Bile salts and fatty acids induce the expression of Escherichia coli AcrAB multidrug efflux pump through their interaction with Rob regulatory protein

AcrAB of Escherichia coli, an archetype among bacterial multidrug efflux pumps, exports an extremely wide range of substrates including solvents, dyes, detergents and antimicrobial agents. Its expression is regulated by three XylS/AraC family regulators, MarA, SoxS and Rob. Although MarA and SoxS regulation works by the alteration of their own expression levels, it was not known how Rob, which is constitutively expressed, exerts its regulatory action. We show here that the induction of the AcrAB efflux pump by decanoate and the more lipophilic unconjugated bile salts is mediated by Rob, and that the low-molecular-weight inducers specifically bind to the C-terminal, non-DNA-binding domain of Rob. Induction of Rob is not needed for induction of AcrAB, and we suggest that the inducers act by producing conformational alterations in pre-existing Rob, as was suggested recently (Rosner, Dangi, Gronenborn and Martin, J Bacteriol 184: 1407-1416, 2002). Decanoate and unconjugated bile salts, which are present in the normal habitat of E. coli, were further shown to make the bacteria more resistant to lipophilic antibiotics, at least in part because of the induction of the AcrAB efflux pump. Thus, it is likely that E. coli is protecting itself by the Rob-mediated upregulation of AcrAB against the harmful effects of bile salts and fatty acids in the intestinal tract.

Elevated risk for autoimmune disorders in iraq and afghanistan veterans with posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with endocrine and immune abnormalities that could increase risk for autoimmune disorders. However, little is known about the risk for autoimmune disorders among individuals with PTSD.

METHODS

We conducted a retrospective cohort study of 666,269 Iraq and Afghanistan veterans under age 55 who were enrolled in the Department of Veterans Affairs health care system between October 7, 2001, and March 31, 2011. Generalized linear models were used to examine if PTSD, other psychiatric disorders, and military sexual trauma exposure increased risk for autoimmune disorders, including thyroiditis, inflammatory bowel disease, rheumatoid arthritis, multiple sclerosis, and lupus erythematosus, adjusting for age, gender, race, and primary care visits.

RESULTS

PTSD was diagnosed in 203,766 veterans (30.6%), and psychiatric disorders other than PTSD were diagnosed in an additional 129,704 veterans (19.5%). Veterans diagnosed with PTSD had significantly higher adjusted relative risk (ARR) for diagnosis with any of the autoimmune disorders alone or in combination compared with veterans with no psychiatric diagnoses (ARR = 2.00; 95% confidence interval, 1.91-2.09) and compared with veterans diagnosed with psychiatric disorders other than PTSD (ARR = 1.51; 95% confidence interval, 1.43-1.59; p < .001). The magnitude of the PTSD-related increase in risk for autoimmune disorders was similar in women and men, and military sexual trauma exposure was independently associated with increased risk in both women and men.

CONCLUSIONS

Trauma exposure and PTSD may increase risk for autoimmune disorders. Altered immune function, lifestyle factors, or shared etiology may underlie this association.

Assessing the accuracy of administrative data in health information systems

BACKGROUND

Administrative data play a central role in health care. Inaccuracies in such data are costly to health systems, they obscure health research, and they affect the quality of patient care.

OBJECTIVES

We sought to prospectively determine the accuracy of the primary and secondary diagnoses recorded in administrative data sets.

RESEARCH DESIGN

Between March and July 2002, standardized patients (SPs) completed unannounced visits at 3 sites. We abstracted the 348 medical records from these visits to obtain the written diagnoses made by physicians. We also examined the patient files to identify the diagnoses recorded on the administrative encounter forms and extracted data from the computerized administrative databases. Because the correct diagnosis was defined by the SP visit, we could determine whether the final diagnosis in the administrative data set was correct and, if not, whether it was caused by physician diagnostic error, missing encounter forms, or incorrectly filled out forms.

SUBJECTS

General internal medicine outpatient clinics at 2 Veterans Administration facilities and a large, private medical center participated in this study.

MEASURES

A total of 45 trained SPs presented to physicians with 4 common outpatient conditions.

RESULTS

The correct primary diagnosis was recorded for 57% of visits. Thirteen percent of errors were caused by physician diagnostic error, 8% to missing encounter forms, and 22% to incorrectly entered data. Findings varied by condition and site but not by level of training. Accuracy of secondary diagnosis data (27%) was even poorer.

CONCLUSIONS

Although more research is needed to evaluate the cause of inaccuracies and the relative contributions of patient, provider, and system level effects, it appears that significant inaccuracies in administrative data are common. Interventions aimed at correcting these errors appear feasible.

When to refer patients with chronic kidney disease for vascular access surgery: Should age be a consideration?

To determine whether age should inform our approach toward permanent vascular access placement in patients with chronic kidney disease, we conducted a retrospective cohort study among 11 290 non-dialysis patients with an estimated glomerular filtration rate (eGFR) <25 ml/min/1.73 m(2) based on 2000-2001 outpatient creatinine measurements in the Department of Veterans Affairs. For each age group, we examined the percentage of patients that had and had not received a permanent access by 1 year after cohort entry, and the percentage in each of these groups that died, started dialysis, or survived without dialysis. We also modeled the number of unnecessary procedures that would have occurred in theoretical scenarios based on existing vascular access guidelines. The mean eGFR was 17.7 ml/min/1.73 m(2) at cohort entry. Twenty-five percent (n=2870) of patients initiated dialysis within a year of cohort entry. Among these, only 39% (n=1104) had undergone surgery to place a permanent access beforehand. As compared with younger patients, older patients were less likely to undergo permanent access surgery, but also less likely to start dialysis. In all theoretical scenarios examined, older patients would have been more likely than younger patients to receive unnecessary procedures. If all patients had been referred for permanent access surgery at cohort entry, the ratio of unnecessary to necessary procedures after 2 years of follow-up would have been 5:1 for patients aged 85-100 years but only 0.5:1 for those aged 18-44 years. Currently recommended approaches to permanent access placement based on a single threshold level of renal function for patients of all ages are not appropriate.

The Relationship of Indwelling Urinary Catheters to Death, Length of Hospital Stay, Functional Decline, and Nursing Home Admission in Hospitalized Older Medical Patients

OBJECTIVES

To determine the association between indwelling urinary catheterization without a specific medical indication and adverse outcomes.

DESIGN

Prospective cohort.

SETTING

General medical inpatient services at a teaching hospital.

PARTICIPANTS

Five hundred thirty-five patients aged 70 and older admitted without a specific medical indication for urinary catheterization.

INTERVENTION

Indwelling urinary catheterization within 48 hours of admission.

MEASUREMENTS

Death, length of hospital stay, decline in ability to perform activities of daily living (ADLs), and new admission to a nursing home.

RESULTS

Indwelling urinary catheters were placed in 76 of the 535 (14%) patients without a specific medical indication. Catheterized patients were more likely to die in the hospital (6.6% vs 1.5% of those not catheterized, P=.006) and within 90 days of hospital discharge (25% vs 10.5%, P<.001); the greater risk of death with catheterization persisted in a propensity-matched analysis (hazard ratio (HR)=2.42, 95% confidence interval (CI)=1.04-5.65). Catheterized patients also had longer lengths of hospital stay (median, 6 days vs 4 days; P=.001); this association persisted in a propensity-matched analysis (HR=1.46, 95% CI=1.03-2.08). Catheterization was not associated (P>.05) with decline in ADL function or with admission to a nursing home.

CONCLUSION

In this cohort of older patients, urinary catheterization without a specific medical indication was associated with greater risk of death and longer hospital stay.

An evaluation of vignettes for predicting variation in the quality of preventive care

OBJECTIVE

Clinical vignettes offer an inexpensive and convenient alternative to the benchmark method of chart audits for assessing quality of care. We examined whether vignettes accurately measure and predict variation in the quality of preventive care.

DESIGN

We developed scoring criteria based on national guidelines for 11 prevention items, categorized as vaccine, vascular-related, cancer screening, and personal behaviors. Three measurement methods were used to ascertain the quality of care provided by clinicians seeing trained actors (standardized patients; SPs) presenting with common outpatient conditions: 1) the abstracted medical record from an SP visit; 2) SP reports of physician practice during those visits; and 3) physician responses to matching computerized case scenarios (clinical vignettes).

SETTING

Three university-affiliated (including 2 VA) and one community general internal medicine clinics.

PATIENTS/PARTICIPANTS

Seventy-one randomly selected physicians from among eligible general internal medicine residents and attending physicians.

MEASUREMENTS AND MAIN RESULTS

Physicians saw 480 SPs (120 at each site) and completed 480 vignettes. We calculated the proportion of prevention items for each visit reported or recorded by the 3 measurement methods. We developed a multiple regression model to determine whether site, training level, or clinical condition predicted prevention performance for each measurement method. We found that overall prevention scores ranged from 57% (SP) to 54% (vignettes) to 46% (chart abstraction). Vignettes matched or exceeded SP scores for 3 prevention categories (vaccine, vascular-related, and personal behavior). Prevention quality varied by site (from 40% to 67%) and was predicted similarly by vignettes and SPs.

CONCLUSIONS

Vignettes can measure and predict prevention performance. Vignettes may be a less costly way to assess prevention performance that also controls for patient case-mix.

The impact of HIV on chronic kidney disease outcomes

Chronic kidney disease (CKD) is a known complication of the human immunodeficiency virus (HIV) but outcomes among HIV-infected patients with kidney disease are unknown. We studied a national sample of 202,927 patients with CKD (stage 3 or higher) for death, end-stage renal disease (ESRD) and the mean annual rate of decline in estimated glomerular filtration rate (eGFR) over a median period of 3.8 years. Within this sample, 0.3% of the patients were diagnosed with HIV, 43.5% were diabetic, whereas the remainder had neither disease. In this national CKD cohort, HIV-infected black patients were at higher risk of death, a similar risk for ESRD and loss of eGFR than black patients with diabetes. HIV-infected white patients experienced higher rates of death but a lower risk of ESRD than their counterparts with diabetes. Our results highlight a need to study mortality and mechanisms of ESRD in the HIV infected population.

Quality of care associated with number of cases seen and self-reports of clinical competence for Japanese physicians-in-training in internal medicine

BACKGROUND

The extent of clinical exposure needed to ensure quality care has not been well determined during internal medicine training. We aimed to determine the association between clinical exposure (number of cases seen), self- reports of clinical competence, and type of institution (predictor variables) and quality of care (outcome variable) as measured by clinical vignettes.

METHODS

Cross-sectional study using univariate and multivariate linear analyses in 11 teaching hospitals in Japan. Participants were physicians-in-training in internal medicine departments. Main outcome measure was standardized t-scores (quality of care) derived from responses to five clinical vignettes.

RESULTS

Of the 375 eligible participants, 263 (70.1%) completed the vignettes. Most were in their first (57.8%) and second year (28.5%) of training; on average, the participants were 1.8 years (range = 1-8) after graduation. Two thirds of the participants (68.8%) worked in university-affiliated teaching hospitals. The median number of cases seen was 210 (range = 10-11400). Greater exposure to cases (p = 0.0005), higher self-reports of clinical competence (p = 0.0095), and type of institution (p < 0.0001) were significantly associated with higher quality of care, using a multivariate linear model and adjusting for the remaining factors. Quality of care rapidly increased for the first 100 to 200 cases seen and tapered thereafter.

CONCLUSION

The amount of clinical exposure and levels of self-reports of clinical competence, not years after graduation, were positively associated with quality of care, adjusting for the remaining factors. The learning curve tapered after about 200 cases.

An evaluation of vignettes for predicting variation in the quality of preventive care

OBJECTIVE

Clinical vignettes offer an inexpensive and convenient alternative to the benchmark method of chart audits for assessing quality of care. We examined whether vignettes accurately measure and predict variation in the quality of preventive care.

DESIGN

We developed scoring criteria based on national guidelines for 11 prevention items, categorized as vaccine, vascular-related, cancer screening, and personal behaviors. Three measurement methods were used to ascertain the quality of care provided by clinicians seeing trained actors (standardized patients; SPs) presenting with common outpatient conditions: 1) the abstracted medical record from an SP visit; 2) SP reports of physician practice during those visits; and 3) physician responses to matching computerized case scenarios (clinical vignettes).

SETTING

Three university-affiliated (including 2 VA) and one community general internal medicine clinics.

PATIENTS/PARTICIPANTS

Seventy-one randomly selected physicians from among eligible general internal medicine residents and attending physicians.

MEASUREMENTS AND MAIN RESULTS

Physicians saw 480 SPs (120 at each site) and completed 480 vignettes. We calculated the proportion of prevention items for each visit reported or recorded by the 3 measurement methods. We developed a multiple regression model to determine whether site, training level, or clinical condition predicted prevention performance for each measurement method. We found that overall prevention scores ranged from 57% (SP) to 54% (vignettes) to 46% (chart abstraction). Vignettes matched or exceeded SP scores for 3 prevention categories (vaccine, vascular-related, and personal behavior). Prevention quality varied by site (from 40% to 67%) and was predicted similarly by vignettes and SPs.

CONCLUSIONS

Vignettes can measure and predict prevention performance. Vignettes may be a less costly way to assess prevention performance that also controls for patient case-mix.

1112 Mental Health And Sleep Disorders Are Associated With Elevated C-reactive Protein In Returning Veterans

Introduction

Mental health disorders and sleep disorders are associated with systemic inflammation, which may be a key element linking these highly co-occurring conditions to negative health outcomes. This study used national VA medical records to examine C-reactive protein (CRP) levels in Iraq/Afghanistan veterans based on presence of mental health and/or sleep disorder diagnoses.

Methods

We examined medical records for 16,576 Iraq/Afghanistan veterans under age 55 who had high-sensitivity CRP results reported. ICD diagnostic codes were used to compare CRP values for: a) veterans without sleep disorders or mental health diagnoses, b) veterans with mental health disorders only, c) veterans with sleep disorders only, and d) veterans with both conditions. In generalized linear models controlling for demographics, we examined the impact of diagnostic category on continuous CRP value as well as the risk of elevated CRP (&gt;3mg/L).

Results

Veterans with mental health disorders (coeff=.14, p&lt;.001) and comorbid sleep and mental health disorders (coeff=.21, p&lt;.001) had higher continuous CRP values compared to veterans without either condition. Veterans with comorbid sleep and mental health disorders had higher continuous CRP values than veterans with sleep disorders alone (coeff=.22, p&lt;.041); however, there were few patients in the current sample who were diagnosed with sleep disorders alone (n=401, 2.4%). Additionally, veterans with mental health disorders (ARR=1.12, p=.004) and comorbid sleep and mental health disorders (ARR=1.15, p=.001) were more likely to have CRP values &gt;3mg/L compared to veterans without either condition.

Conclusion

Sleep disorders were highly likely to co-occur with mental health disorders in this sample of Iraq/Afghanistan veterans. Mental health disorders and comorbid mental health/sleep disorders were associated with elevated C-reactive protein, indicating these patients are at highest risk for negative health outcomes. Future studies should investigate directionality of relationships among sleep disruption, mental health symptoms, and inflammation.

Support

VA Advanced Fellowship Program in Mental Illness Research and Treatment

Developing and testing a COVID-19 vaccination acceptance intervention: A pragmatic trial comparing vaccine acceptance intervention vs usual care - Rationale, methods, and implementation

BACKGROUND

COVID-19 has resulted in significant disability and loss of life. COVID-19 vaccines effectively prevent severe illness, hospitalization, and death. Nevertheless, many people remain hesitant to accept vaccination. Veterans perceive healthcare providers (HCP) and staff as trusted vaccine information sources and thereby are well suited to initiate vaccine discussions. The overall objective of this study is to implement and test a virtual COVID-19 Vaccine Acceptance Intervention (VAI) training that is informed by motivational interviewing (MI) techniques.

METHODS

The VAI training is being delivered to VA HCPs and staff within a Hybrid Type 2 pragmatic implementation-effectiveness trial using Implementation Facilitation as the implementation strategy. The implementation team includes external facilitators paired with VA Healthcare System (VAHCS)-level internal facilitators. The trial has three aims: 1) Examine the effectiveness of the VAI versus usual care on unvaccinated veterans' vaccination rates in a one-year cluster randomized controlled trial, with randomization at the level of VAHCS. 2) Determine factors associated with veterans' decisions to accept or decline primary COVID-19 vaccination, and better understand how these factors influence vaccination decisions, through survey and qualitative data; and 3) Use qualitative interviews with HCPs and staff from clinics with high and low vaccination rates to learn what was helpful and not helpful about the VAI and implementation strategies.

CONCLUSION

This is the first multisite randomized controlled trial to test an MI-informed vaccine acceptance intervention to improve COVID-19 vaccine acceptance. Information gained can be used to inform healthcare systems' approaches to improve future vaccination and other public health campaigns.

CLINICALTRIALS

gov Identifier: NCT05027464.

When clinicians and patients disagree on vaccination: what primary care clinicians can learn from COVID-19-vaccine-hesitant patients about communication, trust, and relationships in healthcare

BACKGROUND

In the United States, discourse on COVID-19 vaccination has become polarized, and the positions of public health officials are met with skepticism by many vaccine-hesitant Americans. This polarization may impact future vaccination efforts as well as clinician-patient relationships.

METHODS

We interviewed 77 vaccine-hesitant patients and 41 clinicians about COVID-19 vaccination communication in primary care as part of a Veterans Affairs (VA) trial evaluating a vaccine-communication intervention. This paper reports the findings of a qualitative analysis focused on one aspect of those interviews-the disconnect between primary care clinicians' and patients' perceptions about COVID-19 vaccination communication and decision-making.

RESULTS

Rapid qualitative analysis of semi-structured interviews revealed fundamental differences in how clinicians and patients understood and described the reasoning, values, and concerns underlying COVID-19 vaccine hesitancy. These differences were significant and value-laden; they included negative judgments that could undermine communication between clinicians and patients and, over time, erode trust and empathy.

CONCLUSION

We advocate for empathic listening and suggest communication strategies to bridge the divide between clinicians and vaccine-hesitant patients.

Evaluation of a New Integrative Health and Wellness Clinic for Veterans at the San Francisco VA Health Care System: A Mixed-Methods Pilot Study

Objective

The Integrative Health and Wellness Clinic (IHWC), established in 2019 at the San Francisco VA Health Care System, is an interdisciplinary clinic consisting of a medical provider, dietician, physical therapist, and psychologist trained in complementary and integrative health (CIH) following the VA Whole Health model of care. Veterans with complex chronic conditions seeking CIH and nonpharmacologic approaches are referred to the IHWC. This study evaluated the clinic's acceptability and feasibility among veteran patients and its preliminary impact on health and wellbeing, health-related goals, and use of CIH approaches.

Methods

Mixed methods were used to assess patient-reported outcomes and experiences with the IHWC. Participants completed surveys administered at baseline and 6-months and a subset completed a qualitative interview. Pre- and post-scores were compared using t-tests and chi-square tests.

Results

Thirty-five veterans completed baseline and 6-month follow up surveys. Of these, 13% were women; 24% < 50 years of age, and 44% identified as racial/ethnic minorities. Compared to baseline, at 6 months, there were significant (P < .05) improvements in overall health, physical health, perceived stress, and perceived helpfulness of clinicians in assisting with goal attainment; there was a trend toward improved mental health (P = .057). Interviews (n = 25) indicated satisfaction with the interdisciplinary clinical model, support of IHWC providers in goal attainment, and positive impact on physical and mental health. Areas for improvement included logistics related to scheduling of multiple IHWC providers and referrals to other CIH services.

Conclusion

Results revealed significant improvement in important clinical domains and satisfaction with interprofessional IHWC clinic providers, but also opportunities to improve clinic processes and care coordination. An interdisciplinary clinic focused on CIH and Whole Health is a feasible and acceptable model of care for veterans with complex chronic health conditions in the VA healthcare system.