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Ratnasekera AM, Seng SS, Kim D, Ji W, Jacovides CL, Kaufman EJ, Sadek HM, Perea LL, Poloni CM, Shnaydman I, Lee AJ, Sharp V, Miciura A, Trevizo E, Rosenthal MG, Lottenberg L, Zhao W, Keininger A, Hunt M, Cull J, Balentine C, Egodage T, Mohamed AT, Kincaid M, Doris S, Cotterman R, Seegert S, Jacobson LE, Williams J, Moncrief M, Palmer B, Mentzer C, Tackett N, Hranjec T, Dougherty T, Morrissey S, Donatelli-Seyler L, Rushing A, Tatebe LC, Nevill TJ, Aboutanos MB, Hamilton D, Redmond D, Cullinane DC, Falank C, McMellen M, Duran C, Daniels J, Ballow S, Schuster KM, Ferrada P. Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study. Injury 2024:111523. [PMID: 38614835 DOI: 10.1016/j.injury.2024.111523] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 03/09/2024] [Accepted: 04/01/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI. METHODS Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest. RESULTS 984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant. CONCLUSION In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH. LEVEL OF EVIDENCE Level III, Therapeutic Care Management.
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Affiliation(s)
- Asanthi M Ratnasekera
- Department of Surgery, Division of Trauma and Surgical Critical Care, Associate Professor of Surgery, Drexel College of Medicine, Philadelphia, PA, United States; Crozer Health Upland PA, Currently at Christianacare Health, Newark, DE, United States.
| | - Sirivan S Seng
- Department of Surgery, Crozer Health, Upland, PA, United States
| | - Daniel Kim
- Department of Surgery, Crozer Health, Upland, PA, United States
| | - Wenyan Ji
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Polytechnic Institute and State University, Roanoke, VA, United States
| | - Christina L Jacovides
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States; Currently at Temple University, Philadelphia, PA, United States
| | - Elinore J Kaufman
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Hannah M Sadek
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - Lindsey L Perea
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, United States
| | - Christina Monaco Poloni
- Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States
| | - Ilya Shnaydman
- Department of Surgery, Medical Director, Surgical Intensive Care Unit, New York Medical College, West Chester Medical Center, Valhalla, NY, United States
| | | | - Victoria Sharp
- Department of Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, United States
| | - Angela Miciura
- Department of Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, United States
| | - Eric Trevizo
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Martin G Rosenthal
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Lawrence Lottenberg
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, FL, United States; Florida Atlantic University, Boca Raton, FL, United States
| | - William Zhao
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, FL, United States; Florida Atlantic University, Boca Raton, FL, United States
| | - Alicia Keininger
- Department of Surgery, Trinity Health Oakland, Pontiac, MI, United States
| | - Michele Hunt
- Department of Surgery, Trinity Health Oakland, Pontiac, MI, United States
| | - John Cull
- Department of Surgery, Prisma Health Upstate, Greenville, SC, United States
| | - Chassidy Balentine
- Department of Surgery, Prisma Health Upstate, Greenville, SC, United States
| | - Tanya Egodage
- Department of Surgery, Cooper University Hospital, Camden, NJ, United States
| | - Aleem T Mohamed
- Department of Surgery, Cooper University Hospital, Camden, NJ, United States
| | - Michelle Kincaid
- Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH, United States
| | - Stephanie Doris
- Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH, United States
| | - Robert Cotterman
- Department of Surgery, Promedica Toledo Hospital, Toledo, OH, United States
| | - Sara Seegert
- Department of Research, Promedica Toledo Hospital, Toledo, OH, United States
| | - Lewis E Jacobson
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, United States
| | - Jamie Williams
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, United States
| | - Melissa Moncrief
- Department of Trauma & Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, United States
| | - Brandi Palmer
- Department of Trauma & Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, United States
| | - Caleb Mentzer
- Department of Surgery, Spartanburg Medical Center, Spartanburg, SC, United States
| | - Nichole Tackett
- Department of Surgery, Spartanburg Medical Center, Spartanburg, SC, United States
| | - Tjasa Hranjec
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, United States
| | - Thomas Dougherty
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, United States
| | - Shawna Morrissey
- Department of Surgery, Conemaugh Memorial Medical Center, Johnstown, PA, United States
| | - Lauren Donatelli-Seyler
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Amy Rushing
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Leah C Tatebe
- Department of Surgery, Cook County Hospital, Chicago, IL, United States; Currently at Northwestern Memorial Hospital, Chicago, IL, United States
| | - Tiffany J Nevill
- Department of Surgery, Cook County Hospital, Chicago, IL, United States
| | - Michel B Aboutanos
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - David Hamilton
- Department of Surgery, Penrose Hospital, Colorado Springs, CO, United States
| | - Diane Redmond
- Department of Surgery, Penrose Hospital, Colorado Springs, CO, United States
| | - Daniel C Cullinane
- Department of Surgery, Maine Medical Center, Portland, ME, United States
| | - Carolyne Falank
- Department of Surgery, Maine Medical Center, Portland, ME, United States
| | - Mark McMellen
- Department of Surgery, St. Anthony Hospital, Lakewood, CO, United States
| | - Chris Duran
- Department of Surgery, St. Anthony Hospital, Lakewood, CO, United States
| | - Jennifer Daniels
- Department of Surgery, University of California San Francisco, Fresno, CA, United States
| | - Shana Ballow
- Department of Surgery, University of California San Francisco, Fresno, CA, United States
| | - Kevin M Schuster
- Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Paula Ferrada
- Department of Surgery, INOVA Fairfax Health System, Fairfax, VA, United States
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Sharp V, Bazzi R, Hecht JP. Clinical outcomes for patients on antiplatelet and anticoagulants in thoracoabdominal trauma. Surg Open Sci 2023; 16:44-48. [PMID: 37808423 PMCID: PMC10550756 DOI: 10.1016/j.sopen.2023.09.019] [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: 05/23/2023] [Revised: 08/01/2023] [Accepted: 09/17/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Trauma outcomes can be greatly affected by antiplatelet and anticoagulant (AP/AC) use. The goal of this study was to compare outcomes in trauma patients on AP/AC undergoing emergent surgery for thoracoabdominal trauma at 35 level 1 and 2 trauma centers from 2014 to 2021. Methods This was a retrospective cohort study of 2460 adult patients with a chest, abdomen, or pelvis abbreviated injury score (AIS) of 2 or more who underwent surgery within 24 h of admission. These patients were segregated into four main cohorts based on antiplatelet/anticoagulation use: those not on AP/AC, those taking direct-acting oral anticoagulants (DOACs), those taking clopidogrel, and those taking warfarin. Patients were excluded if they had surgery >24 h after presentation, were dead on arrival, or had any other body system AIS score of 3 or higher. Results The mean injury severity score (ISS) in all four groups ranged from 16.3 to 18.6 (p = 0.834) with a mean time to operating room from 208 to 478 min (p < 0.001). Laparotomy was performed in 60 to 71 % (p > 0.01) of patients, regardless of AP/AC status, and thoracic procedures were performed in 3.1 to 9.3 % (p = 0.42) of patients. In-hospital mortality and hospice rates were highest in the clopidogrel group at 21.9 %, followed by warfarin at 13 %, DOACs at 15 %, and no AP/AC at 7.63 % (p = 0.008). Serious complications occurred in 61 % of patients on warfarin, 50 % of those on DOACs, and 44 % of those on clopidogrel. All of these groups demonstrated significantly higher complication rates than patients in the no AP/AC control group at 25 % (p < 0.001). Total transfusion of packed red blood cells and fresh frozen plasma did not differ significantly between the groups; however, 24-h platelet transfusion did. Patients on clopidogrel received 14 packs of platelets, while those on warfarin and DOACs received 8 and 13 packs respectively (p = 0.011). Patients on warfarin had the longest hospital length of stay (LOS) at 13 days and ICU LOS at 9 days, compared to those on DOACs (8 and 4), those on clopidogrel (7 and 3), and those not taking AC/AP (7 and 4) (hospital LOS p = 0.03, ICU LOS p = 0.019). Those on AC/AP were also noted to be significantly older than those on neither, with those taking these medications averaging out to be approximately 69 years old and those not on these medications averaging 37 years old (p < 0.001). Conclusion There was significantly higher mortality in patients on clopidogrel and increased length of stay and risk of serious complications in patients taking DOACs and warfarin. In patients on AP/AC there was also a significantly longer time to surgery than in those not taking either. Given these associations trauma surgeons should consider intervening sooner on patients taking AP/AC on admission, as the delay to intervention may contribute to the risks for trauma patients and result in worse outcomes as well as higher rates of mortality.
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Affiliation(s)
- Victoria Sharp
- Trinity Health Ann Arbor, Department of Surgery, 5301 McAuley Dr Suite 2402, Ypsilanti, MI 48197, United States of America
| | - Rola Bazzi
- Trinity Health Ann Arbor, Department of Pharmacy, 5301 E. Huron River Dr Ann Arbor, MI 48106-0995, United States of America
| | - Jason P. Hecht
- Trinity Health Ann Arbor, Department of Pharmacy, 5301 E. Huron River Dr Ann Arbor, MI 48106-0995, United States of America
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Bazzi R, Sharp V, Hecht J. Effect of Antiplatelet and Anticoagulant Agents on Outcomes Following Emergent Surgery for Traumatic Brain Injuries. Am Surg 2023; 89:5397-5406. [PMID: 36786276 DOI: 10.1177/00031348231157412] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
PURPOSE Traumatic brain injury (TBI) is the largest cause of death from injury in the United States. This study utilized the Michigan Trauma Quality Improvement Program (MTQIP) database to determine the effect that antiplatelets and anticoagulants (AP/AC) have on outcomes following emergent surgery for TBI patients. BASIC PROCEDURES Patients were included with age ≥18 years, maximum head/neck abbreviated injury score (AIS) ≥2, and underwent a neurosurgical procedure within 24 hours. Patients were excluded if they had an AIS ≥3 in other body region or no signs of life at initial evaluation. MAIN FINDINGS Within the 1,932 patients analyzed, 139 (8.74%) were in the warfarin with or without (+/-) aspirin cohort, 101 (6.35%) in the direct oral anticoagulants (DOAC) +/- aspirin cohort, 169 (10.62%) in the clopidogrel +/- aspirin cohort, and 1,182 (74.29%) in the no AP/AC cohort (control group). After controlling for demographic and clinical characteristics, no significant difference in mortality rates was observed in the treatment groups (P > 0.05). However, our subgroup analysis did reveal a significantly higher mortality rate within the warfarin and aspirin subgroup when compared to the control group (odds ratio [OR], 2.368; confidence interval [CI], 1.306-4.294, P = 0.005). With regards to hospital complications, there was a significant increase in this outcome within the DOAC +/- aspirin (OR, 1.825; CI, 1.143-2.915, P = 0.012) and clopidogrel +/- aspirin (OR, 1.82; CI, 1.244-2.663, P=0.002) groups. CONCLUSION Patients on AP/AC who experience a TBI requiring an emergent operation do not have an increased risk of mortality compared to patients not on AP/AC.
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Affiliation(s)
- Rola Bazzi
- Inpatient Pharmacy, Trinity Health Ann Arbor, Ypsilant, MI, USA
| | - Victoria Sharp
- Department of Surgery, Trinity Health Ann Arbor, Ypsilant, MI, USA
| | - Jason Hecht
- Inpatient Pharmacy, Trinity Health Ann Arbor, Ypsilant, MI, USA
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Ratnasekera AM, Kim D, Seng SS, Jacovides C, Kaufman EJ, Sadek HM, Perea LL, Monaco C, Shnaydman I, Jeongyoon Lee A, Sharp V, Miciura A, Trevizo E, Rosenthal M, Lottenberg L, Zhao W, Keininger A, Hunt M, Cull J, Balentine C, Egodage T, Mohamed A, Kincaid M, Doris S, Cotterman R, Seegert S, Jacobson LE, Williams J, Whitmill M, Palmer B, Mentzer C, Tackett N, Hranjec T, Dougherty T, Morrissey S, Donatelli-Seyler L, Rushing A, Tatebe LC, Nevill TJ, Aboutanos MB, Hamilton D, Redmond D, Cullinane DC, Falank C, McMellen M, Duran C, Daniels J, Ballow S, Schuster K, Ferrada P. Early VTE Prophylaxis in Severe Traumatic Brain Injury: A Propensity Score Weighted EAST Multi-Center Study. J Trauma Acute Care Surg 2023:01586154-990000000-00329. [PMID: 37017458 DOI: 10.1097/ta.0000000000003985] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND Patients with TBI are at high risk of venous thromboembolism events (VTE). We hypothesized that early chemical VTE prophylaxis initiation (≤24 hours of a stable head CT) in severe TBI would reduce VTE without increasing risk of intracranial hemorrhage expansion (ICHE). METHODS A retrospective review of adult patients ≥18 years of age with isolated severe TBI (AIS ≥ 3) who were admitted to 24 level 1 and level 2 trauma centers from January 1, 2014 to December 31 2020 was conducted. Patients were divided into those who did not receive any VTE prophylaxis (NO VTEP), who received VTE prophylaxis ≤24 hours after stable head CT (VTEP ≤24) and who received VTE prophylaxis >24 hours after stable head CT (VTEP>24). Primary outcomes were VTE and ICHE. Covariate balancing propensity score weighting was utilized to balance demographic & clinical characteristics across three groups. Weighted univariate logistic regression models were estimated for VTE & ICHE with patient group as predictor of interest. RESULTS Of 3,936 patients, 1,784 met inclusion criteria. Incidences of VTE was significantly higher in the VTEP>24 group, with higher incidences of DVT in the group. Higher incidences of ICHE were observed in the VTEP≤24 and VTEP>24 groups. After propensity score weighting, there was a higher risk of VTE in patients in VTEP >24 compared to those in VTEP≤24 ( [OR] = 1.51; [95%CI] = 0.69-3.30; p = 0.307), however was not significant. Although, the No VTEP group had decreased odds of having ICHE compared to VTEP≤24 (OR = 0.75; 95%CI = 0.55-1.02, p = 0.070), the result was not statistically significant. CONCLUSIONS In this large multi-center analysis, there were no significant differences in VTE based on timing of initiation of VTE prophylaxis. Patients who never received VTE prophylaxis had decreased odds of ICHE. Further evaluation of VTE prophylaxis in larger randomized studies will be necessary for definitive conclusions. LEVEL OF EVIDENCE level III, Therapeutic Care Management.
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Cairl N, Sharp V. Splenic abscess secondary to COVID-19 infection - A case report. Int J Surg Case Rep 2022; 101:107807. [PMID: 36455347 PMCID: PMC9705012 DOI: 10.1016/j.ijscr.2022.107807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/25/2022] [Accepted: 11/27/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Nicholas Cairl
- Department of Surgery, Trinity Health Ann Arbor, 5301 McAuley Dr, Ypsilanti, MI 48197, United States of America,Corresponding author.
| | - Victoria Sharp
- Trinity Health IHA Medical Group, Trauma & Surgical Critical Care, Trinity Health Ann Arbor, 5301 McAuley Dr, Ypsilanti, MI 48197, United States of America
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Tracy BM, Valdez CL, Crowley B, Seng S, Ratnasekera A, Collins CM, Bhattacharya B, O'Connor R, Sharp V, Gelbard RB. Academic Medical Centers Experienced Higher Rates of Post-Operative Health-Care-Associated Infections during the COVID-19 Pandemic: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma Multicenter Trial. Surg Infect (Larchmt) 2022; 23:538-544. [PMID: 35917388 DOI: 10.1089/sur.2022.148] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: We sought to examine health-care-associated infections (HAIs) among patients undergoing an appendectomy at academic medical centers (AMCs) and non-AMCs during the coronavirus disease 2019 (COVID-19) peri-pandemic. We hypothesized that AMCs would have higher rates of post-operative HAIs during the first wave of the pandemic. Patients and Methods: We performed a post hoc analysis of a prospective, observational, multi-center study of patients aged >18 years who underwent an appendectomy for acute appendicitis before (pre-CoV), during (CoV), and after pandemic restrictions were lifted (post-CoV). Patients were grouped according to hospital type (AMC vs. non-AMC). Our primary outcome was the incidence of post-operative HAIs. Results: There were 1,003 patients; 69.5% (n = 697) were treated at AMCs and 30.5% (n = 306) at non-AMCs. Patients at AMCs had greater rates of concomitant COVID-19 infections (5.5% vs. 0.7%; p < 0.0001) and worse operative appendicitis severity (p = 0.01). Greater rates of HAIs were seen at AMCs compared with non-AMCs (4.9% vs. 2%; p = 0.03). Surgical site infections were the most common HAI and occurred more often at AMCs (4.3% vs. 1.6%; p = 0.04). Only during CoV were there more HAIs at AMCs (5.1% vs. 0.3%; p = 0.02). Undergoing surgery at an AMC during CoV was a risk factor for HAIs (adjusted odds ratio [aOR], 8.55; 95% confidence interval [CI], 1.03-71.03; p = 0.04). Conclusions: During the COVID-19 pandemic, appendectomies performed at AMCs were an independent risk factor for post-operative HAIs. Our findings stress the importance of adherence to standard infection prevention efforts during future healthcare crises.
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Affiliation(s)
- Brett M Tracy
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Carrie L Valdez
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Brandon Crowley
- Department of Surgery, University of Alabama at Birmingham Medical Center, Birmingham, Alabama, USA
| | - Sirivan Seng
- Department of Surgery, Crozer Chester Medical Center, Chester, Pennsylvania, USA
| | - Asanthi Ratnasekera
- Department of Surgery, Crozer Chester Medical Center, Chester, Pennsylvania, USA
| | - Courtney M Collins
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Rick O'Connor
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Victoria Sharp
- Department of Surgery, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, Michigan, USA
| | - Rondi B Gelbard
- Department of Surgery, University of Alabama at Birmingham Medical Center, Birmingham, Alabama, USA
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Bates JA, Dinnan K, Sharp V. Biliary hyperkinesia, a new diagnosis or misunderstood pathophysiology of dyskinesia: A case report. Int J Surg Case Rep 2019; 55:80-83. [PMID: 30716707 PMCID: PMC6360460 DOI: 10.1016/j.ijscr.2019.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 11/15/2018] [Revised: 01/02/2019] [Accepted: 01/15/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Biliary colic, characterized by intermittent right upper quadrant abdominal pain is a common complaint in the United States population. Patients whose pain is undiagnosed by ultrasound generally undergo hepatobiliary iminodiacetic acid scan with cholecystokinin stimulation (HIDA-CCK) to assess function of the gallbladder and biliary tree. Traditionally, two outcomes are possible based on a measured ejection fraction of the gallbladder: either dyskinesia or normal function is diagnosed. Biliary dyskinesia, or hypokinesia of the gallbladder, is accepted as an ejection fraction less than 35%, while an accepted normal functioning gallbladder ejection fraction is greater than 35%. CASE We report a case of a fifteen-year-old female who had functional gallbladder disease per Rome IV criteria due to intermittent biliary colic, with exception to the ejection fraction measurement which was elevated at 96.5%. She underwent laparoscopic cholecystectomy with complete symptom resolution. DISCUSSION As demonstrated in the literature reviewed here, these subsets of patients, who present with normal to high ejection fractions, have undergone laparoscopic cholecystectomy with resolution of pain in several case studies. CONCLUSION Many unknown variables still exist due to lack of prospective studies, most notably the pathophysiology and definitive indications for surgical treatment. As such, we propose that surgical options should not be limited to those who display the traditional findings of biliary dyskinesia, but also patients who demonstrate typical symptoms with normal to elevated ejection fraction, following work up to rule out the extensive differential diagnoses for right upper quadrant abdominal pain.
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Affiliation(s)
- John A Bates
- Beaumont Health Farmington Hills, General Surgery Department, 28050 Grand River Avenue, Farmington Hills, MI 48336, USA.
| | - Kelly Dinnan
- Beaumont Health Farmington Hills, General Surgery Department, 28050 Grand River Avenue, Farmington Hills, MI 48336, USA.
| | - Victoria Sharp
- Beaumont Health Farmington Hills, General Surgery Department, 28050 Grand River Avenue, Farmington Hills, MI 48336, USA.
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Callon W, Saha S, Wilson IB, Laws MB, Massa M, Korthuis PT, Sharp V, Cohn J, Moore RD, Beach MC. How does decision complexity affect shared decision making? An analysis of patient-provider antiretroviral initiation dialogue. Patient Educ Couns 2017; 100:919-926. [PMID: 28012679 PMCID: PMC5400677 DOI: 10.1016/j.pec.2016.12.013] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 05/25/2023]
Abstract
OBJECTIVES This study analyzed patient-provider dialogue regarding anti-retroviral therapy (ART) initiation, assessing the degree to which shared decision making (SDM) occurred. METHODS We analyzed 24 audio-recorded dialogues between 14 HIV providers and their patients regarding ART initiation. We coded transcribed dialogues for seven SDM elements. We stratified dialogues into three levels of decision complexity (basic, intermediate, complex) based on patient CD4 counts and evaluated SDM criteria fulfillment at each level of decision complexity. RESULTS There were five basic, twelve intermediate, and seven complex decisions in our sample. While only two met the defined criteria for SDM, the mean number of SDM elements present increased with each level of decision complexity. Discussion of the clinical issue requiring the decision occurred most frequently (88%), while discussion of pros/cons (13%), patient's understanding (21%), and decision alternatives (29%) occurred least frequently. CONCLUSION/PRACTICE IMPLICATIONS While few dialogues met the defined SDM criteria, providers are having conversations that respond to decision complexity. Clinicians should be aware that discussion of pros/cons, alternatives, and uncertainties are frequently skipped, even when these elements are clearly relevant, as in complex decisions. In addition, rhetorical questions to assess patient preferences and understanding are insufficient to fully engage patients in SDM.
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Affiliation(s)
- Wynne Callon
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Somnath Saha
- Portland VA Medical Center, Portland, OR, USA; Department of Medicine, Oregon Health Sciences University, Portland, OR, USA
| | - Ira B Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Michael Barton Laws
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Michele Massa
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - P Todd Korthuis
- Department of Medicine, Oregon Health Sciences University, Portland, OR, USA
| | | | - Jonathan Cohn
- Department of Medicine, Wayne State University, Detroit, MI, USA
| | - Richard D Moore
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Flickinger TE, Saha S, Roter D, Korthuis PT, Sharp V, Cohn J, Moore RD, Ingersoll KS, Beach MC. Respecting patients is associated with more patient-centered communication behaviors in clinical encounters. Patient Educ Couns 2016; 99:250-5. [PMID: 26320821 PMCID: PMC5271348 DOI: 10.1016/j.pec.2015.08.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 08/11/2015] [Accepted: 08/14/2015] [Indexed: 05/25/2023]
Abstract
OBJECTIVE Attitudes towards patients may influence how clinicians interact. We investigated whether respect for patients was associated with communication behaviors during HIV care encounters. METHODS We analyzed audio-recordings of visits between 413 adult HIV-infected patients and 45 primary HIV care providers. The independent variable was clinician-reported respect for the patient and outcomes were clinician and patient communication behaviors assessed by the Roter Interaction Analysis System (RIAS). We performed negative binomial regressions for counts outcomes and linear regressions for global outcomes. RESULTS When clinicians had higher respect for a patient, they engaged in more rapport-building, social chitchat, and positive talk. Patients of clinicians with higher respect for them engaged in more rapport-building, social chitchat, positive talk, and gave more psychosocial information. Encounters between patients and clinicians with higher respect for them had more positive clinician emotional tone [regression coefficient 2.97 (1.92-4.59)], more positive patient emotional tone [2.71 (1.75-4.21)], less clinician verbal dominance [0.81 (0.68-0.96)] and more patient-centeredness [1.28 (1.09-1.51)]. CONCLUSIONS Respect is associated with positive and patient-centered communication behaviors during encounters. PRACTICE IMPLICATIONS Clinicians should be mindful of their respectful attitudes and work to foster positive regard for patients. Educators should consider methods to enhance trainees' respect in communication skills training.
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Affiliation(s)
- Tabor E Flickinger
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Somnath Saha
- Department of Medicine, Portland VA Medical Center, Portland, OR, USA; Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Debra Roter
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - P Todd Korthuis
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Victoria Sharp
- Department of Medicine, St. Luke's Roosevelt, New York, NY, USA
| | - Jonathan Cohn
- Department of Medicine, Wayne State University, Detroit, MI, USA
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen S Ingersoll
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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10
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Flickinger TE, Saha S, Roter D, Korthuis PT, Sharp V, Cohn J, Eggly S, Moore RD, Beach MC. Clinician empathy is associated with differences in patient-clinician communication behaviors and higher medication self-efficacy in HIV care. Patient Educ Couns 2016; 99:220-6. [PMID: 26395313 PMCID: PMC5610904 DOI: 10.1016/j.pec.2015.09.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/11/2015] [Accepted: 09/01/2015] [Indexed: 05/18/2023]
Abstract
OBJECTIVE We examined associations of clinicians' empathy with patient-clinician communication behaviors, patients' rating of care, and medication self-efficacy. METHODS We analyzed 435 adult patients and 45 clinicians at four outpatient HIV care sites in the United States. Negative binomial regressions investigated associations between clinician empathy and patient-clinician communication, assessed using the Roter Interaction Analysis System (RIAS). Logistic regressions investigated associations between clinician empathy and patient ratings of clinician communication, overall satisfaction, and medication self-efficacy. RESULTS Clinicians in the highest vs. lowest empathy tertile engaged in less explicitly emotional talk (IRR 0.79, p<0.05), while clinicians in the middle vs. lowest engaged in more positive talk (IRR 1.31, p<0.05), more questions (IRR 1.42, p<0.05), and more patient activating talk (IRR 1.43, p<0.05). Patients of higher empathy clinicians disclosed more psychosocial and biomedical information. Patients of clinicians in both the middle and highest (vs. lowest) empathy tertiles had greater odds of reporting highest medication self-efficacy (OR 1.80, 95% CI 1.16-2.80; OR 2.13, 95% CI 1.37-3.32). CONCLUSIONS Clinician empathy may be expressed through addressing patient engagement in care, by fostering cognitive, rather than primarily emotional, processing. PRACTICE IMPLICATIONS Clinicians should consider enhancing their own empathic capacity, which may encourage patients' self-efficacy in medication adherence.
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Affiliation(s)
| | - Somnath Saha
- Portland VA Medical Center, Portland, OR, USA; Oregon Health and Science University, Portland, OR, USA
| | - Debra Roter
- Johns Hopkins University, Baltimore, MD, USA
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11
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Beach MC, Roter DL, Saha S, Korthuis PT, Eggly S, Cohn J, Sharp V, Moore RD, Wilson IB. Impact of a brief patient and provider intervention to improve the quality of communication about medication adherence among HIV patients. Patient Educ Couns 2015; 98:1078-83. [PMID: 26021185 PMCID: PMC4546873 DOI: 10.1016/j.pec.2015.05.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 04/13/2015] [Accepted: 05/14/2015] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Medication adherence is essential in HIV care, yet provider communication about adherence is often suboptimal. We designed this study to improve patient-provider communication about HIV medication adherence. METHODS We randomized 26 providers at three HIV care sites to receive or not receive a one-hour communication skills training based on motivational interviewing principles applied to medication adherence. Prior to routine office visits, non-adherent patients of providers who received the training were coached to discuss adherence with their providers. Patients of providers who did not receive the training providers were not coached. We audio-recorded and coded patient-provider interactions using the roter interaction analysis system (RIAS). RESULTS There was more dialogue about therapeutic regimen in visits with intervention patients and providers (167 vs 128, respectively, p=.004), with the majority of statements coming from providers. These visits also included more brainstorming solutions to nonadherence (41% vs. 22%, p=0.026). Intervention compared with control visit providers engaged in more positive talk (44 vs. 38 statements, p=0.039), emotional talk (26 vs. 18 statements, p<0.001), and probing of patient opinion (3 vs. 2 statements, p=0.009). CONCLUSION A brief provider training combined with patient coaching sessions, improved provider communication behaviors and increased dialogue regarding medication adherence.
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Affiliation(s)
- Mary Catherine Beach
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, USA; Department of Medicine, Johns Hopkins School of Medicine, Baltimore, USA; Department of Health, Behavior & Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA; Welch Center for Prevention, Epidemiology and Clinical Research, USA.
| | - Debra L Roter
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, USA; Department of Health, Behavior & Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Somnath Saha
- Portland VA Medical Center, Portland, USA; Department of Medicine, Oregon Health Sciences University, Portland, USA
| | - P Todd Korthuis
- Department of Medicine, Oregon Health Sciences University, Portland, USA
| | - Susan Eggly
- Department of Medicine, Wayne State University, Detroit, USA
| | - Jonathan Cohn
- Department of Medicine, Wayne State University, Detroit, USA
| | | | - Richard D Moore
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, USA; Department of Health, Behavior & Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Ira B Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, USA
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Hughes HK, Korthuis PT, Saha S, Eggly S, Sharp V, Cohn J, Moore R, Beach MC. A mixed methods study of patient-provider communication about opioid analgesics. Patient Educ Couns 2015; 98:453-461. [PMID: 25601279 PMCID: PMC4417607 DOI: 10.1016/j.pec.2014.12.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 12/21/2014] [Accepted: 12/22/2014] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To describe patient-provider communication about opioid pain medicine and explore how these discussions affect provider attitudes toward patients. METHODS We audio-recorded 45 HIV providers and 423 patients in routine outpatient encounters at four sites across the country. Providers completed post-visit questionnaires assessing their attitudes toward patients. We identified discussions about opioid pain management and analyzed them qualitatively. We used logistic regression to assess the association between opioid discussion and providers' attitudes toward patients. RESULTS 48 encounters (11% of the total sample) contained substantive discussion of opioid-related pain management. Most conversations were initiated by patients (n=28, 58%) and ended by the providers (n=36, 75%). Twelve encounters (25%) contained dialog suggesting a difference of opinion or conflict. Providers more often agreed than disagreed to give the prescription (50% vs. 23%), sometimes reluctantly; in 27% (n=13) of encounters, no decision was made. Fewer than half of providers (n=20, 42%) acknowledged the patient's experience of pain. Providers had a lower odds of positive regard for the patient (adjusted OR=0.51, 95% CI: 0.27-0.95) when opioids were discussed. CONCLUSIONS Pain management discussions are common in routine outpatient HIV encounters and providers may regard patients less favorably if opioids are discussed during visits. The sometimes-adversarial nature of these discussions may negatively affect provider attitudes toward patients. PRACTICE IMPLICATIONS Empathy and pain acknowledgment are tools that clinicians can use to facilitate productive discussions of pain management.
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Affiliation(s)
| | | | - Somnath Saha
- Oregon Health Sciences University, Portland, USA; Portland VA Medical Center, Portland, USA
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13
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Crowell TA, Gebo KA, Blankson JN, Korthuis PT, Yehia BR, Rutstein RM, Moore RD, Sharp V, Nijhawan AE, Mathews WC, Hanau LH, Corales RB, Beil R, Somboonwit C, Edelstein H, Allen SL, Berry SA. Hospitalization Rates and Reasons Among HIV Elite Controllers and Persons With Medically Controlled HIV Infection. J Infect Dis 2014; 211:1692-702. [PMID: 25512624 DOI: 10.1093/infdis/jiu809] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 10/22/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Elite controllers spontaneously suppress human immunodeficiency virus (HIV) viremia but also demonstrate chronic inflammation that may increase risk of comorbid conditions. We compared hospitalization rates and causes among elite controllers to those of immunologically intact persons with medically controlled HIV. METHODS For adults in care at 11 sites from 2005 to 2011, person-years with CD4 T-cell counts ≥350 cells/mm(2) were categorized as medical control, elite control, low viremia, or high viremia. All-cause and diagnostic category-specific hospitalization rates were compared between groups using negative binomial regression. RESULTS We identified 149 elite controllers (0.4%) among 34 354 persons in care. Unadjusted hospitalization rates among the medical control, elite control, low-viremia, and high-viremia groups were 10.5, 23.3, 12.6, and 16.9 per 100 person-years, respectively. After adjustment for demographic and clinical factors, elite control was associated with higher rates of all-cause (adjusted incidence rate ratio, 1.77 [95% confidence interval, 1.21-2.60]), cardiovascular (3.19 [1.50-6.79]) and psychiatric (3.98 [1.54-10.28]) hospitalization than was medical control. Non-AIDS-defining infections were the most common reason for admission overall (24.1% of hospitalizations) but were rare among elite controllers (2.7%), in whom cardiovascular hospitalizations were most common (31.1%). CONCLUSIONS Elite controllers are hospitalized more frequently than persons with medically controlled HIV and cardiovascular hospitalizations are an important contributor.
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Affiliation(s)
- Trevor A Crowell
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kelly A Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joel N Blankson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - P Todd Korthuis
- Department of Public Health/Preventive Medicine, Oregon Health and Science University, Portland
| | - Baligh R Yehia
- Department of Medicine, University of Pennsylvania Perelman School of Medicine
| | | | - Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Victoria Sharp
- Center for Comprehensive Care, St Luke's Roosevelt Hospital Center
| | - Ank E Nijhawan
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | | | | | | | | | | | - Howard Edelstein
- Department of Internal Medicine, Alameda County Medical Center, Oakland, California
| | - Sara L Allen
- Department of Medicine, Drexel University College of Medicine, Pennsylvania
| | - Stephen A Berry
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Laws MB, Lee Y, Rogers WH, Beach MC, Saha S, Korthuis PT, Sharp V, Cohn J, Moore R, Wilson IB. Provider-patient communication about adherence to anti-retroviral regimens differs by patient race and ethnicity. AIDS Behav 2014; 18:1279-87. [PMID: 24464408 PMCID: PMC4047172 DOI: 10.1007/s10461-014-0697-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Disparities in HIV care and outcomes negatively affect Black and Hispanic patients. Features of clinical communication may be a factor. This study is based on coding transcripts of 404 routine outpatient visits by people with HIV at four sites, using a validated system. In models adjusting for site and patient characteristics, with provider as a random effect, providers were more "verbally dominant" with Black patients than with others. There was more discussion about ARV adherence with both Black and Hispanic patients, but no more discussion about strategies to improve adherence. Providers made more directive utterances discussing ARV treatment with Hispanic patients. Possible interpretations of these findings are that providers are less confident in Black and Hispanic patients to be adherent; that they place too much confidence in their White, non-Hispanic patients; or that patients differentially want such discussion. The lack of specific problem solving and high provider directiveness suggests areas for improvement.
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Affiliation(s)
- M Barton Laws
- Department of Health Services, Policy and Practice, Brown University, G-S121-7, Providence, RI, 02912, USA,
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15
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Sharp V. Transforming to meet Iowa physicians' changing needs. IMS seeks historic change to policy setting, governance forums. Iowa Med 2014; 104:4-11. [PMID: 25167621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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16
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Sharp V. Iowa Congressional Delegation supports fixing Medicare. Iowa Med 2014; 104:4. [PMID: 25167612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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17
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Sharp V. 2 key task forces could bring change in 2014. Iowa Med 2013; 103:4-6. [PMID: 25188940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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18
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Flickinger TE, Rose G, Wilson IB, Wolfe H, Saha S, Korthuis PT, Massa M, Berry S, Laws MB, Sharp V, Moore RD, Beach MC. Motivational interviewing by HIV care providers is associated with patient intentions to reduce unsafe sexual behavior. Patient Educ Couns 2013; 93:122-9. [PMID: 23647982 PMCID: PMC3759567 DOI: 10.1016/j.pec.2013.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 03/15/2013] [Accepted: 04/07/2013] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Motivational interviewing (MI) can promote behavior change, but HIV care providers rarely have training in MI. Little is known about the use of MI-consistent behavior among untrained providers. This study examines the prevalence of such behaviors and their association with patient intentions to reduce high-risk sexual behavior. METHODS Audio-recorded visits between HIV-infected patients and their healthcare providers were searched for counseling dialog regarding sexual behavior. The association of providers' MI-consistence with patients' statements about behavior change was assessed. RESULTS Of 417 total encounters, 27 met inclusion criteria. The odds of patient commitment to change were higher when providers used more reflections (p=0.017), used more MI consistent utterances (p=0.044), demonstrated more empathy (p=0.049), and spent more time discussing sexual behavior (p=0.023). Patients gave more statements in favor of change (change talk) when providers used more reflections (p<0.001) and more empathy (p<0.001), even after adjusting for length of relevant dialog. CONCLUSION Untrained HIV providers do not consistently use MI techniques when counseling patients about sexual risk reduction. However, when they do, their patients are more likely to express intentions to reduce sexual risk behavior. PRACTICE IMPLICATIONS MI holds promise as one strategy to reduce transmission of HIV and other sexually transmitted infections.
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Affiliation(s)
- Tabor E Flickinger
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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19
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Beach MC, Roter D, Korthuis PT, Epstein RM, Sharp V, Ratanawongsa N, Cohn J, Eggly S, Sankar A, Moore RD, Saha S. A multicenter study of physician mindfulness and health care quality. Ann Fam Med 2013; 11:421-8. [PMID: 24019273 PMCID: PMC3767710 DOI: 10.1370/afm.1507] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Mindfulness (ie, purposeful and nonjudgmental attentiveness to one's own experience, thoughts, and feelings) is associated with physician well-being. We sought to assess whether clinician self-rated mindfulness is associated with the quality of patient care. METHODS We conducted an observational study of 45 clinicians (34 physicians, 8 nurse practitioners, and 3 physician assistants) caring for patients infected with the human immunodeficiency virus (HIV) who completed the Mindful Attention Awareness Scale and 437 HIV-infected patients at 4 HIV specialty clinic sites across the United States. We measured patient-clinician communication quality with audio-recorded encounters coded using the Roter Interaction Analysis System (RIAS) and patient ratings of care. RESULTS In adjusted analyses comparing clinicians with highest and lowest tertile mindfulness scores, patient visits with high-mindfulness clinicians were more likely to be characterized by a patient-centered pattern of communication (adjusted odds ratio of a patient-centered visit was 4.14; 95% CI, 1.58-10.86), in which both patients and clinicians engaged in more rapport building and discussion of psychosocial issues. Clinicians with high-mindfulness scores also displayed more positive emotional tone with patients (adjusted β = 1.17; 95% CI, 0.46-1.9). Patients were more likely to give high ratings on clinician communication (adjusted prevalence ratio [APR] = 1.48; 95% CI, 1.17-1.86) and to report high overall satisfaction (APR = 1.45; 95 CI, 1.15-1.84) with high-mindfulness clinicians. There was no association between clinician mindfulness and the amount of conversation about biomedical issues. CONCLUSIONS Clinicians rating themselves as more mindful engage in more patient-centered communication and have more satisfied patients. Interventions should determine whether improving clinician mindfulness can also improve patient health outcomes.
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20
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Sharp V. Paying homage to pioneering women who paved the way. Iowa Med 2013; 103:4-5. [PMID: 25208444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Earl TR, Saha S, Lombe M, Korthuis PT, Sharp V, Cohn J, Moore R, Beach MC. Race, Relationships and Trust in Providers among Black Patients with HIV/AIDS. Soc Work Res 2013; 37:219-226. [PMID: 24764690 PMCID: PMC3994892 DOI: 10.1093/swr/svt017] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
A trustful patient-provider relationship is a strong predictor of positive outcomes, including treatment adherence and viral suppression, among patients with HIV/AIDS. Understanding factors that inform this relationship is especially relevant for Black patients, who bear a disproportionate burden of HIV morbidity and mortality, and may face challenges associated with seeing providers of a racial/ethnic background that is different from their own. Using data collected through the Enhancing Communication and HIV Outcomes (ECHO) study, we build upon extant research by examining patient and provider characteristics that may influence Black patients' trust in their provider. ECHO data were collected from four ambulatory care sites in Baltimore, Detroit, New York and Portland, Oregon (N=435). Regression analysis results indicate that trust in health care institutions and cultural similarity between patient and provider are strongly associated with patients' trust in their provider. Lower perceived social status, being currently employed, and having an older provider were also related to greater patient-provide trust. These findings can inform interventions to improve trust and reduce disparities in HIV care and outcomes that stem from mistrust among Black patients.
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Sharp V. Advice to medical students: believe in yourself. Iowa Med 2013; 103:6. [PMID: 25211972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Flickinger TE, Berry S, Korthuis PT, Saha S, Laws MB, Sharp V, Moore RD, Beach MC. Counseling to reduce high-risk sexual behavior in HIV care: a multi-center, direct observation study. AIDS Patient Care STDS 2013; 27:416-24. [PMID: 23802144 PMCID: PMC3704109 DOI: 10.1089/apc.2012.0426] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A key opportunity to reduce HIV transmission lies with healthcare providers counseling HIV-infected patients about safer sex. We audio-recorded and transcribed clinical encounters between 45 healthcare providers and 417 of their HIV-infected patients at four outpatient sites in the United States. We used logistic regressions to evaluate associations between patient and provider characteristics, and the occurrence of discussion (any talk about sex) and counseling (advice about safer sex). Of the 417 encounters, discussion of sex occurred in 187 (45% of encounters, 95% CI: 40-50%). Counseling occurred for 49% (95% CI: 35-63%) of patients reporting unsafe sex. Discussion of sex was more likely with younger or less-educated patients and with less cultural difference between patient and provider, while counseling was associated with greater provider mindfulness and lower provider empathy. These findings suggest targets to improve communication regarding sexual risk reduction in HIV care.
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Affiliation(s)
- Tabor E Flickinger
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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24
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Yehia BR, Agwu AL, Schranz A, Korthuis PT, Gaur AH, Rutstein R, Sharp V, Spector SA, Berry SA, Gebo KA. Conformity of pediatric/adolescent HIV clinics to the patient-centered medical home care model. AIDS Patient Care STDS 2013; 27:272-9. [PMID: 23651104 DOI: 10.1089/apc.2013.0007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [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
The patient-centered medical home (PCMH) has been introduced as a model for providing high-quality, comprehensive, patient-centered care that is both accessible and coordinated, and may provide a framework for optimizing the care of youth living with HIV (YLH). We surveyed six pediatric/adolescent HIV clinics caring for 578 patients (median age 19 years, 51% male, and 82% black) in July 2011 to assess conformity to the PCMH. Clinics completed a 50-item survey covering the six domains of the PCMH: (1) comprehensive care, (2) patient-centered care, (3) coordinated care, (4) accessible services, (5) quality and safety, and (6) health information technology. To determine conformity to the PCMH, a novel point-based scoring system was devised. Points were tabulated across clinics by domain to obtain an aggregate assessment of PCMH conformity. All six clinics responded. Overall, clinics attained a mean 75.8% [95% CI, 63.3-88.3%] on PCMH measures-scoring highest on patient-centered care (94.7%), coordinated care (83.3%), and quality and safety measures (76.7%), and lowest on health information technology (70.0%), accessible services (69.1%), and comprehensive care (61.1%). Clinics moderately conformed to the PCMH model. Areas for improvement include access to care, comprehensive care, and health information technology. Future studies are warranted to determine whether greater clinic PCMH conformity improves clinical outcomes and cost savings for YLH.
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Affiliation(s)
- Baligh R. Yehia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Allison L. Agwu
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Asher Schranz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - P. Todd Korthuis
- Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Aditya H. Gaur
- Department of Infectious Diseases, St. Jude's Children's Research Hospital, Memphis, Tennessee
| | - Richard Rutstein
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Victoria Sharp
- HIV Center for Comprehensive Care, St. Luke's-Roosevelt Hospital, New York, New York
| | - Stephen A. Spector
- Department of Pediatrics, University of California San Diego, La Jolla, California, and Rady Children's Hospital San Diego, California
| | - Stephen A. Berry
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kelly A. Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Sharp V. We are the guardians of medicine. Iowa Med 2013; 103:6. [PMID: 25211966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Jonassaint CR, Haywood C, Korthuis PT, Cooper LA, Saha S, Sharp V, Cohn J, Moore RD, Beach MC. The impact of depressive symptoms on patient-provider communication in HIV care. AIDS Care 2013; 25:1185-92. [PMID: 23320529 DOI: 10.1080/09540121.2012.752788] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Persons with HIV who develop depression have worse medical adherence and outcomes. Poor patient-provider communication may play a role in these outcomes. This cross-sectional study evaluated the influence of patient depression on the quality of patient-provider communication. Patient-provider visits (n=406) at four HIV care sites were audio-recorded and coded with the Roter Interaction Analysis System (RIAS). Negative binomial and linear regressions using generalized estimating equations tested the association of depressive symptoms, as measured by the Center for Epidemiology Studies Depression scale (CES-D), with RIAS measures and postvisit patient-rated quality of care and provider-reported regard for his or her patient. The patients, averaged 45 years of age (range =20-77), were predominately male (n=286, 68.5%), of black race (n=250, 60%), and on antiretroviral medications (n=334, 80%). Women had greater mean CES-D depression scores (12.0) than men (10.6; p=0.03). There were no age, race, or education differences in depression scores. Visits with patients reporting severe depressive symptoms compared to those reporting none/mild depressive symptoms were longer and speech speed was slower. Patients with severe depressive symptoms did more emotional rapport building but less social rapport building, and their providers did more data gathering/counseling (ps<0.05). In postvisit questionnaires, providers reported lower levels of positive regard for, and rated more negatively patients reporting more depressive symptoms (p<0.01). In turn, patients reporting more depressive symptoms felt less respected and were less likely to report that their provider knows them as a person than none/mild depressive symptoms patients (ps<0.05). Greater psychosocial needs of patients presenting with depressive symptoms and limited time/resources to address these needs may partially contribute to providers' negative attitudes regarding their patients with depressive symptoms. These negative attitudes may ultimately serve to adversely impact patient-provider communication and quality of HIV care.
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Affiliation(s)
- Charles R Jonassaint
- a Division of General Internal Medicine , Johns Hopkins University , Baltimore , MD , USA
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Affiliation(s)
- Victoria Sharp
- Community Child Health, Sirona Care and Health, Bath & North East Somerset NHS Trust, Bath, UK.
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Laws MB, Beach MC, Lee Y, Rogers WH, Saha S, Korthuis PT, Sharp V, Wilson IB. Provider-patient adherence dialogue in HIV care: results of a multisite study. AIDS Behav 2013; 17:148-59. [PMID: 22290609 DOI: 10.1007/s10461-012-0143-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Few studies have analyzed physician-patient adherence dialogue about ARV treatment in detail. We comprehensively describe physician-patient visits in HIV care, focusing on ARV-related dialogue, using a system that assigns each utterance both a topic code and a speech act code. Observational study using audio recordings of routine outpatient visits by people with HIV at specialty clinics. Providers were 34 physicians and 11 non-M.D. practitioners. Of 415 patients, 66% were male, 59% African-American. 78% reported currently taking ARVs. About 10% of utterances concerned ARV treatment. Among those using ARVs, 15% had any adherence problem solving dialogue. ARV problem solving talk included significantly more directives and control parameter utterances by providers than other topics. Providers were verbally dominant, asked five times as many questions as patients, and made 21 times as many directive utterances. Providers asked few open questions, and rarely checked patients' understanding. Physicians respond to the challenges of caring for patients with HIV by adopting a somewhat physician-centered approach which is particularly evident in discussions about ARV adherence.
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Affiliation(s)
- M Barton Laws
- Department of Health Services Policy and Practice, Brown University, G-S121-7, Providence, RI 02912, USA.
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Wolfe H, Haller DL, Benoit E, Bolger KW, Cancienne JC, Ingersoll KS, Sharp V. Developing PeerLink to engage out-of-care HIV+ substance users: training peers to deliver a peer-led motivational intervention with fidelity. AIDS Care 2012; 25:888-94. [PMID: 23230862 DOI: 10.1080/09540121.2012.748169] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Substance use among HIV+ individuals can be a barrier to HIV care, resulting in poor health outcomes. Motivational interviewing (MI) is an effective intervention to reduce substance abuse and increase HIV-related health. Healthcare workers from various backgrounds can be effectively trained in delivering MI interventions; however, there has been limited evidence that peers can effectively deliver MI interventions with fidelity. Peers have traditionally worked in HIV care settings and represent a valid context for a peer-delivered intervention focused on motivational issues. We trained four peers in MI. In this paper, we describe the intervention, explain the MI training methods, and investigate whether peers can be trained in MI with fidelity. The MI training included didactic instruction, group workshops, and individual feedback sessions. Two of four peers achieved MI treatment fidelity as measured by the Motivational Interviewing Treatment Integrity Code Version 3.0. Overall, peers had difficulty using open-ended questions and querying pros and cons, skills thought necessary to elicit change talk. They also tended to give too much direct advice where reflections would have been appropriate. A challenge was training peers to change familiar ways of communicating. Nonetheless, they did well at assessing and highlighting motivation to change. The total training hours (40 h) was long compared with other published MI studies. However, the intervention included several components with two targeted change behaviors. It is likely that peers can be trained in MI with fidelity in less time given a more streamlined intervention. When working with peers who have life stressors similar to the target group, it is important to be flexible in the training.
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Affiliation(s)
- Hannah Wolfe
- St. Luke's-Roosevelt Hospital Center, Center for Comprehensive Care, NY, USA
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Helfand BT, Lee JY, Sharp V, Foster H, Naslund M, Williams OD, McVary KT. Associations between improvements in lower urinary tract symptoms and sleep disturbance over time in the CAMUS trial. J Urol 2012; 188:2288-93. [PMID: 23083656 DOI: 10.1016/j.juro.2012.07.104] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Indexed: 01/23/2023]
Abstract
PURPOSE We recently reported an association between the bother and severity of lower urinary tract symptoms secondary to benign prostatic hyperplasia and the severity of sleep disturbance. However, few studies have examined whether alterations in the severity of urinary symptoms influence the degree of sleep problems over time. MATERIALS AND METHODS The severity of lower urinary tract symptoms in men enrolled in CAMUS (Complementary and Alternative Medicine for Urological Symptoms), a clinical trial of saw palmetto (Serenoa repens), was evaluated using AUASI (American Urological Association symptom index) and quality of life scores. Sleep disturbance was evaluated by the Jenkins sleep scale at 0, 24, 48 and 72 weeks. Statistical analyses were used to assess the relationship(s) between changes in lower urinary tract symptoms and sleep disturbance. RESULTS The baseline characteristics of the 339 men (172 placebo arm and 167 saw palmetto arm) enrolled in the CAMUS trial with assessment of sleep disturbance and urinary symptoms were similar. There were no differences between improvements in the severity of sleep disturbance or urinary symptoms between the 2 experimental arms. Combined analyses of the entire cohort revealed significant associations (p <0.001) between the AUASI score and sleep disturbance severity with time. Multivariate analyses demonstrated that improvements in lower urinary tract symptoms other than nocturia were the most significant predictors of improvements in sleep disturbance. Specific analyses adjusting for other baseline characteristics demonstrated that a 3-point improvement in AUASI score was associated with a 0.73-point improvement in the Jenkins sleep scale with time. CONCLUSIONS Improvements in lower urinary tract symptoms correlate with changes in sleeping abilities with time in men with benign prostatic hyperplasia. While nocturia is significantly associated with sleep disturbance, other changes in overall lower urinary tract symptoms are better predictors of changes in sleep dysfunction.
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Affiliation(s)
- Brian T Helfand
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Degregori MD, McElroy C, Psevdos G, Mueller J, Sharp V. Immune Reconstitution Inflammatory Syndrome Presenting as Mycobacterium avium intracellulare Mediastinitis. Chest 2012. [DOI: 10.1378/chest.1380610] [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: 11/01/2022] Open
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Hsu I, Saha S, Korthuis PT, Sharp V, Cohn J, Moore RD, Beach MC. Providing support to patients in emotional encounters: a new perspective on missed empathic opportunities. Patient Educ Couns 2012; 88:436-42. [PMID: 22818767 PMCID: PMC3448439 DOI: 10.1016/j.pec.2012.06.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 06/11/2012] [Accepted: 06/14/2012] [Indexed: 05/19/2023]
Abstract
OBJECTIVE Studies have repeatedly found that providers miss 70-90% of opportunities to express empathy. Our study sought to characterize provider responses to patients' emotions, with the overall goal of better understanding reasons for lack of empathic response. METHODS We analyzed 47 visits between patients and their providers. We defined empathic opportunities as instances where patients expressed a strong negative emotion. We then developed thematic categories to describe provider response. RESULTS We found a total of 29 empathic opportunities within 21 visits. Provider responses were categorized as ignore, dismiss, elicit information, problem-solve, or empathize. An empathic statement occurred at some point in the response sequence in 13/29 opportunities (45%). When problem-solving was the initial response, empathic statements rarely occurred in subsequent dialogue. Among the 16 instances with no empathic statements, providers engaged in problem-solving in 8 (50%). CONCLUSION Similar to other studies, we found providers missed most opportunities to respond empathically to patient emotion. Yet contrary to common understanding, providers often addressed the problem underlying the emotion, especially when the problem involved logistical or biomedical issues, as opposed to grief. PRACTICE IMPLICATIONS With enhanced awareness, providers may better recognize situations where they can offer empathy in addition to problem-solving.
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Affiliation(s)
- Ian Hsu
- Johns Hopkins University, Baltimore, USA
| | - Somnath Saha
- Oregon Health and Science University, Portland, USA
- Portland VA Medical Center, Portland, USA
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Abstract
A retrospective review of 4,721 human immunodeficiency virus (HIV)-infected patients, followed at St. Luke's Roosevelt Hospital Center, New York City, was conducted from January 1, 2005 to December 31, 2009. HIV-Hepatitis B virus (HBV) co-infection rate was 218/4,721, 4.6%. Among co-infected patients, 19 patients (19/218, 8.7%) died; 13 patients (13/19, 68.4%) died from non-acquired immune deficiency syndrome (AIDS) defining including 2 patients with liver failure. More non-survivors (5 patients, 5/19, 26.3%) had liver cirrhosis than those who survived (8 patients, 8/199, 4.0%; P = 0.002). There were more patients with positive HBV e antigen (HBeAg) among non-survivors, (12 patients, 12/19, 63.2%) than among survivors (74 patients, 74/199, 37.2%; P = 0.047). HIV-HBV co-infection is associated with increased overall mortality. Therefore, use of dual active antiretrovirals, particularly, tenofovir (TDF) based regimen for optimal suppression of HIV-HBV and immune restoration with prevention of high risk behaviors may contribute to improved outcomes.
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Affiliation(s)
- Jong Hun Kim
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - George Psevdos
- Department of Infectious Diseases, St.Luke's-Roosevelt Hospital Center, Affiliate of Columbia University College of Physicians and Surgeons, New York, NY, USA
- Center for Comprehensive Care, St.Luke's-Roosevelt Hospital Center, New York, NY, USA
| | - Victoria Sharp
- Center for Comprehensive Care, St.Luke's-Roosevelt Hospital Center, New York, NY, USA
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Kim JH, Gandhi V, Psevdos G, Espinoza F, Park J, Sharp V. Evaluation of vitamin D levels among HIV-infected patients in New York City. AIDS Res Hum Retroviruses 2012; 28:235-41. [PMID: 21644847 DOI: 10.1089/aid.2011.0040] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [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
Few studies have examined the vitamin D status in HIV-infected patients. A cross-sectional retrospective chart review of 2992 HIV-infected patients was conducted from 9/2008 to 5/2009. A total of 274 adult patients had 25-hydroxyvitamin D [25(OH)D] obtained by radioimmunoassay. None was receiving vitamin D (vitD) supplements. Vitamin D status was defined as the following: vitD deficiency (vitDd) as 25(OH)D <25 nmol/liter, vitD insufficiency (vitDi) as 25(OH)D 25-74 nmol/liter, and vitD optimal (vitDo) as 25(OH)D ≥75 nmol/liter. We analyzed demographic/laboratory data. vitDd, vitDi, and vitDo were 21.2% (58 patients, 58/274), 68.6% (188 patients, 188/274), and 10.2% (28 patients, 28/274), respectively. There were significant racial differences. Blacks were 60.3% (35 patients, 35/58), 40.4% (76 patients, 76/188), and 28.6 % (8 patients, 8/28) in vitDd, vitDi, and vitDo, respectively, p=0.002. CD4 T cell count was not different in these three groups. However, HIV viral load was significantly different. Median log (10) HIV viral load was 2.31 with IQR 1.70-409, 1.70 with IQR 1.70-2.96, and 1.70 with IQR 1.70-2.78 in vitDd, vitDi, and vitDo, respectively, p=0.039. Multivariate logistic regression analysis showed that black race [odd ratio (OR) 4.108, 95% confidence interval (CI) 1.462-11.543, p=0.007] and HIV viral load>50 copies/ml (OR 2.396, 95% CI 1.120-5.127, p=0.024) were significantly associated with vitamin D deficiency. Vitamin D deficiency was highly prevalent in HIV-infected patients. Detectable HIV viremia and dark skin (black ethnicity) were significantly associated with vitamin D deficiency. Evaluation of vitamin D status in HIV-infected patients should be considered and further studies are needed to define the effects of vitamin D.
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Affiliation(s)
- Jong Hun Kim
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vani Gandhi
- Center for Comprehensive Care, St. Luke's–Roosevelt Hospital Center, New York, New York
- Division of Infectious Diseases, St. Luke's–Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York
| | - George Psevdos
- Center for Comprehensive Care, St. Luke's–Roosevelt Hospital Center, New York, New York
- Division of Infectious Diseases, St. Luke's–Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York
| | - Fabiola Espinoza
- Division of Infectious Diseases, Albert Einstein College of Medicine, New York, New York
| | - Joyce Park
- Center for Comprehensive Care, St. Luke's–Roosevelt Hospital Center, New York, New York
| | - Victoria Sharp
- Center for Comprehensive Care, St. Luke's–Roosevelt Hospital Center, New York, New York
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Kim JH, Psevdos G, Groce V, Sharp V. Persistence of Protective Hepatitis B Surface Antibody Titers after Successful Double-Dose Hepatitis B Virus Rescue Vaccination in HIV-Infected Patients. Gut Liver 2012; 6:86-91. [PMID: 22375176 PMCID: PMC3286744 DOI: 10.5009/gnl.2012.6.1.86] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 06/20/2011] [Accepted: 07/06/2011] [Indexed: 12/23/2022] Open
Abstract
Background/Aims To assess the durability of protective hepatitis B surface antibody (anti-HBs) titers in HIV-infected patients who responded to double-dose hepatitis B virus (HBV) rescue vaccination. Methods A retrospective chart review was performed for HIV-infected patients who received the double-dose HBV rescue vaccination at 0-, 1-, and 2-month intervals after they had failed conventional HBV vaccination series. A protective antibody response was defined as an anti-HBs titer ≥10 mIU/mL. Results Of 54 HIV-infected patients who received a double-dose HBV rescue vaccination, 44 patients (81.5%) had a positive response and achieved protective anti-HB titers. Of the 44 patients who developed protective anti-HB titers, 33 patients received an evaluation of their anti-HB titers 12 months later. Of the 33 patients, 19 (57.6%) had persistent protective anti-HB titers (persistent responders, PR), and 14 patients (42.4%) lost their protective anti-HB titers (nonpersistent responders, NPR). There were significantly more patients who had an undetectable HIV viral load (<50 copies/mL) at baseline and follow-up in the PR group (11/19, 57.9%) than in the NPR group (3/14, 21.4%, p=0.036). Logistic regression analysis showed that an undetectable HIV viral load at baseline and follow-up (odds ratio, 12.973; 95% confidence interval, 1.189 to 141.515; p=0.036) was associated with PR. Conclusions Protective anti-HB titers may decrease over time after successful double-dose HBV rescue vaccination in HIV-infected patients. HIV viral load suppression could improve the persistence of anti-HB titers.
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Affiliation(s)
- Jong Hun Kim
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
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Goloborodko V, Georgescu A, Psevdos G, Buonocore D, Sharp V. Listeria monocytogenes Bacteremia and Meningitis in HIV-Infected Patients. Infectious Diseases in Clinical Practice 2011. [DOI: 10.1097/ipc.0b013e31822e9d81] [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: 11/25/2022]
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Rahman NA, Bennink HJTC, Chrusciel M, Sharp V, Zimmerman Y, Dina R, Li X, Ellonen A, Rivero-Müller A, Dilworth S, Ghaem-Maghami S, Vainio O, Huhtaniemi I. A novel treatment strategy for ovarian cancer based on immunization against zona pellucida protein (ZP) 3. FASEB J 2011; 26:324-33. [PMID: 21974931 DOI: 10.1096/fj.11-192468] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We tested the principle of treating malignant ovarian tumors by vaccination against their ectopically expressed protein, zona pellucida glycoprotein (ZP) 3, using as the experimental model the granulosa cell tumors that develop in transgenic mice expressing the simian virus 40 T-antigen under the inhibin-α promoter (inhα/Tag). We found high ZP3 expression in granulosa cell tumors of the transgenic mice, in human surface ovarian cancer and granulosa cell lines, and in human granulosa cell tumors and their metastases. Early preventive immunization (between 2 and 5.5 mo of age) of transgenic mice with recombinant human (rh) ZP3 prevented ovarian tumorigenesis, and delayed therapeutic immunization (between 4.5 and 7 mo) reduced weights of existing tumors by 86 and 75%, respectively (P<0.001), compared to vehicle-treated control mice. No objective side effects of the immunizations were observed. Liver metastases were found in nontreated/vehicle-treated controls (n=7/39), but none following active rhZP3 immunizations (n=0/36; P<0.05). Immunization with rhZP3 was highly effective, as demonstrated by the induction of anti-ZP3 antibodies, as well as proliferative responses to the ZP3 antigen. These results signal rhZP3 immunization as a novel strategy to be developed for the immunotherapy of ovarian granulosa cell tumors, as well as for that of other malignancies that may express ZP3.
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Affiliation(s)
- Nafis A Rahman
- Department of Physiology, University of Turku, Turku, Finland.
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Kim JH, Psevdos G, Suh J, Sharp V. Factors influencing syphilis treatment failure and/or re-infection in HIV co-infected patients: immunosuppression or behaviors. Chin Med J (Engl) 2011; 124:2123-2126. [PMID: 21933613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Recent studies have reported overall increasing rates of syphilis with a high rate of human immunodeficiency virus (HIV) co-infection. However, there is little information about factors influencing syphilis treatment failure and/or re-infection in HIV co-infected patients. We conducted a study to evaluate factors associated with syphilis treatment failure/re-infection in HIV co-infected patients. METHODS We reviewed 3542 medical records of HIV-infected patients from January 2005 to December 2007 followed up at HIV Clinic in New York City. Patients were categorized by rapid plasma regain titer (RPR) into success/serofast (4-fold decrease in RPR by 12 months after treatment, RPR conversion to nonreactive, persistently stable reactive RPR with no 4-fold increase), and failure/re-infection (failure to decrease 4 folds in RPR by 12 months after treatment, 4-fold increase in RPR from baseline). RESULTS Among a total of 156 patients who met the eligibility criteria, 122 (78.2%) were under success/serofast category, and 34 (21.8%) were under failure/re-infection category. HIV viral load, CD4 cell count, and use of highly active antiretroviral therapy (HAART) were not associated with syphilis treatment failure/re-infection. However, early syphilis stage (OR: 11.036, 95%CI: 2.499 - 48.740, P = 0.002) and high (> 1:64) RPR titers (OR: 715.921, 95%CI: 422.175 - 23 113.396, P < 0.001) were significantly associated. CONCLUSIONS No correlations were seen with depressed immune states with syphilis treatment failure and/or re-infection. However, association with early stage syphilis suggests that risky psychological sexual behaviors may be the most important leading factor, emphasizing needs for safe sex education.
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Affiliation(s)
- Jong Hun Kim
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Samal L, Saha S, Chander G, Korthuis PT, Sharma RK, Sharp V, Cohn J, Moore RD, Beach MC. Internet health information seeking behavior and antiretroviral adherence in persons living with HIV/AIDS. AIDS Patient Care STDS 2011; 25:445-9. [PMID: 21682586 DOI: 10.1089/apc.2011.0027] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract While the Internet has the potential to educate persons living with HIV/AIDS (PLWHA), websites may contain inaccurate information and increase the risk of nonadherence with antiretroviral therapy (ART). The objectives of our study were to determine the extent to which PLWHA engage in Internet health information seeking behavior (IHISB) and to determine whether IHISB is associated with ART adherence. We conducted a survey of adult, English-speaking HIV-infected patients at four HIV outpatient clinic sites in the United States (Baltimore, Maryland; Detroit, Michigan; New York, and Portland, Oregon) between December 2004 and January 2006. We assessed IHISB by asking participants how much information they had received from the Internet since acquiring HIV. The main outcome was patient-reported ART adherence over the past three days. Data were available on IHISB for 433 patients, 334 of whom were on ART therapy. Patients had a mean age of 45 (standard error [SE] 0.45) years and were mostly male (66%), African American (58%), and had attained a high school degree (73%). Most (55%) reported no IHISB, 18% reported some, and 27% reported "a fair amount" or "a great deal." Patients who reported higher versus lower levels of IHISB were significantly younger, had achieved a higher level of education, and had higher medication self-efficacy. In unadjusted analyses, higher IHISB was associated with ART adherence (odds ratio [OR], 2.96, 95% confidence interval [CI] 1.27-6.94). This association persisted after adjustment for age, gender, race, education, clinic site, and medication self-efficacy (adjusted odds ratio [AOR] 2.76, 95% CI 1.11-6.87). Our findings indicate that IHISB is positively associated with ART adherence even after controlling for potentially confounding variables. Future studies should investigate the ways in which Internet health information may promote medication adherence among PLWHA.
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Affiliation(s)
- Lipika Samal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Somnath Saha
- Section of General Internal Medicine, Portland VA Medical Center, Portland, Oregon
- Division of General Internal Medicine & Geriatrics, Oregon Health Science University, Portland, Oregon
| | - Geetanjali Chander
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - P. Todd Korthuis
- Departments of Medicine and Public Health & Preventive Medicine, Oregon Health Science University, Portland, Oregon
| | - Rashmi K. Sharma
- Division of Hospital Medicine, Northwestern University, Chicago Illinois
| | - Victoria Sharp
- HIV Center for Comprehensive Care, Saint Lukes-Roosevelt Hospital, New York, New York
| | - Jonathan Cohn
- Division of Infectious Diseases, Wayne State University, Detroit, Michigan
| | - Richard D. Moore
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Catherine Beach
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Helfand BT, McVary KT, Meleth S, Sharp V, Foster H, Naslund M, Williams OD. The Relationship Between Lower Urinary Tract Symptom Severity and Sleep Disturbance in the CAMUS Trial. J Urol 2011; 185:2223-8. [DOI: 10.1016/j.juro.2011.02.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Indexed: 10/18/2022]
Affiliation(s)
- Brian T. Helfand
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kevin T. McVary
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sreelatha Meleth
- Division of Preventive Medicine, University of Alabama, Birmingham, Alabama
| | - Victoria Sharp
- Department of Urology, University of Iowa, Iowa City, Iowa
| | - Harris Foster
- Department of Urology, Yale University School of Medicine, New Haven, Connecticut
| | - Michael Naslund
- Department of Urology, University of Maryland, Baltimore, Maryland
| | - O. Dale Williams
- Division of Preventive Medicine, University of Alabama, Birmingham, Alabama
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Beach MC, Saha S, Korthuis PT, Sharp V, Cohn J, Wilson IB, Eggly S, Cooper LA, Roter D, Sankar A, Moore R. Patient-provider communication differs for black compared to white HIV-infected patients. AIDS Behav 2011; 15:805-11. [PMID: 20066486 DOI: 10.1007/s10461-009-9664-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Poor patient-provider interactions may play a role in explaining racial disparities in the quality and outcomes of HIV care in the United States. We analyzed 354 patient-provider encounters coded with the Roter Interaction Analysis System across four HIV care sites in the United States to explore possible racial differences in patient-provider communication. Providers were more verbally dominant in conversations with black as compared to white patients. This was largely due to black patients' talking less than white patients. There was no association between race and other measures of communication. Black and white patients rated their providers' communication similarly. Efforts to more effectively engage patients in the medical dialogue may lead to improved patient-provider relationships, self-management, and outcomes among black people living with HIV/AIDS.
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Affiliation(s)
- Mary Catherine Beach
- Johns Hopkins University Schools of Medicine and Public Health, Baltimore, MD, USA.
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Myerson M, Cohen S, Park J, Galatowitsch P, Urbina A, Sharp V. Prevalence of LDL Dyslipidemia, Assessment of Goal Attainment and Variables Associated with Goal Attainment in HIV+ Patients in a Dedicated HIV Clinic. J Clin Lipidol 2011. [DOI: 10.1016/j.jacl.2011.03.030] [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: 11/30/2022]
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Krutskikh A, De Gendt K, Sharp V, Verhoeven G, Poutanen M, Huhtaniemi I. Targeted inactivation of the androgen receptor gene in murine proximal epididymis causes epithelial hypotrophy and obstructive azoospermia. Endocrinology 2011; 152:689-96. [PMID: 21084446 PMCID: PMC3101806 DOI: 10.1210/en.2010-0768] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
The epithelial lining of the epididymal duct expresses the androgen receptor (Ar) along its entire length and undergoes rapid and profound degeneration when androgenic support is withdrawn. However, experiments involving orchidectomy with systemic testosterone replacement, and testicular efferent duct ligation, have indicated that structural and functional integrity of the initial segment cannot be maintained by circulating androgen alone, leaving the role of androgen in this epididymal zone unclear. We addressed this question in a mouse model with intact testicular output and selective Ar inactivation in the proximal epididymis by creating double-transgenic males carrying a conditional Ar(loxP) allele and expressing Cre recombinase under the promoter of Rnase10, a gene specifically expressed in proximal epididymis. At 20-25 d of life, on the onset of Rnase10 expression, Ar became selectively inactivated in the principal cells of proximal epididymis, resulting in epithelial hypoplasia and hypotrophy. Upon the subsequent onset of spermiation, epididymal obstruction ensued, with the consequent development of spermatic granulomata, back pressure-induced atrophy of the seminiferous epithelium, orchitis, and fibrosis of the testicular parenchyma. Consistent with these findings, the mice were infertile. When the effect of Ar knockout on gene expression in the proximal epididymis was compared with that of efferent duct ligation and orchidectomy, we identified genes specifically regulated by androgen, testicular efferent fluid, and both. Our findings demonstrate that the development and function of the epididymal initial segment is critically dependent on direct androgen regulation. The phenotype of the produced knockout mouse provides a novel model for obstructive azoospermia.
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Affiliation(s)
- Anton Krutskikh
- Department of Surgery and Cancer, Imperial College London, London W12 0NN, United Kingdom
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Ahtiainen P, Sharp V, Rulli SB, Rivero-Müller A, Mamaeva V, Röyttä M, Huhtaniemi I. Enhanced LH action in transgenic female mice expressing hCGbeta-subunit induces pituitary prolactinomas; the role of high progesterone levels. Endocr Relat Cancer 2010; 17:611-21. [PMID: 20453081 PMCID: PMC2881531 DOI: 10.1677/erc-10-0016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The etiology of pituitary adenomas remains largely unknown, with the exception of involvement of estrogens in the formation of prolactinomas. We have examined the molecular pathogenesis of prolactin-producing pituitary adenomas in transgenic female mice expressing the human choriongonadotropin (hCG) beta-subunit. The LH/CG bioactivity is elevated in the mice, with consequent highly stimulated ovarian progesterone (P(4)) production, in the face of normal estrogen secretion. Curiously, despite normal estrogen levels, large prolactinomas developed in these mice, and we provide here several lines of evidence that the elevated P(4) levels are involved in the growth of these estrogen-dependent tumors. The antiprogestin mifepristone inhibited tumor growth, and combined postgonadectomy estradiol/P(4) treatment was more effective than estrogen alone in inducing tumor growth. Evidence for direct growth-promoting effect of P(4) was obtained from cultures of primary mouse pituitary cells and rat somatomammotroph GH3 cells. The mouse tumors and cultured cells revealed stimulation of the cyclin D1/cyclin-dependent kinase 4/retinoblastoma protein/transcription factor E2F1 pathway in the growth response to P(4). If extrapolated to humans, and given the importance of endogenous P(4) and synthetic progestins in female reproductive functions and their pharmacotherapy, it is relevant to revisit the potential role of these hormones in the origin and growth of prolactinomas.
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Affiliation(s)
- Petteri Ahtiainen
- Department of PhysiologyUniversity of TurkuFIN-20520, TurkuFinland
- Turku Graduate School of Biomedical ScienceUniversity of TurkuFIN-20520, TurkuFinland
| | - Victoria Sharp
- Department of Surgery and CancerImperial College LondonHammersmith Campus, Du Cane Road, London, W12 0NNUK
| | - Susana B Rulli
- Department of PhysiologyUniversity of TurkuFIN-20520, TurkuFinland
- Institute of Biology and Experimental Medicine-CONICETVuelta de Obligado 2490, , Buenos Aires, 1428Argentina
| | | | - Veronika Mamaeva
- Department of PhysiologyUniversity of TurkuFIN-20520, TurkuFinland
| | - Matias Röyttä
- Department of PathologyUniversity of TurkuTurku, FIN-20520Finland
| | - Ilpo Huhtaniemi
- Department of PhysiologyUniversity of TurkuFIN-20520, TurkuFinland
- Department of Surgery and CancerImperial College LondonHammersmith Campus, Du Cane Road, London, W12 0NNUK
- Correspondence should be addressed to I Huhtaniemi at Department of Surgery and Cancer, Imperial College London, London W12 ONN, UK ()
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Nakao J, Egan D, Newman D, Sharp V, He X, Tsao D, Skalak T, Lord A, Nollen C, Wiener D. 131: Falling Through the Cracks? Missed Opportunities for Earlier Diagnosis of HIV Infection. Ann Emerg Med 2010. [DOI: 10.1016/j.annemergmed.2010.06.175] [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: 10/19/2022]
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Abstract
Impaired hepatitis B virus vaccine (HBVV) efficacy has been observed in HIV-infected patients. We assessed the immunogenicity of double-dose (DD) hepatitis B virus revaccination in patients who had failed to respond to standard vaccination. A retrospective chart review of 4,663 patients ensued in two urban HIV clinics between January 2004 and March 2009. Of 363 patients who received three standard doses (SDs) of HBVV, 126 (34.7%) responded with detectable hepatitis B surface antibody [(HBsAb) HBsAb titer of > or =10 mIU/ml] and 237 (65.3%) nonresponders (NRs) remained seronegative. Among NRs, 61 received three to eight additional SDs of HBVV; 29 received three double doses (DDs) of HBVV (40 microg/dose), spaced at monthly dosing intervals; and 11 received from one to five additional SD HBVV (who remained seronegative) and then received three DDs HBVV. Response rate was significantly higher among the 40 DD recipients than among the 61 who received only additional SD (34/40, 85%, vs. 36/61, 59%; p = 0.006). In the revaccinated NR group (61 SD + 40 DD), a logistic regression analysis found that use of highly active antiretroviral therapy (HAART) (OR, 10.166; CI, 1.359-76.026; p = 0.024), and CD4 cell counts > or =200 cells/mm(3) at the time of revaccination (OR, 9.233; CI, 1.393-61.207; p = 0.021) were associated with HBsAb response, as was DD HBV revaccination (OR, 4.177; CI, 1.282-13.614; p = 0.018). Rescue DD hepatitis B vaccination appears to improve the HBsAb response rate significantly in HIV-infected NR patients, especially after an adequate immune restoration with HAART. More prospective studies are needed to confirm these findings.
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Affiliation(s)
- George Psevdos
- Center for Comprehensive Care, St.Luke's–Roosevelt Hospital Center, New York, New York
- Division of Infectious Diseases, St. Luke's–Roosevelt Hospital Center, New York, New York
| | - Jong Hun Kim
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vanessa Groce
- Center for Comprehensive Care, St.Luke's–Roosevelt Hospital Center, New York, New York
| | - Victoria Sharp
- Center for Comprehensive Care, St.Luke's–Roosevelt Hospital Center, New York, New York
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Kumar R, Korthuis PT, Saha S, Chander G, Sharp V, Cohn J, Moore R, Beach MC. Decision-making role preferences among patients with HIV: associations with patient and provider characteristics and communication behaviors. J Gen Intern Med 2010; 25:517-23. [PMID: 20180157 PMCID: PMC2869417 DOI: 10.1007/s11606-010-1275-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 12/29/2009] [Accepted: 01/20/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND A preference for shared decision-making among patients with HIV has been associated with better health outcomes. One possible explanation for this association is that patients who prefer a more active role in decision-making are more engaged in the communication process during encounters with their providers. Little is known, however, about patient and provider characteristics or communication behaviors associated with patient decision-making preferences in HIV settings. OBJECTIVE We examined patient and provider characteristics and patient-provider communication behaviors associated with the decision-making role preferences of patients with HIV. DESIGN Cross-sectional analysis of patient and provider questionnaires and audio recorded clinical encounters from four sites. PARTICIPANTS A total of 45 providers and 434 of their patients with HIV. MEASURES Patients were asked how they prefer to be involved in the decision-making process (doctor makes all/most decisions, patients and doctors share decisions, or patients make decisions alone). Measures of provider and patient communication behaviors were coded from audio recordings using the Roter Interaction Analysis System. MAIN RESULTS Overall, 72% of patients preferred to share decisions with their provider, 23% wanted their provider to make decisions, and 5% wanted to make decisions themselves. Compared to patients who preferred to share decisions with their provider, patients who preferred their provider make decisions were less likely to be above the age of 60 (ARR 0.09, 95% CI 0.01-0.89) and perceive high quality provider communication about decision-making (ARR 0.41, 95% CI 0.23-0.73), and more likely to have depressive symptoms (ARR 1.92, 95% CI 1.07-3.44). There was no significant association between patient preferences and measures of provider or patient communication behavior. CONCLUSION Observed measures of patient and provider communication behavior were similar across all patient decision-making role preferences, indicating that it may be difficult for providers to determine these preferences based solely on communication behavior. Engaging patients in open discussion about decision-making preferences may be a more effective approach.
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Affiliation(s)
- Rashmi Kumar
- Johns Hopkins University, 2024 East Monument Street, Suite 2-600, Baltimore, MD 21205, USA.
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Kinsman H, Roter D, Berkenblit G, Saha S, Korthuis PT, Wilson I, Eggly S, Sankar A, Sharp V, Cohn J, Moore RD, Beach MC. "We'll do this together": the role of the first person plural in fostering partnership in patient-physician relationships. J Gen Intern Med 2010; 25:186-93. [PMID: 20033624 PMCID: PMC2839333 DOI: 10.1007/s11606-009-1178-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Revised: 09/30/2009] [Accepted: 10/17/2009] [Indexed: 12/30/2022]
Abstract
BACKGROUND Partnership is integral to therapeutic relationships, yet few studies have examined partnership-fostering communication behaviors in the clinic setting. We conducted this study to better understand how statements in which physicians use the first person plural might foster partnership between patient and provider. METHODS We audio-recorded encounters between 45 HIV providers and 418 patients in the Enhancing Communication and HIV Outcomes (ECHO) Study. We used the Roter Interaction Analysis System (RIAS) to code for statements made by the physician that used the first person plural to refer to themselves and their patient. Using multiple logistic regression, we examined the associations between the occurrence of one or more first person plural statements with patient ratings of provider communication. To better understand the meaning of first person plural statements, we conducted a qualitative analysis. MAIN RESULTS Providers were mostly white (69%) and Asian (24%); 57% were female. Patients were black (60%), white (25%), and Hispanic (15%); 33% were female. One or more first person plural statements occurred in 92/418 (22%) of encounters. In adjusted analyses, encounters with first person plural statements were associated with younger patient age (OR 0.97, 95% CI 0.94-0.99), higher patient depression scores (highest tertile compared to lowest tertile: OR 1.89, 95% CI 1.01-3.51), the patient not being on anti-retroviral therapy (OR 0.53, 95% CI 0.29-0.93), and older provider age (OR 1.05, 95% CI 1.00-1.09). After adjustment, patients were less likely to highly rate their provider's communication style if first person plural statements were used (AOR 0.57, 95% CI 0.33-0.96). There were 167 first person plural statements made by physicians in the 418 encounters. Qualitative analysis revealed that many first person plural features had at least one negative feature such as being overtly persuasive ("That's going to be our goal"), indirect ("What can we do to improve your diet?"), or ambiguous ("Let's see what we can do"), although there were also positive statements that involved patients in the health-care process, contributed to a mutual understanding, and addressed the patients' goals. CONCLUSIONS Contrary to our hypotheses, use of first person plural was not associated with higher ratings of provider communication, probably because some of these statements were overtly persuasive, indirect, or ambiguous. Physicians should become aware of benefits and pitfalls of using the first person plural with patients. Further research is needed to determine the most effective methods through which providers can build alliances with patients.
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Affiliation(s)
- Helen Kinsman
- Johns Hopkins University, 2024 East Monument Street, Room 2-521, Baltimore, MD 21287, USA
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Psevdos G, Sharp V. Successful treatment of uncomplicated gonococcal urethritis in HIV-infected patients with single-dose oral cefpodoxime. Can J Infect Dis Med Microbiol 2010; 21:e109-e110. [PMID: 21886642 PMCID: PMC2951812 DOI: 10.1155/2010/561908] [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] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Fluoroquinolones are no longer recommended for the treatment of gonococcal infections in the United States. Cephalosporins - ceftriaxone and cefixime - are the treatment of choice, as suggested by the Centers for Disease Control and Prevention (USA). There are limited data on the efficacy of cefpodoxime for the treatment of uncomplicated gonococcal infections. Two cases of HIV-infected homosexual men who were successfully treated with cefpodoxime for urethritis caused by Neisseria gonorrhoeae are described in the present study.
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Affiliation(s)
- George Psevdos
- Correspondence: Dr George Psevdos Jr, 1000 10th Avenue, Suite 2T, Samuels Clinic, St Luke’s Roosevelt Hospital, New York, New York 10019, USA. Telephone 212-523-6500, fax 212-523-7182, e-mail
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Sharp V, Thurston LM, Fowkes RC, Michael AE. Expression and activities of 11betaHSD enzymes in the testes and reproductive tracts of sexually immature male pigs. J Steroid Biochem Mol Biol 2009; 115:98-106. [PMID: 19500728 DOI: 10.1016/j.jsbmb.2009.03.009] [Citation(s) in RCA: 10] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Revised: 03/02/2009] [Accepted: 03/31/2009] [Indexed: 10/20/2022]
Abstract
In light of studies implicating glucocorticoids in the control of testicular steroidogenesis and/or spermatogenesis, the objective of this study was to characterise the expression and activities of the 11beta-hydroxysteroid dehydrogenase (11betaHSD) enzymes in the testis and reproductive tract of the pre-pubertal pig. Although 11betaHSD1 and 11betaHSD2 mRNA transcripts and proteins were co-expressed in all regions of the reproductive tract, cortisol-cortisone inter-conversion was detectable in the testis, caput epididymidis and bulbourethral glands only. In homogenates of these 3 tissues, the apparent K(m) for NADP(+)- and NAD(+)-dependent 11beta-dehydrogenase activities ranged between 152-883 and 47-479 nmoll(-1), respectively. Irrespective of the pyridine nucleotide co-substrate, estimates of V(max) were consistently two orders of magnitude higher in the testis. Moreover, while, in each tissue, levels of cortisol oxidation were comparable in the presence of either NADP(+) or NAD(+), maximal rates of NAD(P)(+)-dependent cortisol oxidation were up to 33-fold greater than the V(max) for NADPH-dependent reduction of cortisone. We conclude that in the testis, caput epididymidis and bulbourethral gland of the immature pig, NADP(+)- and NAD(+)-dependent 11betaHSD enzymes catalyse net inactivation of cortisol, suggesting a physiological role for these enzymes in limiting local actions of glucocorticoids within these male reproductive tissues prior to puberty.
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Affiliation(s)
- Victoria Sharp
- Endocrine Signalling Group, Department of Veterinary Basic Sciences, Royal Veterinary College, Royal College Street, London, NW1 0TU, UK.
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