10.3102-3107.1999] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Four Australian hospital laboratories evaluated the performance of the Abbott LCx Mycobacterium tuberculosis assay with 2,347 specimens (2,083 respiratory and 264 nonrespiratory specimens) obtained from 1, 411 patients. A total of 152 specimens (6.5%) were culture positive for Mycobacterium tuberculosis complex (MTBC); of these, 79 (52%) were smear positive. After resolution of discrepant data, the overall sensitivity, specificity, and positive and negative predictive values for the LCx assay were 69.7, 99.9, 99.1, and 97.7% respectively. For smear-positive respiratory specimens that were culture positive for MTBC, the values were 98.5, 100, 100, and 98.4%, respectively, while the values for smear-negative respiratory specimens were 41.5, 99.9, 96.4, and 98%, respectively. Relative operating characteristic curves were constructed to demonstrate the relationship between sensitivity and specificity for a range of possible cutoff values in the LCx assay. These graphs suggested that the assay sensitivity for respiratory samples could be increased from 70.2 to 78.6%, while the specificity would be reduced from 99.9 to 99.4% by inclusion of a grey zone (i.e., LCx assay values of between 0.2 and 0.99). An algorithm is presented for the handling of specimens with LCx assay values within this grey zone.
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Affiliation(s)
- R Lumb
- Infectious Diseases Laboratories, Institute of Medical and Veterinary Science, Adelaide, South Australia, Australia.
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16
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Fordice J, Kershaw C, El-Naggar A, Goepfert H. Adenoid cystic carcinoma of the head and neck: predictors of morbidity and mortality. Arch Otolaryngol Head Neck Surg 1999; 125:149-52. [PMID: 10037280 DOI: 10.1001/archotol.125.2.149] [Citation(s) in RCA: 279] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To review 160 patients treated at a single institution for adenoid cystic carcinoma during the 20 years between 1977 and 1996, applying a consistent treatment of surgery and postoperative radiation therapy to 140 patients. To analyze factors governing treatment failure, treatment-related morbidity, and mortality. DESIGN Retrospective review. SETTING Tertiary referral center. PATIENTS Seventy-seven males and 83 females aged 13 to 89 years (average age, 49.5 years). RESULTS AND CONCLUSIONS Combined treatment yielded an 85% locoregional freedom from relapse and disease-specific survival at 5, 10, and 15 years was 89%, 67.4%, and 39.6%, respectively. Thirty-five patients (21.9%) had distant metastases as the only site of failure. Patients treated for paranasal sinus tumor experienced the most treatment-related morbidity vs other sites. Perineural invasion of major nerves, positive margins at surgery, and solid histological features were associated with increased treatment failures. Four or more symptoms present at diagnosis, positive lymph nodes, solid histology, and perineural invasion of major nerves were associated with increased mortality from disease.
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Affiliation(s)
- J Fordice
- Department of Head and Neck Surgery, University of Texas M.D. Anderson Cancer Center, Houston 77030-4662, USA
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Abstract
Accurate information is important for the successful implementation of the Resource Management Initiative and the NHS White Paper. A review of 153 joint replacements performed in a three-month period in Leicester showed that 24 per cent of 139 procedures for which medical notes were available had been given incorrect Diagnosis-Related Groupings (DRGs). Of these, 64 per cent could be ascribed to errors in allocating OPCS-3 codes and 36 per cent to errors in converting OPCS-3 codes to DRGs by computer. It is of concern that inaccurate information may in future be used to allocate resources. The resource implications of assiduous quality control of recording, coding and computing is pointed out, and it is suggested that improved classification systems should be assessed for use in the NHS.
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Affiliation(s)
- S H Smith
- University of Leicester, Department of Community Health
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