Systemic Delays in the Initiation of Antiretroviral Therapy for Clinically Eligible HIV-Infected Patients in Houston, Texas: The Providers' Report Card

Background:

The current US HIV treatment guidelines support initiation of antiretroviral therapy (ART) for persons with HIV for personal health benefits and prevention of HIV transmission. However, high levels of adherence to ART are critical to maximize individual and public health benefits. We examined the nonclinical barriers to ART initiation for clinically eligible individuals and the provider- and patient-related factors associated with these barriers among HIV-infected patients in Houston/Harris County, Texas.

Methods:

We analyzed data obtained from a probability sample of HIV medical care providers (HMCPs) in 13 outpatient facilities in Houston/Harris County, Texas surveyed between June and September 2009. We used an inductive thematic approach to code HMCP responses to an open-ended question that asked the main reasons why providers may delay initiating ART for clinically eligible patients.

Results:

The reasons cited by providers for delaying ART for clinically eligible patients were adherence (42.5%; 95% confidence interval [CI]: 28.5-57.8), acceptance (30%; 95% CI: 18.1-45.4), and structural concerns (27.5%; 95% CI: 16.1-42.8), with significant variations (P < .0001) noted across patients’ race/ethnicity and transmission category. HIV medical care providers with 6 to 10 years’ experience in HIV care and those providing medical care for more than 100 patients monthly were about 4 times (adjusted odds ratio [aOR]: 3.80; 95% CI: 1.20-5.92; P = .039) and 10 times (aOR: 10.36; 95% CI: 1.42-22.70; P = .019) more likely to state adherence and acceptance concerns, respectively, as reasons for delaying ART for clinically eligible patients.

Conclusion:

Our findings highlight the fact that clinical guidelines are only a starting point for medical decision-making process and that patients themselves play an important role. HMCP access to referrals for other medical issues, support services, and treatment education may help improve adherence and patient readiness for ART, thereby avoiding systemic delays.

Epidemic Clostridioides difficile Ribotype 027 Lineages: Comparisons of Texas Versus Worldwide Strains

Background

The epidemic Clostridioides difficile ribotype 027 strain resulted from the dissemination of 2 separate fluoroquinolone-resistant lineages: FQR1 and FQR2. Both lineages were reported to originate in North America; however, confirmatory large-scale investigations of C difficile ribotype 027 epidemiology using whole genome sequencing has not been undertaken in the United States.

Methods

Whole genome sequencing and single-nucleotide polymorphism (SNP) analysis was performed on 76 clinical ribotype 027 isolates obtained from hospitalized patients in Texas with C difficile infection and compared with 32 previously sequenced worldwide strains. Maximum-likelihood phylogeny based on a set of core genome SNPs was used to construct phylogenetic trees investigating strain macro- and microevolution. Bayesian phylogenetic and phylogeographic analyses were used to incorporate temporal and geographic variables with the SNP strain analysis.

Results

Whole genome sequence analysis identified 2841 SNPs including 900 nonsynonymous mutations, 1404 synonymous substitutions, and 537 intergenic changes. Phylogenetic analysis separated the strains into 2 prominent groups, which grossly differed by 28 SNPs: the FQR1 and FQR2 lineages. Five isolates were identified as pre-epidemic strains. Phylogeny demonstrated unique clustering and resistance genes in Texas strains indicating that spatiotemporal bias has defined the microevolution of ribotype 027 genetics.

Conclusions

Clostridioides difficile ribotype 027 lineages emerged earlier than previously reported, coinciding with increased use of fluoroquinolones. Both FQR1 and FQR2 ribotype 027 epidemic lineages are present in Texas, but they have evolved geographically to represent region-specific public health threats.

Managing the Personal Side of Health Care among Patients with HIV/AIDS

The study describes the HIV care providers' sociodemographic and medical practice characteristics and the health care services offered to patients during medical care encounters in Houston/Harris County, Texas. We used data from the pilot cycle of the Centers for Disease Control and Prevention Medical Monitoring Project Provider Survey conducted in June to September 2009. The average age and HIV care experience of the providers were 46.7 and 11.7 years, respectively, and they provided care to an average of 113 patients monthly. The average proportion of HIV-infected patients seen per month by race/ethnicity was 43.3% for blacks, 28.5% for whites, 26.6% for Hispanics, 1.3% for Asians, and 0.6% for other races. A total of 67% of providers offered HIV testing to all patients 13 to 64 years of age. Most HIV care providers (73.9%) reported that patients in their practices sought HIV care only after experiencing symptoms. Understanding the HIV care delivery system from providers' perspectives may help enhance support services, patients' ongoing care and retention, leading to improved health outcomes.

Frequency and Determinants of Preventive Care Counseling by HIV Medical Care Providers during Encounters with Newly Diagnosed and Established HIV-Infected Patients

This study evaluates the frequency and determinants of preventive care counseling by HIV medical care providers (HMCPs) during encounters with newly diagnosed and established HIV-infected patients. Data used were from a probability sample of HMCPs in Houston/Harris County, Texas, surveyed in 2009. Overall, HMCPs offered more preventive care counseling to newly diagnosed than the established patients (adjusted odds ratio [AOR] = 7.28; 95% confidence interval [CI] = 2.86-16.80). They were more likely to counsel newly diagnosed patients than the established ones on medication and adherence (AOR = 14.70; 95% CI = 1.24-24.94), HIV risk reduction (AOR = 5.91; 95% CI = 0.48-7.13), and disease screening (AOR = 7.20; 95% CI = 0.72-11.81). HIV medical care providers who were less than 45 years of age, infectious disease specialists, and had less than 30 minutes of encounter time were less likely to counsel patients regardless of the status. Our findings suggest the need for HMCPs to improve their preventive care counseling efforts, in order to help patients build skills for adopting and maintaining safe behavior that could assist in reducing the risk of HIV transmission.

Assessment of Antimicrobial Stewardship Activities in a Large Metropolitan Area

PURPOSE

To describe antimicrobial stewardship programs (ASPs) of acute and long-term acute care (LTAC) hospitals in Houston, Texas.

METHODS

Two-part survey to clinical pharmacists and pharmacy directors. All acute care and LTAC facilities from the Harris County Medical Society database were invited to participate.

RESULTS

In part 1 of the telephone survey, 82 facilities within Houston, Harris county, were contacted by telephone of which 51 responded (response rate: 62%). Of respondents, 55% (n = 28) reported having an active ASP and 8% (n = 4) planned implementation within 12 months. Acute care and LTAC hospitals reported ASPs in 57% and 67% of facilities, respectively. Physician champions were involved in 71% (n = 20) of active ASPs; clinical pharmacists were involved in 75% (n = 21) of programs. In part II, 22 (43%) facilities completed the online survey; postprescription review with feedback was used in facilities with an ASP and medical training program (5 of 5) while formulary restriction was in facilities without stewardship or medical training (6 of 8).

CONCLUSION

This is the first major survey of ASP in a major metropolitan area. The stewardship effort in the city of Houston is encouraging; we expect the number of stewardship programs in all facilities will continue to rise as focus on antimicrobial resistance grows.

System and Patient Barriers to Care among People Living with HIV/AIDS in Houston/Harris County, Texas: HIV Medical Care Providers' Perspectives

In the United States, a considerable number of people diagnosed with HIV are not receiving HIV medical care due to some barriers. Using data from the Medical Monitoring Project survey of HIV medical care providers in Houston/Harris County, Texas, we assessed the HIV medical care providers' perspectives of the system and patient barriers to HIV care experienced by people living with HIV/AIDS (PLWHA). The study findings indicate that of the 14 HIV care barriers identified, only 1 system barrier and 7 patient barriers were considered of significant (P ≤ .05) importance, with the proportion of HIV medical care providers' agreement to these barriers ranging from 73.9% (cost of health care) to 100% (lack of social support systems and drug abuse problems). Providers' perception of important system and patient barriers varied significantly (P ≤ .05) by profession, race/ethnicity, and years of experience in HIV care. To improve access to and for consistent engagement in HIV care, effective intervention programs are needed to address the barriers identified especially in the context of the new health care delivery system.

Identification of dengue fever cases in Houston, Texas, with evidence of autochthonous transmission between 2003 and 2005

Houston, Texas, maintains an environment conducive to dengue virus (DENV) emergence; however, surveillance is passive and diagnostic testing is not readily available. To determine if DENV is present in the area, we tested 3768 clinical specimens (2138 cerebrospinal fluid [CSF] and 1630 serum) collected from patients with suspected mosquito-borne viral disease between 2003 and 2005. We identified 47 immunoglobulin M (IgM)-positive dengue cases, including two cases that were positive for viral RNA in serum for dengue serotype 2. The majority of cases did not report any history of travel outside the Houston area prior to symptom onset. The epidemic curve suggests an outbreak occurred in 2003 with continued low-level transmission in 2004 and 2005. Chart abstractions were completed for 42 of the 47 cases; 57% were diagnosed with meningitis and/or encephalitis, and 43% met the case definition for dengue fever. Two of the 47 cases were fatal, including one with illness compatible with dengue shock syndrome. Our results support local transmission of DENV during the study period. These findings heighten the need for dengue surveillance in the southern United States.

Determinants of fruits and vegetables consumption among persons with doctor-diagnosed chronic diseases

OBJECTIVE

The objective of this study was to examine the factors associated with fruits and vegetables consumption pattern among persons with doctor-diagnosed chronic diseases.

METHOD

The authors examined cross-sectional, random-digit-dialed health survey data collected in 2008 in Houston, Texas, a city with a diverse ethnic population. The survey sample, which was designed to represent all households with telephones, was drawn using standard list-assisted random-digit-dialing methodology from telephone exchanges that serve the study area. A total of 1001 households were interviewed, and data obtained were subjected to both bivariate and multivariate analyses.

RESULTS

Findings from this study indicate that fruits and vegetables consumption for persons with single chronic disease was significantly predicted (R (2) = 0.83) by the participants' age, educational level, and insurance status. None of the covariates considered in the study were significant predictors of fruits and vegetables consumption pattern among persons who had multiple chronic diseases. But when the subpopulation with any number of chronic diseases was considered, only gender (P < .05) and marital status (P < .001) were noted as the significant predictors of fruits and vegetables (R (2) = 0.34).

CONCLUSION

More public health efforts are needed to make individuals with chronic diseases aware of the importance of consumption of fruits and vegetables. Clinicians and health care professionals should be encouraged to emphasize the importance of consumption of fruits and vegetables in their routine practice to the patients with chronic disease(s), especially to those who are unmarried and male.

Risk factors for encephalitis from West Nile Virus: a matched case-control study using hospitalized controls

We conducted a case-control study to determine risk factors for developing encephalitis among West Nile virus cases when compared with age-, gender and race/ethnicity-matched hospitalized controls. In the multivariable conditional logistic regression analysis, we identified the following independent risk factors associated with being an encephalitis case: hypertension (OR 4.0; P = 0.005), immunosuppressing conditions (OR 5.6; P = 0.001) and cardiovascular disease (OR = 28.3; P < 0.001). Individuals with these comorbidities should be targeted for education on protecting themselves from mosquito exposures.

Occupational burnout levels in emergency medicine--a stage 2 nationwide study and analysis

INTRODUCTION

The first stage of this nationwide study and analysis of the occupational burnout and psychological risk parameters showed a high consistency of emotional exhaustion, depersonalization and low personal accomplishment for doctors working in Emergency Departments and Emergency and Resuscitation Services. These workers were then set in the highest risk group for burnout syndrome and depression. This stage II of our research will focus on those two groups analyzing causal factors, coping mechanisms and possible repercussions of these findings.

MATERIAL AND METHODS

DEMOGRAPHICS

We have issued a total of 272 surveys from which we have received a total of 263 complete and valid ones (n = 263, response rate = 96, 69%).

INSTRUMENTS

The Maslach Burnout Inventory--Human Services Survey MBI-HSS is an instrument designed to assess the three components of the burnout syndrome: emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA). The COPE questionnaire is a 52 item addressing different ways of coping with stress. The Center for Epidemiologic Studies Depression Scale (CES-D) has been shown to be a reliable measure in assessing the number, types, and duration of depressive symptoms across racial, gender, and age categories.

RESULTS AND DISCUSSION

Results were not correlated with gender, age or marital status, but an important correlation was found with professional experience in the Emergency Departments. We have shown that during the first 4 years of experience, the EE factor has been at a satisfying average of 2.4, this variable rising to an average of 2.85 after another 3 years of work. The same type of correlation was found with the CES-D results.

CONCLUSIONS

Of the two surveyed groups, the EMD group showed higher values for all risk parameters and low personal accomplishment on the MBI-HSS survey. Also, emotional exhaustion and depression were found to have a powerful correlation with work experience. Coping mechanisms were found to be invariable to the general population, with a slight incline towards active coping and behavioral disengagement.

Occupational burnout levels in emergency medicine--a nationwide study and analysis

INTRODUCTION

The specificity of the emergency medical act strongly manifests itself on account of a wide series of psycho-traumatizing factors augmented both by the vulnerable situation of the patient and the paroxysmal state of the act. Also, it has been recognized that the physical solicitation and distress levels are the highest among all medical specialties, this being a valuable marker for establishing the quality of the medical act.

MATERIAL AND METHODS

We have surveyed a total of 4725 emergency medical workers with the MBI-HSS instrument, receiving 4693 valid surveys (99.32% response rate). Professional categories included Emergency Department doctors (M-EMD), ambulance doctors (M-AMB), ED doctors with field work in emergency and resuscitation (including mobile intensive care units and airborne intensive care units) (D-SMU), medical nurses in Emergency Departments (N-EMD), medical nurses in the ambulance service (N-AMB), ED medical nurses with field activity in emergency and resuscitation (N-SMU), ambulance drivers (DRV) and paramedic (EMT). The n values for every category of subjects and percentage of system coverage (table 3) shows that we have covered an estimated total of 29.94% of the Romanian emergency medical field workers.

RESULTS

MBI-HSS results show a moderate to high level of occupational stress for the surveyed subjects. The average values for the three parameters, corresponding to the entire Romanian emergency medical field were 1.41 for EE, 0.99 for DP and 4.47 for PA (95% CI). Average results stratified by professional category show higher EE average values (v) for the M-SMU (v=2.01, 95%CI) and M-EMD (v=2.21, 95% CI) groups corresponding to higher DP values for the same groups (vM-EMD=1.41 and vM-SMU=1.22, 95% CI). PA values for these groups are below average, corresponding to an increased risk factor for high degrees of burnout. Calculated PA values are 4.30 for the M-EMD group and 4.20 for the M-SMU group.

CONCLUSIONS

Of all surveyed groups, our study shows a high risk of burnout consisting of high emotional exhaustion (EE) and high depersonalization (DP) values for Emergency Department doctors, Emergency, and Resuscitation Service doctors (M-SMU). Possible explanations for this might be linked to high patient flow, Emergency Department crowding, long work hours and individual parameters such as coping mechanisms, social development and work environment.

Social and mental health needs assessment of Katrina evacuees

Hurricane Katrina made landfall along the Gulf Coast as a Category 3 storm on August 29, 2005. Many residents were evacuated to neighboring cities owing to massive destruction. Working with the City of Houston Health Department, researchers conducted a medical and psychological needs assessment of 124 Hurricane Katrina evacuees in Houston shelters from September 4-12, 2005. Among those willing to talk about their experiences, 41% were afraid they would die, 16% saw someone close to them injured or die, 17% saw violence, and 6% directly experienced physical violence. When using a version of the Impact of Stress Experiences scale, the majority of evacuees scored as experiencing moderate (38.6%) to severe (23.9%) post-traumatic stress disorder (PTSD) symptoms. These data suggest that in addition to challenges in finding loved ones, housing, and jobs, many Katrina survivors have experienced significant psychological trauma that may lead to future PTSD.

Synthesis of a new series of heterocyclic scaffolds for medicinal purposes

A new series of substituted 8-fluro-4H-pyrimido[2,1-b] [1,3]benzothiazole-4-ones () substituted 7-methyl-4H-isoxazolo[2,3-a]pyrimidin-4-ones, and substituted 2-methyl-5,6,7,8-tetrahydro-9H-isoxazolo[2,3-a]pyridopyrimidin-9-ones, compounds I-VII, have been prepared via condensation of beta-keto esters with 2-aminopyridine derivatives, in the presence of polyphosphoric acid. The same technique has also been used to prepare diazepine compounds, VIII-X, by condensation of a gamma-keto ester with 2-aminopyridine derivatives. Details of synthetic procedures are shown. The new compounds have been characterized by elemental analysis, GC-MS, FT-IR and NMR spectrometry. Antibacterial, antifungal and anticancer (cytotoxic) activities, for three of these compounds, have been investigated and are presented.

Risk factors for encephalitis and death from West Nile virus infection

We conducted a nested case-control study to determine potential risk factors for developing encephalitis from West Nile virus (WNV) infection. Retrospective medical chart reviews were completed for 172 confirmed WNV cases hospitalized in Houston between 2002 and 2004. Of these cases, 113 had encephalitis, including 17 deaths, 47 had meningitis, and 12 were fever cases; 67% were male. Homeless patients were more likely to be hospitalized from WNV compared to the general population. A multiple logistic regression model identified age [odds ratio (OR) 1.1, P<0.001], history of hypertension, including those cases taking hypertension-inducing drugs (OR 2.9, P=0.012), and history of cardiovascular disease (OR 3.5, P=0.061) as independent risk factors for developing encephalitis from WNV infection. After adjusting for age, race/ethnicity (being black) (OR 12.0, P<0.001), chronic renal disease (OR 10.6, P<0.001), hepatitis C virus (OR 23.1, P=0.0013), and immunosuppression (OR 3.9, P=0.033) were identified as risk factors for death from WNV infection.

Services oriented architectures and rapid deployment of ad-hoc health surveillance systems: lessons from Katrina relief efforts

During the Hurricane Katrina relief efforts, a new city was born overnight within the City of Houston to provide accommodation and health services for thousands of evacuees deprived of food, rest, medical attention, and sanitation. The hurricane victims had been exposed to flood water, toxic materials, physical injury, and mental stress. This scenario was an invitation for a variety of public health hazards, primarily infectious disease outbreaks. Early detection and monitoring of morbidity and mortality among evacuees due to unattended health conditions was an urgent priority and called for deployment of real-time surveillance to collect and analyze data at the scene, and to enable and guide appropriate response and planning activities. The University of Texas Health Science Center at Houston (UTHSC) and the Houston Department of Health and Human Services (HDHHS) deployed an ad hoc surveillance system overnight by leveraging Internet-based technologies and Services Oriented Architecture (SOA). The system was post-coordinated through the orchestration of Web Services such as information integration, natural language processing, syndromic case finding, and online analytical processing (OLAP). Here we will report the use of Internet-based and distributed architectures in providing timely, novel, and customizable solutions on demand for unprecedented events such as natural disasters.

The utility of geographic information systems (GIS) in rapid epidemiological assessments following weather-related disasters: methodological issues based on the Tropical Storm Allison Experience

Flooding is the most common natural disaster worldwide, and is the leading cause of weather-related deaths in the United States. Tropical storm Allison hit landfall near Galveston, Texas on June 5, 2001, causing the most severe flood-related damage ever recorded in the Houston metropolitan area. This devastating storm dumped 37 in of rain in 24h on parts of the city, killing 22 people and causing more than $5 billion in damage. The main goal of the public health response to tropical storm Allison was to rapidly evaluate the immediate health needs of the community. Geographical information system (GIS) technology was instrumental to the timeliness of this effort. We conducted a rapid needs assessment in the areas most affected by flooding using modified cluster sampling facilitated by GIS methodology. Of the 420 households participating in the survey, we found a significant increase in illness (OR, 5.1; 95% CI, 2.7-9.4), injuries (OR, 4.8; 95% CI, 1.9-12.8), and immediate health needs (OR, 3.3; 95% CI, 1.7-6.1) among persons living in flooded homes compared to non-flooded homes. There were 60 households reporting serious damage, 24 of which were outside the 500-year flood plain. We also obtained reliable estimates of the extent of damage and household needs to help guide relief efforts. These findings underscore the usefulness of rapid needs assessment as a tool to identify actual health threats and to facilitate delivery of resources to those with the greatest and most immediate need. Our ability to swiftly plan and implement a rapid needs assessment over a large geographical region within 1 week following the damage would not have been possible without the utilization of GIS methodology and the availability of skilled personnel and timely data resources.

Cross-sectional survey of the extent and indicators of hepatitis C virus infection in Houston Department of Health and Human Services' sexually transmitted disease clinics

To evaluate the prevalence and indicators of hepatitis C virus (HCV) infection in Houston and determine the effectiveness of targeted HCV screening in sexually transmitted disease (STD) clinics. We performed a cross-sectional survey in low-risk and high-risk groups in Houston. This included a blinded survey of HCV conducted in 1010 STD clinic clients having serological syphilis tests, and 1885 multi-speciality group practice patients having metabolic blood work. This was followed with a targeted hepatitis C survey of 822 high-risk clients from STD clinics. The seroprevalence of hepatitis C infection in the blinded survey was 3.9% (95% CI 3.0-4.8) in the multi-speciality group and 5.0% (95% CI 3.7-6.3) in the STD clinics. Prevalence of hepatitis C infection among targeted STD clinic clients was significantly higher at 15.3% (95% CI 12.7-17.7). Risk factors that correlated with HCV infection after logistic regression included: injection drug use (OR = 10, 95% CI = 3.4-30.3), heroin use (OR = 6.6, 95% CI = 2.2-20.5), non-transfusion/ transplantation blood exposure (OR = 3.0, 95% CI = 1.3-6.9), sharing equipment to snort drugs (OR = 2.5, 95% CI 1.2-5.4), and age above 25 years (OR = 51, 95% CI = 9-47). This study demonstrates that targeting clients in STD clinics for known risk behaviours is an effective way to identify cases of HCV infection. STD clinics allow access to clients with both drug use and sexual risk behaviours and are a useful location for targeting hepatitis C screening and prevention efforts.

Potency trends of delta9-THC and other cannabinoids in confiscated marijuana from 1980-1997

The analysis of 35,312 cannabis preparations confiscated in the USA over a period of 18 years for delta-9-tetrahydrocannabinol (delta9-THC) and other major cannabinoids is reported. Samples were identified as cannabis, hashish, or hash oil. Cannabis samples were further subdivided into marijuana (loose material, kilobricks and buds), sinsemilla, Thai sticks and ditchweed. The data showed that more than 82% of all confiscated samples were in the marijuana category for every year except 1980 (61%) and 1981 (75%). The potency (concentration of delta9-THC) of marijuana samples rose from less than 1.5% in 1980 to approximately 3.3% in 1983 and 1984, then fluctuated around 3% till 1992. Since 1992, the potency of confiscated marijuana samples has continuously risen, going from 3.1% in 1992 to 4.2% in 1997. The average concentration of delta9-THC in all cannabis samples showed a gradual rise from 3% in 1991 to 4.47% in 1997. Hashish and hash oil, on the other hand, showed no specific potency trends. Other major cannabinoids [cannabidiol (CBD), cannabinol (CBN), and cannabichromene (CBC)] showed no significant change in their concentration over the years.