Cost-Effectiveness of HIV Screening in Emergency Departments: Results From the Pragmatic Randomized HIV Testing Using Enhanced Screening Techniques in Emergency Departments Trial

STUDY OBJECTIVE

Identification of HIV remains a critical health priority for which emergency departments (EDs) are a central focus. The comparative cost-effectiveness of various HIV screening strategies in EDs remains largely unknown. The goal of this study was to compare programmatic costs and cost-effectiveness of nontargeted and 2 forms of targeted opt-out HIV screening in EDs using results from a multicenter, pragmatic randomized clinical trial.

METHODS

This economic evaluation was nested in the HIV Testing Using Enhanced Screening Techniques in Emergency Departments (TESTED) trial, a multicenter pragmatic clinical trial of different ED-based HIV screening strategies conducted from April 2014 through January 2016. Patients aged 16 years or older, with normal mental status and not critically ill, or not known to be living with HIV were randomized to 1 of 3 HIV opt-out screening approaches, including nontargeted, enhanced targeted, or traditional targeted, across 4 urban EDs in the United States. Each screening method was fully integrated into routine emergency care. Direct programmatic costs were determined using actual trial results, and time-motion assessment was used to estimate personnel activity costs. The primary outcome was newly diagnosed HIV. Total annualized ED programmatic costs by screening approach were calculated using dollars adjusted to 2023 as were costs per patient newly diagnosed with HIV. One-way and multiway sensitivity analyses were performed.

RESULTS

The trial randomized 76,561 patient visits, resulting in 14,405 completed HIV tests, and 24 (0.2%) new diagnoses. Total annualized new diagnoses were 12.9, and total annualized costs for nontargeted, enhanced targeted, and traditional targeted screening were $111,861, $88,629, and $70,599, respectively. Within screening methods, costs per new HIV diagnoses were $20,809, $23,554, and $18,762, respectively. Enhanced targeted screening incurred higher costs but with similar annualized new cases detected compared with traditional targeted screening. Nontargeted screening yielded an incremental cost-effectiveness ratio of $25,586 when compared with traditional targeted screening. Results were most sensitive to HIV prevalence and costs of HIV tests.

CONCLUSION

Nontargeted HIV screening was more costly than targeted screening largely due to an increased number of HIV tests performed. Each HIV screening strategy had similar within-strategy costs per new HIV diagnosis with traditional targeted screening yielding the lowest cost per new diagnosis. For settings with budget constraints or very low HIV prevalences, the traditional targeted approach may be preferred; however, given only a slightly higher cost per new HIV diagnosis, ED settings looking to detect the most new cases may prefer nontargeted screening.

Open Source Antibiotics: Simple Diarylimidazoles Are Potent against Methicillin-Resistant Staphylococcus aureus

Antimicrobial resistance (AMR) is widely acknowledged as one of the most serious public health threats facing the world, yet the private sector finds it challenging to generate much-needed medicines. As an alternative discovery approach, a small array of diarylimidazoles was screened against the ESKAPE pathogens, and the results were made publicly available through the Open Source Antibiotics (OSA) consortium (https://github.com/opensourceantibiotics). Of the 18 compounds tested (at 32 μg/mL), 15 showed >90% growth inhibition activity against methicillin-resistant Staphylococcus aureus (MRSA) alone. In the subsequent hit-to-lead optimization of this chemotype, 147 new heterocyclic compounds containing the diarylimidazole and other core motifs were synthesized and tested against MRSA, and their structure-activity relationships were identified. While potent, these compounds have moderate to high intrinsic clearance and some associated toxicity. The best overall balance of parameters was found with OSA_975, a compound with good potency, good solubility, and reduced intrinsic clearance in rat hepatocytes. We have progressed toward the knowledge of the molecular target of these phenotypically active compounds, with proteomic techniques suggesting TGFBR1 is potentially involved in the mechanism of action. Further development of these compounds toward antimicrobial medicines is available to anyone under the licensing terms of the project.

Finalising the administration of co-SSPedi, a dyad approach to symptom screening for paediatric patients receiving cancer treatments

OBJECTIVES

Symptom Screening in Pediatrics Tool (SSPedi) is a validated self-report symptom screening tool for patients with cancer 8-18 years of age. Co-SSPedi is a novel dyad approach in which both child and parent complete SSPedi together. The objective was to finalise the approach to co-SSPedi administration with instruction that is easy to understand, resulting in dyads completing co-SSPedi correctly.

METHOD

We enrolled child and parent dyads, who understood English and where children (4-18 years) had cancer or were hematopoietic stem cell transplantation recipients. We provided each dyad with instruction on how to complete co-SSPedi together. Mixed methods were used to determine how easy or hard the instruction was to understand. Two raters adjudicated if co-SSPedi was completed correctly. Dyads were enrolled in cohorts of 12 evenly divided by age (4-7, 8-10, 11-14 and 15-18 years).

RESULTS

We enrolled 5 cohorts of 12 dyads, resulting in 60 dyads. Following verbal instruction provided in the first cohort, we identified the need for written instruction emphasising children should wait for parent response prior to entering scores. The instruction was iteratively refined based on qualitative feedback until the fifth cohort, where all 12 dyads found the instruction easy to understand and completed co-SSPedi correctly.

CONCLUSIONS

We developed a standard approach to dyad symptom screening named co-SSPedi with instruction that is easy to understand, resulting in correct co-SSPedi completion. Future efforts should focus on co-SSPedi validation and understanding how co-SSPedi scores compare to self- or proxy-reported symptom reporting.

The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Linkage-to-Care Trial: rationale and design of an emergency department-based randomized clinical trial of linkage-to-care strategies for hepatitis C

BACKGROUND

Hepatitis C (HCV) poses a major public health problem in the USA. While early identification is a critical priority, subsequent linkage to a treatment specialist is a crucial step that bridges diagnosed patients to treatment, cure, and prevention of ongoing transmission. Emergency departments (EDs) serve as an important clinical setting for HCV screening, although optimal methods of linkage-to-care for HCV-diagnosed individuals remain unknown. In this article, we describe the rationale and design of The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Linkage-to-Care Trial.

METHODS

The DETECT Hep C Linkage-to-Care Trial will be a single-center prospective comparative effectiveness randomized two-arm parallel-group superiority trial to test the effectiveness of linkage navigation and clinician referral among ED patients identified with untreated HCV with a primary hypothesis that linkage navigation plus clinician referral is superior to clinician referral alone when using treatment initiation as the primary outcome. Participants will be enrolled in the ED at Denver Health Medical Center (Denver, CO), an urban, safety-net hospital with approximately 75,000 annual adult ED visits. This trial was designed to enroll a maximum of 280 HCV RNA-positive participants with one planned interim analysis based on methods by O'Brien and Fleming. This trial will further inform the evaluation of cost effectiveness, disparities, and social determinants of health in linkage-to-care, treatment, and disease progression.

DISCUSSION

When complete, the DETECT Hep C Linkage-to-Care Trial will significantly inform how best to perform linkage-to-care among ED patients identified with HCV.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04026867 Original date: July 1, 2019 URL: https://clinicaltrials.gov/ct2/show/NCT04026867.

NHS knowledge and library services in England in the digital age

National Health Service (NHS) knowledge and library services in England are integrating digital advances into their systems and services. Health Education England (HEE) leads on the development of NHS library services. A key workstream focuses on (1) improving the infrastructure to enable discovery and management of digital knowledge resources; (2) collaborating with local teams to establish regional library management systems that are integrated with the new national discovery service for healthcare staff and learners. This article explores initiatives on resource discovery as well as the need for system-wide partnership working to ensure that biomedical knowledge in computable form is findable, accessible, interoperable and reusable. Low levels of health and digital literacy pose a significant barrier to using health information and accessing health services. A range of interventions are aimed at enhancing citizens' digital and health literacy skills. The education and life-long learning needs of the knowledge and library services workforce are considered. Working with CILIP and higher education institutions, HEE delivers a range of educational offers through its Learning Academy. As Artificial Intelligence and automation are implemented in health systems, knowledge and library staff form a crucial bridge between technology and those who use it.

Evaluation of a Novel Point-of-Care Ultrasound Curriculum for First-Year Pediatric Residents

OBJECTIVE

The aim of the study is to evaluate a novel point-of-care ultrasound (POCUS) educational curriculum for pediatric residents.

METHODS

The cohort study in graduate medical education was completed from January 2017 to March 2019. Postgraduate year 1 (PGY1) pediatric residents attended the educational curriculum that consisted of 3 half-day sessions over a 3-month period. Each session consisted of a lecture (introduction, extended focused assessment with sonography for trauma, soft tissue/musculoskeletal, cardiac, and resuscitative applications) followed by supervised hands-on scanning sessions. Group ratio was 3 learners to 1 machine/expert instructor. Main outcome measures included pre- and post-written test scores, as well as objective structured clinical examination (OSCE) scores.

RESULTS

Forty-nine PGY1 residents (78% women) completed the curriculum. The mean (SD) pretest score was 68% (8.5), and the mean posttest score was 83% (8.3) with a difference of 15 (95% confidence interval, 12.5-17.6; P < 0.001). Mean (SD) focused assessment with sonography for trauma OSCE score after the curriculum was 88.7% (11.9). The number of PGY1 pediatric residents that were comfortable performing POCUS examinations increased from pretraining to posttraining for soft tissue/musculoskeletal (14%-61%, P < 0.001), extended focused assessment with sonography for trauma (24%-90%, P < 0.001), and cardiac (18%-86%, P < 0.001). All participants found the curriculum useful, and 42 of 49 (86%) stated the curriculum increased their ability to acquire and interpret images.

CONCLUSIONS

Postgraduate year 1 pediatric residents learned the basics of POCUS through 3 brief educational sessions. The increase in posttest scores demonstrated improved POCUS knowledge, and the high OSCE score demonstrated their ability to acquire ultrasound images. Point-of-care ultrasound guidelines are needed for pediatric residency programs.

Development of a clinical prediction instrument to estimate risk of initial violent injury

BACKGROUND

Interpersonal violent injury is a public health crisis, disproportionately affecting young people of color. We aimed to evaluate associations between sociobehavioral predictors and first-time violent injury, and to develop a predictive risk score for violent injury.

METHODS

We performed a retrospective case-cohort study of adolescents aged 12-18 years. Multivariable logistic regression was used to estimate associations between 35 candidate variables and interpersonal first-time violent injury resulting in an emergency department (ED) visit. Multiple imputation was used to account for missing values and a risk score was developed by multiplying regression coefficients by 10 to generate a composite tool to predict initial violent injury (IVI). Discrimination and calibration were assessed using 10-fold cross validation.

RESULTS

19,210 adolescents were included, 276 (1.4%) as victims of IVI. The final model, the Initial Violent Injury Risk Prediction Tool (IVI-RPT), included: age, fight within the prior year, trouble with the law, and alcohol use. IVI-RPT scores were categorized as: 0-7 (low risk), 8-16 (moderate), and 17-26 (high), and IVI prevalence was 0.8% (95% confidence interval [CI]: 0.6%, 0.9%), 2.5% (95% CI: 1.9%, 3.1%), and 5.3% (95% CI: 4.1%, 6.6%), respectively. The area under the receiver operating characteristic curve was 0.70 (95% CI: 0.66, 0.73), while the slope of the calibration curve was 1.1 (95% CI: 0.9, 1.2).

CONCLUSIONS

We developed a promising clinical prediction instrument, the IVI-RPT, that categorizes individuals into risk groups with increasing probabilities of violent injury. External validation of this tool is required prior to clinical practice implementation.

Predictive accuracy of adding shock index to the American College of Surgeons' minimum criteria for full trauma team activation

BACKGROUND

The American College of Surgeons requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation: hypotension, gunshot wound to the neck or torso, Glasgow Coma Scale (GCS) score < 9, respiratory compromise, transfers receiving blood transfusion, or physician discretion. Our goal was to evaluate the effect of adding varying shock index (SI) thresholds to the ACS-6 in an adult trauma population with the hypothesis that SI would significantly improve sensitivity at the expense of an acceptable decrease in specificity.

METHODS

We performed a secondary analysis of EMS and trauma registry data from an urban Level I trauma center. Consecutive patients > 15 years of age were included from 1993 through 2006. SI at thresholds of ≥0.8, ≥0.85, ≥0.9, and ≥1 were evaluated. Primary outcome was emergency operative (within 1 h of arrival) or procedural (cricothyrotomy or thoracotomy) intervention (EOPI); secondary outcomes were Injury Severity Score (ISS) > 15, ISS > 24, a composite of EOPI or ISS > 15, and urgent operative intervention (within 4 h).

RESULTS

A total of 20,872 patients were included, 27% with an ISS > 15 and 5% who underwent EOPI. Sensitivity and specificity of the ACS-6 alone for EOPI were 86% (95% confidence interval [CI] = 84% to 88%) and 81% (95% CI = 80% to 81%), respectively. Inclusion of SI thresholds of 0.8, 0.85, 0.9, and 1 resulted in sensitivities of 95% (95% CI = 93% to 96%), 93% (CI = 91% to 94%), 92% (95% CI = 90% to 93%), and 90% (95% CI = 88% to 92%), respectively, and specificities of 52% (95% CI = 51% to 52%), 59% (95% CI = 58% to 59%), 64% (95% CI = 64% to 65%), and 72% (95% CI = 71% to 73%), respectively. Similar trends were found for each secondary outcome.

CONCLUSION

The addition of SI to the ACS-6 for trauma team activation increased sensitivity for EOPI with a larger decrease in specificity across all thresholds. Inclusion of a SI threshold of ≥0.9 closely aligns with under- and overtriage benchmarks in this trauma registry cohort using a strict definition of trauma team activation need.

The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Screening Trial: rationale and design of a multi-center pragmatic randomized clinical trial of hepatitis C screening in emergency departments

Background

Early identification of HCV is a critical health priority, especially now that treatment options are available to limit further transmission and provide cure before long-term sequelae develop. Emergency departments (EDs) are important clinical settings for HCV screening given that EDs serve many at-risk patients who do not access other forms of healthcare. In this article, we describe the rationale and design of The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Screening Trial.

Methods

The DETECT Hep C Screening Trial is a multi-center prospective pragmatic randomized two-arm parallel-group superiority trial to test the comparative effectiveness of nontargeted and targeted HCV screening in the ED with a primary hypothesis that nontargeted screening is superior to targeted screening when identifying newly diagnosed HCV. This trial will be performed in the EDs at Denver Health Medical Center (Denver, CO), Johns Hopkins Hospital (Baltimore, MD), and the University of Mississippi Medical Center (Jackson, MS), sites representing approximately 225,000 annual adult visits, and designed using the PRECIS-2 framework for pragmatic trials. When complete, we will have enrolled a minimum of 125,000 randomized patient visits and have performed 13,965 HCV tests. In Denver, the Screening Trial will serve as a conduit for a distinct randomized comparative effectiveness trial to evaluate linkage-to-HCV care strategies. All sites will further contribute to embedded observational studies to assess cost effectiveness, disparities, and social determinants of health in screening, linkage-to-care, and treatment for HCV.

Discussion

When complete, The DETECT Hep C Screening Trial will represent the largest ED-based pragmatic clinical trial to date and all studies, in aggregate, will significantly inform how to best perform ED-based HCV screening.

Trial registration

ClinicalTrials.gov ID: NCT04003454. Registered on 1 July 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06265-1.

Development of a 2-step algorithm to identify emergency department patients for HIV pre-exposure prophylaxis

BACKGROUND

Expanded access to HIV PrEP is a central pillar of the "Ending the HIV Epidemic" initiative. Identification of PrEP eligible individuals in EDs remains understudied. Our goal was to estimate the accuracy of the Denver HIV Risk Score (DHRS), a quantitative HIV risk tool, for determining PrEP eligibility, and to incorporate it into a novel screening algorithm to optimize sensitivity and specificity.

METHODS

We performed a prospective cross-sectional study in two urban EDs. Patients were eligible if ≥18 years of age and without HIV. Research staff collected individual HIV risk, components of the DHRS, and PrEP eligibility per 2017 CDC guidelines. Accuracy estimates were calculated for the DHRS alone and the DHRS plus additional PrEP-specific questions.

RESULTS

1002 patients were enrolled with a median age of 39 years; 54.8% were male, 29.5% Black/non-Hispanic, and 22.5% Hispanic. Overall, 119 (11.9%, 95% CI: 9.9%-14.0%) were PrEP eligible; 5% endorsed history of sex with a partner at higher risk for HIV or condomless sex with multiple partners, 4% an STI, and 2% sharing IDU equipment. A DHRS ≥25 had a sensitivity of 92.4% (95% CI: 86.1%-96.5%) and a specificity of 17.2% (95% CI: 14.8%-19.9%) for PrEP eligibility. A 2-step algorithm, "DHRS-PrEP", beginning with a DHRS ≥25, followed by a step with questions specific to IDU, STI, and sexual partners improved the specificity to 100% (95% CI: 99.6%-100%).

CONCLUSIONS

Among a heterogeneous ED sample, a substantial proportion was identified as PrEP eligible, and a 2-step algorithm had high sensitivity and specificity for identifying PrEP-eligible patients.

Search Club: Using peer support to develop search skills and share knowledge in a specialist NHS team

The newly-formed Knowledge Management team at Health Education England (HEE) established an internal "Search Club" for their Knowledge Specialists to share good practice, exchange ideas, and discuss approaches to developing search strategies. The article describes how this was initiated and run online. The sessions improved the Knowledge Management team skills, and gave them an opportunity to share and learn from each other. A further benefit has been the creation of resources such as a "synonyms bank", search strategies, and a bank of grey literature sources. These reduce duplication of effort, save time, and improve consistency across the team's output. D.I.

Comparison of HIV Screening Strategies in the Emergency Department: A Randomized Clinical Trial

IMPORTANCE

The National HIV Strategic Plan for the US recommends HIV screening in emergency departments (EDs). The most effective approach to ED-based HIV screening remains unknown.

OBJECTIVE

To compare strategies for HIV screening when integrated into usual ED practice.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included patients visiting EDs at 4 US urban hospitals between April 2014 and January 2016. Patients included were ages 16 years or older, not critically ill or mentally altered, not known to have an HIV positive status, and with an anticipated length of stay 30 minutes or longer. Data were analyzed through March 2021.

INTERVENTIONS

Consecutive patients underwent concealed randomization to either nontargeted screening, enhanced targeted screening using a quantitative HIV risk prediction tool, or traditional targeted screening as adapted from the Centers for Disease Control and Prevention. Screening was integrated into clinical practice using opt-out consent and fourth-generation antigen-antibody assays.

MAIN OUTCOMES AND MEASURES

New HIV diagnoses using intention-to-treat analysis, absolute differences, and risk ratios (RRs).

RESULTS

A total of 76 561 patient visits were randomized; median (interquartile range) age was 40 (28-54) years, 34 807 patients (51.2%) were women, and 26 776 (39.4%) were Black, 22 131 (32.6%) non-Hispanic White, and 14 542 (21.4%) Hispanic. A total of 25 469 were randomized to nontargeted screening; 25 453, enhanced targeted screening; and 25 639, traditional targeted screening. Of the nontargeted group, 6744 participants (26.5%) completed testing and 10 (0.15%) were newly diagnosed; of the enhanced targeted group, 13 883 participants (54.5%) met risk criteria, 4488 (32.3%) completed testing, and 7 (0.16%) were newly diagnosed; and of the traditional targeted group, 7099 participants (27.7%) met risk criteria, 3173 (44.7%) completed testing, and 7 (0.22%) were newly diagnosed. When compared with nontargeted screening, targeted strategies were not associated with a higher rate of new diagnoses (enhanced targeted and traditional targeted combined: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.7; 95% CI, 0.30 to 1.56; P = .38; and enhanced targeted only: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.70; 95% CI, 0.27 to 1.84; P = .47).

CONCLUSIONS AND RELEVANCE

Targeted HIV screening was not superior to nontargeted HIV screening in the ED. Nontargeted screening resulted in significantly more tests performed, although all strategies identified relatively low numbers of new HIV diagnoses.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01781949.

HIV Risk and Pre-Exposure Prophylaxis Eligibility Among Emergency Department Patients

Our objective was to estimate the prevalence of pre-exposure prophylaxis (PrEP) eligibility, characterize self-perceived and quantified human immunodeficiency virus (HIV) risk, and assess PrEP knowledge and receptiveness of initiating PrEP among emergency department (ED) patients. We performed an IRB-approved cross-sectional study from two urban EDs. Patients were eligible if ≥18 years of age and not known to have HIV. Research staff obtained verbal consent and used a structured 29-item instrument to assess HIV risk, PrEP eligibility based on 2017 Centers for Disease Control and Prevention (CDC) guidelines, and general PrEP knowledge among unselected and enriched patient samples, the latter informed by the Denver HIV Risk Score (DHRS). We enrolled 1002 patients with a median age of 39 years; 54.8% were male, 30.9% White/non-Hispanic, 29.5% Black/non-Hispanic, and 22.5% Hispanic. In the full cohort, 119 [11.9%, 95% confidence interval (CI): 9.9-14.0%] were PrEP eligible, and among the unselected cohort, 36 (7.1%, 95% CI: 5.1-9.8%) were PrEP eligible. Using the DHRS, 100 patients were considered "high risk" with 32 (32.0%) reporting zero perceived risk. Correlation between the DHRS and self-perceived HIV risk was low (r = 0.13). Of the full cohort, 203 (20.3%) had heard of PrEP, and of these, 33 (16.3%) were PrEP eligible with 25 (75.8%) willing to start PrEP immediately. Yet, of the 119 patients who were PrEP eligible, only 34 (28.6%) had heard of PrEP. In summary, among a heterogeneous ED population, there was discordance in self-perceived and quantified HIV risk. HIV PrEP eligibility was ∼7% with the highest eligibility among those identified as DHRS "high risk." A significant opportunity exists to identify and initiate PrEP among ED patients.

Ultrasound Hypotension Protocol Time-motion Study Using the Multifrequency Single Transducer Versus a Multiple Transducer Ultrasound Device

INTRODUCTION

Ultrasound hypotension protocols (UHP) involve imaging multiple body areas, each with different transducers and imaging presets. The time for task switching between presets and transducers to perform an UHP has not been previously studied. A novel hand-carried ultrasound (HCU) has been developed that uses a multifrequency single transducer to image areas of the body (lung, heart, abdomen, superficial) that would typically require three transducers using a traditional cart-based ultrasound (CBU) system. Our primary aim was to compare the time to complete UHPs with a single transducer HCU to a multiple transducer CBU.

METHODS

We performed a randomized, crossover feasibility trial in the emergency department of an urban, safety-net hospital. This was a convenience sample of non-hypotensive emergency department patients presenting during a two-month period of time. Ultrasound hypotension protocols were performed by emergency physicians (EP) on patients using the HCU and the CBU. The EPs collected UHP views in sequential order using the most appropriate transducer and preset for the area/organ to be imaged. Time to complete each view, time for task switching, total time to complete the examination, and image diagnostic quality were recorded.

RESULTS

A total of 29 patients were scanned by one of eight EPs. When comparing the HCU to the CBU, the median time to complete the UHP was 4.3 vs 8.5 minutes (P <0.0001), respectively. When the transport and plugin times were excluded, the median times were 4.1 vs 5.8 minutes (P <0.0001), respectively. There was no difference in the diagnostic quality of images obtained by the two devices.

CONCLUSION

Ultrasound hypotension protocols were performed significantly faster using the single transducer HCU compared to a multiple transducer CBU with no difference in the number of images deemed to be diagnostic quality.

Levels of Human Immunodeficiency Virus DNA Are Determined Before ART Initiation and Linked to CD8 T-Cell Activation and Memory Expansion

Initiation of antiretroviral therapy (ART) in early compared with chronic human immunodeficiency virus (HIV) infection is associated with a smaller HIV reservoir. This longitudinal analysis of 60 individuals who began ART during primary HIV infection (PHI) investigates which pre- and posttherapy factors best predict HIV DNA levels (a correlate of reservoir size) after treatment initiation during PHI. The best predictor of HIV DNA at 1 year was pre-ART HIV DNA, which was in turn significantly associated with CD8 memory T-cell differentiation (effector memory, naive, and T-bet⁻Eomes⁻ subsets), CD8 T-cell activation (CD38 expression) and T-cell immunoglobulin and mucin-domain containing-3 (Tim-3) expression on memory T cells. No associations were found for any immunological variables after 1 year of ART. Levels of HIV DNA are determined around the time of ART initiation in individuals treated during PHI. CD8 T-cell activation and memory expansion are linked to HIV DNA levels, suggesting the importance of the initial host-viral interplay in eventual reservoir size.

Emergency Ultrasound Literature and Adherence to Standards for Reporting of Diagnostic Accuracy Criteria

BACKGROUND

Given the wide usage of emergency point-of-care ultrasound (EUS) among emergency physicians (EPs), rigorous study surrounding its accuracy is essential. The Standards for Reporting of Diagnostic Accuracy (STARD) criteria were established to ensure robust reporting methodology for diagnostic studies. Adherence to the STARD criteria among EUS diagnostic studies has yet to be reported.

OBJECTIVES

Our objective was to evaluate a body of EUS literature shortly after STARD publication for its baseline adherence to the STARD criteria.

METHODS

EUS studies in 5 emergency medicine journals from 2005-2010 were evaluated for their adherence to the STARD criteria. Manuscripts were selected for inclusion if they reported original research and described the use of 1 of 10 diagnostic ultrasound modalities designated as "core emergency ultrasound applications" in the 2008 American College of Emergency Physicians Ultrasound Guidelines. Literature search identified 307 studies; of these, 45 met inclusion criteria for review.

RESULTS

The median STARD score was 15 (interquartile range [IQR] 12-17), representing 60% of the 25 total STARD criteria. The median STARD score among articles that reported diagnostic accuracy was significantly higher than those that did not report accuracy (17 [IQR 15-19] vs. 11 [IQR 9-13], respectively; p < 0.0001). Seventy-one percent of articles met ≥50% of the STARD criteria (56-84%) and 4% met >80% of the STARD criteria.

CONCLUSIONS

Significant opportunities exist to improve methodological reporting of EUS research. Increased adherence to the STARD criteria among diagnostic EUS studies will improve reporting and improve our ability to compare outcomes.

CD32 expressing doublets in HIV-infected gut-associated lymphoid tissue are associated with a T follicular helper cell phenotype

Gut-associated lymphoid tissue (GALT) is a key location for the HIV reservoir. The observation that B-cell-T-cell doublets are enriched for CD32a (a low-affinity IgG receptor) in peripheral blood raises interesting questions, especially as these cells have been associated with HIV DNA in some studies. We sought to determine if similar doublets were present in GALT, the significance of these doublets, and their implications for the HIV reservoir. Given the importance of GALT as a reservoir for HIV, we looked for expression of CD32 on gut CD4 T cells and for evidence of doublets, and any relationship with HIV DNA in HIV + individuals initiated on antiretroviral therapy (ART) during primary HIV infection (PHI). Tonsil tissue was also available for one individual. As previously shown for blood, CD32^high CD4 cells were mainly doublets of CD4 T cells and B cells, with T-cell expression of ICOS in tonsil and gut tissue. CD4 T cells associated with CD32 (compared with 'CD32-' CD4 cells) had higher expression of follicular markers CXCR5, PD-1, ICOS, and Bcl-6 consistent with a T follicular helper (TFH) phenotype. There was a significant correlation between rectal HIV DNA levels and CD32 expression on TFH cells. Together, these data suggest that CD32^high doublets are primarily composed of TFH cells, a subset known to be preferentially infected by HIV.

Virological remission after antiretroviral therapy interruption in female African HIV seroconverters

INTRODUCTION

There are few data on the frequency of virological remission in African individuals after treatment with antiretroviral therapy (ART) in primary HIV infection (PHI).

METHODS

We studied participants (n = 82) from South Africa and Uganda in Short Pulse Antiretroviral Treatment at HIV-1 Seroconversion, the first trial of treatment interruption in African individuals with PHI randomized to deferred ART or 48 weeks of immediate ART. All were female and infected with non-B HIV subtypes, mainly C. We measured HIV DNA in CD4+ T cells, CD4+ cell count, plasma viral load (pVL), cell-associated HIV RNA and T-cell activation and exhaustion. We explored associations with clinical progression and time to pVL rebound after treatment interruption (n = 22). Data were compared with non-African Short Pulse Antiretroviral Treatment at HIV-1 Seroconversion participants.

RESULTS

Pretherapy pVL and integrated HIV DNA were lower in Africans compared with non-Africans (median 4.16 vs. 4.72 log10 copies/ml and 3.07 vs. 3.61 log10 copies/million CD4+ T cells, respectively; P < 0.001). Pre-ART HIV DNA in Africans was associated with clinical progression (P = 0.001, HR per log10 copies/million CD4+ T cells increase (95% CI) 5.38 (1.95-14.79)) and time to pVL rebound (P = 0.034, HR per log10 copies/ml increase 4.33 (1.12-16.84)). After treatment interruption, Africans experienced longer duration of viral remission than non-Africans (P < 0.001; HR 3.90 (1.75-8.71). Five of 22 African participants (22.7%) maintained VL less than 400 copies/ml over a median of 188 weeks following treatment interruption.

CONCLUSION

We find evidence of greater probability of virological remission following treatment interruption among African participants, although we are unable to differentiate between sex, ethnicity and viral subtype. The finding warrants further investigation.

BOS is associated with decreased HDAC2 from steroid resistant lymphocytes in the small airways

Immunosuppression therapies including corticosteroids fail to prevent bronchiolitis obliterans syndrome (BOS), primarily a disease of the small airways, following lung transplantation. We reported increases in steroid-resistant proinflammatory lymphocytes and their loss of histone deacetylase 2 (HDAC2), an important mediator of steroid action, in the blood of stable lung transplant recipients. We noted similar increases in the steroid-resistant lymphocytes in both the blood and small airways in BOS compared with the large airways. We hypothesized that these small airway cells would also exhibit a loss of HDAC2, and that these changes could be reversed by treatment with theophylline (HDAC2 activator). Blood, bronchoalveolar lavage and large and small airway brushings were collected from lung transplant patients with BOS (n = 12) or stable lung function (n = 18) and healthy aged-matched controls (n = 13). Intracellular proinflammatory cytokines [interferon (IFN-γ) and tumour necrosis factor (TNF)-α and HDAC2 were measured in CD8⁺ T, natural killer (NK) T-like and NK cells from cultured small airway brushings ± 5 mg/l theophylline ± 1 µM prednisolone using flow cytometry. Increased small airway CD8 T, NK T-like and NK cells were identified in BOS versus stable transplant and controls. In BOS, these cells exhibited increased IFN-γ/TNF-α and a loss of HDAC2. HDAC2 expression by small airway CD8⁺ T cells correlated with forced expiratory volume in 1 s (FEV₁ ) (R = 0·880, P = 0·031). Theophylline and prednisolone synergistically up-regulated HDAC2 in CD8⁺ T cells. BOS is associated with loss of HDAC2 from steroid-resistant proinflammatory CD8⁺ T, NK T-like and NK cells in the small airways. Therapeutically increasing HDAC2 in these lymphocytes may reduce steroid resistance and improve graft survival.

Accuracy of rapid on-site evaluation of endobronchial ultrasound guided transbronchial needle aspirates by respiratory registrars in training and medical scientists compared to specialist pathologists-an initial pilot study

Background

Rapid on-site evaluation (ROSE) of endobronchial ultrasound guided transbronchial needle aspirates (EBUS-TBNA) increases diagnostic accuracy but in many institutions requires a specialist pathologist. This study aimed to determine if medical scientists or respiratory registrars could adequately perform ROSE to determine sufficiency of EBUS samples.

Methods

ROSE was performed on the first two EBUS-TBNA passes per patient by a pathologist, a medical scientist and two respiratory registrars. The medical scientists involved had all previously performed ROSE on over 50 procedures. The two respiratory registrars received cytology education from a pathologist in four separate hour-long training sessions. Each ROSE reviewer recorded whether each sample was sufficient or insufficient. Pathologist interpretation was taken as gold standard. Specific diagnosis was not required. Final diagnosis and the total number of passes were also recorded. This study recruited 25 patients (50 passes) for statistical evaluation.

Results

Assessment by specialist pathologists deemed 16/50 (32%) to be sufficient and 34/50 (68%) insufficient respectively. Medical scientists were 90% concordant with the pathologist (K =0.774; 95% CI, 0.587-0.961). The two respiratory registrars were 78% (K =0.568; 95% CI, 0.338-0.798) and 72% (K =0.448; 95% CI, 0.222-0.674) concordant, respectively. The mean number of passes per patient was 4.9 (range, 3-7). A diagnosis was established in 21/25 (82%) patients from the first EBUS-TBNA procedures with the remaining four patients requiring a further procedure or monitoring with serial CT scans to establish the diagnosis. Malignancy was found in 14/25 (56%) patients and a benign process in 11/25 (44%) patients.

Conclusions

Medical scientist review of ROSE samples is not significantly different to a specialist pathologist and is an acceptable alternative. Respiratory registrars are not a realistic alternative for ROSE without more intensive training, which may be difficult to facilitate in addition to existing respiratory training commitments.

The uncoupling of autophagy and zinc homeostasis in airway epithelial cells as a fundamental contributor to COPD

The proper regulation of zinc (Zn) trafficking proteins and the cellular distribution of Zn are critical for the maintenance of autophagic processes. However, there have been no studies that have examined Zn dyshomeostasis and the disease-related modulation of autophagy observed in the airways afflicted with chronic obstructive pulmonary disease (COPD). We hypothesized that dysregulated autophagy in airway epithelial cells (AECs) is related to Zn dysregulation in cigarette smoke (CS)-induced COPD. We applied a human ex vivo air-liquid interface model, a murine model of smoke exposure, and human lung tissues and investigated Zn, ZIP1, and ZIP2 Zn-influx proteins, autophagy [microtubule-associated 1A/1B-light chain-3 (LC3), Beclin-1], autophagic flux (Sequestosome), apoptosis [Bcl2; X-linked inhibitor of apoptosis (XIAP), poly (ADP)-ribose polymerase (PARP)], and inflammation [thymic stromal lymphopoietin (TSLP), regulated on activation, normal T cell expressed and secreted (RANTES), and IL-1β]. Lung tissues from CS-exposed mice exhibit reduced free-Zn in AECs, with elevated ZIP1 and diminished ZIP2 expression. Interestingly, increased LC3 colocalized with ZIP1, suggesting an autophagic requirement for free-Zn to support its catabolic function. In human AECs, autophagy was initiated but was unable to efficiently degrade cellular debris, as evidenced by stable Beclin-1 and increased LC3-II, but with a concomitant elevation in Sequestosome. Autophagic dysfunction due to CS exposure coupled with Zn depletion also induced apoptosis, with the reduction of antiapoptotic and antiautophagic proteins Bcl2 and XIAP and PARP cleavage. This was accompanied by an increase in RANTES and TSLP, an activator of adaptive immunity. We conclude that the uncoupling of Zn trafficking and autophagy in AECs constitutes a fundamental disease-related mechanism for COPD pathogenesis and could provide a new therapeutic target.

The impact of immunoglobulin in acute HIV infection on the HIV reservoir: a randomized controlled trial

OBJECTIVES

Antiretroviral therapy (ART) during acute HIV infection (AHI) restricts the HIV reservoir, but additional interventions are necessary to induce a cure. Intravenous immunoglobulin (IVIG) is not HIV-specific but is safe and temporarily reduces the HIV reservoir in chronic HIV infection. We present a randomized controlled trial to investigate whether IVIG plus ART in AHI reduces the HIV reservoir and immune activation compared with ART alone.

METHODS

Ten men with AHI (Fiebig II-IV) initiated ART (tenofovir, entricitabine, ritonavir boosted darunavir and raltegravir) at HIV-1 diagnosis and were randomized to ART alone or ART plus 5 days of IVIG, once virally suppressed (week 19). Blood samples were evaluated for viral reservoir, immune activation, immune exhaustion and microbial translocation. Flexible sigmoidoscopy was performed at weeks 19, 24 and 48, and gut proviral DNA and cell numbers determined.

RESULTS

IVIG was well tolerated and no viral blips (> 50 HIV-1 RNA copies/mL) occurred during IVIG therapy. From baseline to week 48, total HIV DNA in peripheral blood mononuclear cells (PBMCs) (cases: -3.7 log₁₀ copies/10⁶ CD4 cells; controls: -3.87 log₁₀ copies/10⁶ CD4 cells) declined with no differences observed between the groups (P = 0.49). Declines were observed in both groups from week 19 to week 48 in total HIV DNA in PBMCs (P = 0.38), serum low copy RNA (P = 0.57) and gut total HIV DNA (P = 0.55), but again there were no significant differences between arms. Biomarkers of immune activation, immune exhaustion and microbial translocation and the CD4:CD8 ratio were similar between arms for all comparisons.

CONCLUSIONS

Although safe, IVIG in AHI did not impact total HIV DNA, immune function or microbial translocation in peripheral blood or gut tissue.

Knowledge Management in healthcare libraries: the current picture

Knowledge management has seen something of a resurgence in attention amongst health librarians recently. Of course it has never ceased to exist, but now many library staff are becoming more involved in organisational knowledge management, and positioning themselves as key players in the sphere. No single model of knowledge management is proliferating, but approaches that best fit the organisation's size, structure and culture, and a blending of evidence based practice and knowledge sharing. Whatever it is called and whatever models are used, it's clear that for librarians and information professionals, the importance of putting knowledge and evidence into practice, sharing knowledge well and capturing it effectively, are still what we will continue to do.

Short Communication: Lack of Effect of Maraviroc Intensification on Blood and Gut Reservoir

We show that intensification of treatment with maraviroc in patients chronically infected with HIV-1 receiving successful long-term antiretroviral therapy was not associated with improvements in HIV-related morbidity, HIV reservoir, microbial translocation, immune activation, or immune exhaustion in either gut or peripheral blood. The measurement of reservoir in both gut and blood longitudinally contributes to a paucity of data in the area.

Central Congenital Hypoventilation Syndrome associated with hypoglycemia and seizure

Central Congenital Hypoventilation Syndrome (CCHS) is a rare diagnosis that presents with various forms of autonomic dysfunction. The disease is characterized by reduced chemoreflexes and severe hypoventilation during sleep. Several case reports have noted that patients with CCHS have been found to suffer from hypoglycemic episodes, which frequently present as a seizure. In this report, we will review previous case presentations to alert the physicians about this association with hypoglycemic episodes. Early treatment and monitoring of hypoglycemia will prevent further complications for these populations.

Cell block samples from endobronchial ultrasound transbronchial needle aspiration provide sufficient material for ancillary testing in lung cancer-a quaternary referral centre experience

BACKGROUND

Rapid on site examination (ROSE) is encouraged at endobronchial ultrasound transbronchial needles aspiration (EBUS-TBNA) to improve diagnostic yield. Due to new therapeutic options in lung cancer, it is not sufficient to merely distinguish between non-small cell lung carcinoma (NSCLC) and small cell lung carcinoma (SCLC). Immunohistochemistry (IHC) distinction is now standard practice, as well as additional molecular testing where clinically indicated. We investigated the diagnostic yield of on-site smears vs. cell block and the provision of cellular material for ancillary testing at our centre.

METHODS

A retrospective audit of all EBUS-TBNA procedures performed until July 2012 was undertaken. Diagnostic yield on smears versus cell block was recorded. Cell blocks were reviewed by an experienced pathologist to determine diagnostic accuracy and whether IHC and molecular testing were possible.

RESULTS

In total, 234 procedures were recorded with 101 (43.2%) malignant cases, 107 (45.7%) benign cases and an initial 26/234 (11.1%) insufficient for diagnosis of which 11/234 (4.7%) were false negatives for malignancy after further follow up. The average number of passes was 4.5. For malignancies, smear diagnosis was possible in 95% (96/101) of cases and cell block diagnosis in 93.5% (87/93) of cases. There was sufficient material for IHC in 97.7% (85/87) of malignant cases. In 79.3% (69/87) of NSCLCs molecular testing for epidermal growth factor receptor (EGFR) mutation analysis was theoretically possible on samples obtained.

CONCLUSIONS

Cell blocks are not inferior to smears for diagnostic accuracy and provide sufficient samples for histology. However, ROSE assists the physician on how best to manage samples for ancillary testing.

Effect of Volume of Fluid Resuscitation on Metabolic Normalization in Children Presenting in Diabetic Ketoacidosis: A Randomized Controlled Trial

BACKGROUND

The optimal rate of fluid administration in pediatric diabetic ketoacidosis (DKA) is unknown.

OBJECTIVE

Our aim was to determine whether the volume of fluid administration in children with DKA influences the rate of metabolic normalization.

METHODS

We performed a randomized controlled trial conducted in a tertiary pediatric emergency department from December 2007 until June 2010. The primary outcome was time to metabolic normalization; secondary outcomes were time to bicarbonate normalization, pH normalization, overall length of hospital treatment, and adverse outcomes. Children between 0 and 18 years of age were eligible if they had type 1 diabetes mellitus and DKA. Patients were randomized to receive intravenous (IV) fluid at low volume (10 mL/kg bolus + 1.25 × maintenance rate) or high volume (20 mL/kg bolus + 1.5 × maintenance rate) (n = 25 in each).

RESULTS

After adjusting for initial differences in bicarbonate levels, time to metabolic normalization was significantly faster in the higher-volume infusion group compared to the low-volume infusion group (hazard ratio [HR] = 2.0; 95% confidence interval [CI] 1.0-3.9; p = 0.04). Higher-volume IV fluid infusion appeared to hasten, to a greater extent, normalization of pH (HR = 2.5; 95% CI 1.2-5.0; p = 0.01) than normalization of serum bicarbonate (HR = 1.2; 95% CI 0.6-2.3; p = 0.6). The length of hospital treatment HR (0.8; 95% CI 0.4-1.5; p = 0.5) and time to discharge HR (0.8; 95% CI 0.4-1.5; p = 0.5) did not differ between treatment groups.

CONCLUSIONS

Higher-volume fluid infusion in the treatment of pediatric DKA patients significantly shortened metabolic normalization time, but did not change overall length of hospital treatment. ClinicalTrials.gov ID NCT01701557.

Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: A randomized crossover trial

BACKGROUND

Medication dosing errors remain commonplace and may result in potentially life-threatening outcomes, particularly for pediatric patients where dosing often requires weight-based calculations. Novel medication delivery systems that may reduce dosing errors resonate with national healthcare priorities. Our goal was to evaluate novel, prefilled medication syringes labeled with color-coded volumes corresponding to the weight-based dosing of the Broselow Tape, compared to conventional medication administration, in simulated prehospital pediatric resuscitation scenarios.

METHODS

We performed a prospective, block-randomized, cross-over study, where 10 full-time paramedics each managed two simulated pediatric arrests in situ using either prefilled, color-coded syringes (intervention) or their own medication kits stocked with conventional ampoules (control). Each paramedic was paired with two emergency medical technicians to provide ventilations and compressions as directed. The ambulance patient compartment and the intravenous medication port were video recorded. Data were extracted from video review by blinded, independent reviewers.

RESULTS

Median time to delivery of all doses for the intervention and control groups was 34 (95% CI: 28-39) seconds and 42 (95% CI: 36-51) seconds, respectively (difference=9 [95% CI: 4-14] seconds). Using the conventional method, 62 doses were administered with 24 (39%) critical dosing errors; using the prefilled, color-coded syringe method, 59 doses were administered with 0 (0%) critical dosing errors (difference=39%, 95% CI: 13-61%).

CONCLUSIONS

A novel color-coded, prefilled syringe decreased time to medication administration and significantly reduced critical dosing errors by paramedics during simulated prehospital pediatric resuscitations.

Denver ED Trauma Organ Failure Score outperforms traditional methods of risk stratification in trauma

BACKGROUND

Early identification of trauma patients at risk for inhospital mortality may facilitate goal-directed resuscitation and secondary triage to improve outcomes. The objective of this study was to compare prognostic accuracies of the Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score, ED Sequential Organ Failure Assessment (SOFA) score, and ED base deficit and ED lactate for inhospital mortality in adult trauma patients.

METHODS

Consecutive adult trauma patients from 2005 to 2008 from the Denver Health Trauma Registry were included. Prognostic accuracies of the Denver ED TOF Score, ED SOFA score, ED base deficit, and ED lactate for inhospital mortality were evaluated with receiver operating characteristic curves.

RESULTS

Of the 4355 patients, the median age was 37 years (interquartile range [IQR], 26-51 years), median Injury Severity Score was 9 (IQR, 4-16), and 81% had blunt mechanisms. In addition, 38% (1670 patients) were admitted to the intensive care unit with a median intensive care unit length of stay of 2.5 days (IQR, 1-8 days), and 3% (138 patients) died. The areas under the receiver operating characteristic curves for the Denver ED TOF, ED lactate, ED base deficit, and ED SOFA were 0.94 (95% confidence interval [CI], 0.94-0.96), 0.88 (95% CI, 0.85-0.91), 0.82 (95% CI, 0.78-0.86), and 0.78 (95% CI, 0.73-0.82), respectively.

CONCLUSIONS

The Denver ED TOF Score more accurately predicts inhospital mortality in adult trauma patients compared to the ED SOFA score, ED base deficit, or ED lactate. The Denver ED TOF Score may help identify patients early who are at risk for mortality, allowing for targeted resuscitation and secondary triage to improve outcomes.

Brief report: Validation of a quantitative HIV risk prediction tool using a national HIV testing cohort

Routine screening is recommended for HIV detection. HIV risk estimation remains important. Our goal was to validate the Denver HIV Risk Score using a national cohort from the Centers for Disease Control and Prevention. Patients of 13 years and older were included, 4,830,941 HIV tests were performed, and 0.6% newly diagnosed infections were identified. Of all visits, 9% were very low risk (HIV prevalence = 0.20%), 27% low risk (HIV prevalence = 0.17%), 41% moderate risk (HIV prevalence = 0.39%), 17% high risk (HIV prevalence = 1.19%), and 6% very high risk (HIV prevalence = 3.57%). The Denver HIV Risk Score accurately categorized patients into different HIV risk groups.

Color-Coded Prefilled Medication Syringes Decrease Time to Delivery and Dosing Error in Simulated Emergency Department Pediatric Resuscitations

STUDY OBJECTIVE

The Institute of Medicine has called on the US health care system to identify and reduce medical errors. Unfortunately, medication dosing errors remain commonplace and may result in potentially life-threatening outcomes, particularly for pediatric patients when dosing requires weight-based calculations. Novel medication delivery systems that may reduce dosing errors resonate with national health care priorities. Our goal was to evaluate novel, prefilled medication syringes labeled with color-coded volumes corresponding to the weight-based dosing of the Broselow Tape, compared with conventional medication administration, in simulated pediatric emergency department (ED) resuscitation scenarios.

METHODS

We performed a prospective, block-randomized, crossover study in which 10 emergency physician and nurse teams managed 2 simulated pediatric arrest scenarios in situ, using either prefilled, color-coded syringes (intervention) or conventional drug administration methods (control). The ED resuscitation room and the intravenous medication port were video recorded during the simulations. Data were extracted from video review by blinded, independent reviewers.

RESULTS

Median time to delivery of all doses for the conventional and color-coded delivery groups was 47 seconds (95% confidence interval [CI] 40 to 53 seconds) and 19 seconds (95% CI 18 to 20 seconds), respectively (difference=27 seconds; 95% CI 21 to 33 seconds). With the conventional method, 118 doses were administered, with 20 critical dosing errors (17%); with the color-coded method, 123 doses were administered, with 0 critical dosing errors (difference=17%; 95% CI 4% to 30%).

CONCLUSION

A novel color-coded, prefilled syringe decreased time to medication administration and significantly reduced critical dosing errors by emergency physician and nurse teams during simulated pediatric ED resuscitations.

Ultrasound-guided small vessel cannulation: long-axis approach is equivalent to short-axis in novice sonographers experienced with landmark-based cannulation

Introduction

Our primary objective was to describe the time to vessel penetration and difficulty of long-axis and short-axis approaches for ultrasound-guided small vessel penetration in novice sonographers experienced with landmark-based small vessel penetration.

Methods

This was a prospective, observational study of experienced certified emergency nurses attempting ultrasound-guided small vessel cannulation on a vascular access phantom. We conducted a standardized training, practice, and experiment session for each participant. Five long-axis and five short-axis approaches were attempted in alternating sequence. The primary outcome was time to vessel penetration. Secondary outcomes were number of skin penetrations and number of catheter redirections. We compared long-axis and short-axis approaches using multivariable regression adjusting for repeated measures, vessel depth, and vessel caliber.

Results

Each of 10 novice sonographers made 10 attempts for a total of 100 attempts. Median time to vessel penetration in the long-axis and short-axis was 11 (95% confidence interval [CI] 7–12) and 10 (95% CI 6–13) seconds, respectively. Skin penetrations and catheter redirections were equivalent and near optimal between approaches. The median caliber of cannulated vessels in the long-axis and short-axis was 4.6 (95% CI 4.1–5.5) and 5.6 (95% CI 5.1–6.2) millimeters, respectively. Both axes had equal success rates of 100% for all 50 attempts. In multivariable regression analysis, long-axis attempts were 32% (95% CI 11%–48%; p=0.009) faster than short-axis attempts.

Conclusion

Novice sonographers, highly proficient with peripheral IV cannulation, can perform after instruction ultrasound-guided small vessel penetration successfully with similar time to vessel penetration in either the long-axis or short-axis approach on phantom models.

Motor vehicle crash severity estimations by physicians and prehospital personnel

OBJECTIVE

To determine whether emergency physicians (EPs) and prehospital emergency medical services (EMS) personnel differ in their assessment of motor vehicle crash (MVC) severity and the potential for serious injury when viewing crash scene photographs.

METHODS

Attending and resident EPs, paramedics, and emergency medical technicians (EMTs) from a single emergency medicine system used a web-based survey platform to rate the severity of 100 crash photographs on a 10-point Likert scale (Crash Score) and the potential for serious injury on a 0-100% scale (Injury Score). Serious injury was defined as skull fracture or intracranial bleeding, spine fracture or spinal cord injury, intrathoracic or intraabdominal injury, or long bone fracture. Crash and Injury Scores were stratified into EP and paramedic/EMT (EMS) groups and the mean score was calculated for each photo. Spearman rank correlation coefficients with 95% confidence intervals (95% CI) and Bland-Altman plots were constructed to assess agreement. Secondary analyses were performed after categorizing data into quartiles based on participants' estimations of MVC severity.

RESULTS

A total of 54 attending and 53 resident EPs, 156 paramedics, and 34 EMTs were invited to participate in the survey. Of these, 39 (72%) attending and 46 (87%) resident EPs, 107 (69%) paramedics, and 17 (50%) EMTs completed the survey. A total of 183 (88%) surveys were completed in full. The overall Crash Score correlation coefficient between EPs and EMS was 0.98 (95% CI, 0.97-0.99). The Crash Score correlation coefficients for each quartile were 0.86 (0.57-0.97), 0.93 (0.85-0.96), 0.58 (0.16-0.85), and 0.88 (0.66-0.97), respectively. The overall Injury Score correlation coefficient between EPs and EMS was 0.98 (0.88-0.97). The Injury Score correlation coefficients for each quartile were 0.94 (0.48-0.91), 0.76 (0.50-0.92), 0.80 (0.69-1.00), and 0.94 (0.57-0.97), respectively.

CONCLUSION

Although overall agreement between EPs and EMS personnel was excellent, differences in estimation of crash severity and potential for injury were identified among crashes estimated to be moderate in severity.

Programmatic cost evaluation of nontargeted opt-out rapid HIV screening in the emergency department

BACKGROUND

The Centers for Disease Control and Prevention recommends nontargeted opt-out HIV screening in healthcare settings. Cost effectiveness is critical when considering potential screening methods. Our goal was to compare programmatic costs of nontargeted opt-out rapid HIV screening with physician-directed diagnostic rapid HIV testing in an urban emergency department (ED) as part of the Denver ED HIV Opt-Out Trial.

METHODS

This was a prospective cohort study nested in a larger quasi-experiment. Over 16 months, nontargeted rapid HIV screening (intervention) and diagnostic rapid HIV testing (control) were alternated in 4-month time blocks. During the intervention phase, patients were offered HIV testing using an opt-out approach during registration; during the control phase, physicians used a diagnostic approach to offer HIV testing to patients. Each method was fully integrated into ED operations. Direct program costs were determined using the perspective of the ED. Time-motion methodology was used to estimate personnel activity costs. Costs per patient newly-diagnosed with HIV infection by intervention phase, and incremental cost effectiveness ratios were calculated.

RESULTS

During the intervention phase, 28,043 eligible patients were included, 6,933 (25%) completed testing, and 15 (0.2%, 95% CI: 0.1%-0.4%) were newly-diagnosed with HIV infection. During the control phase, 29,925 eligible patients were included, 243 (0.8%) completed testing, and 4 (1.7%, 95% CI: 0.4%-4.2%) were newly-diagnosed with HIV infection. Total annualized costs for nontargeted screening were $148,997, whereas total annualized costs for diagnostic HIV testing were $31,355. The average costs per HIV diagnosis were $9,932 and $7,839, respectively. Nontargeted HIV screening identified 11 more HIV infections at an incremental cost of $10,693 per additional infection.

CONCLUSIONS

Compared to diagnostic testing, nontargeted HIV screening was more costly but identified more HIV infections. More effective and less costly testing strategies may be required to improve the identification of patients with undiagnosed HIV infection in the ED.

Sexual assault training in emergency medicine residencies: a survey of program directors

INTRODUCTION

There is currently no standard forensic medicine training program for emergency medicine residents. In the advent of sexual assault nurse examiner (SANE) programs aimed at improving the quality of care for sexual assault victims, it is also unclear how these programs impact emergency medicine (EM) resident forensic medicine training. The purpose of this study was to gather information on EM residency programs' training in the care of sexual assault patients and determine what impact SANE programs may have on the experience of EM resident training from the perspective of residency program directors (PDs).

METHODS

This was a cross-sectional survey. The study cohort was all residency PDs from approved EM residency training programs who completed a closed-response self-administered survey electronically.

RESULTS

We sent surveys to 152 PDs, and 71 responded for an overall response rate of 47%. Twenty-two PDs (31%) reported that their residency does not require procedural competency for the sexual assault exam, and 29 (41%) reported their residents are required only to observe sexual assault exam completion to demonstrate competency. Residency PDs were asked how their programs established resident requirements for sexual assault exams. Thirty-seven PDs (52%) did not know how their sexual assault exam requirement was established.

CONCLUSION

More than half of residency PDs did not know how their sexual assault guidelines were established, and few were based upon recommendations from the literature. There is no clear consensus as to how PDs view the effect of SANE programs on resident competency with the sexual assault exam. This study highlights both a need for increased awareness of EM resident sexual assault education nationally and also a possible need for a training curriculum defining guidelines for EM residents performing sexual assault exams.

Validation of rules to predict emergent surgical intervention in pediatric trauma patients

BACKGROUND

Trauma centers use guidelines to determine when a trauma surgeon is needed in the emergency department (ED) on patient arrival. A decision rule from Loma Linda University identified patients with penetrating injury and tachycardia as requiring emergent surgical intervention. Our goal was to validate this rule and to compare it with the American College of Surgeons' Major Resuscitation Criteria (MRC).

STUDY DESIGN

We used data from 1993 through 2010 from 2 level 1 trauma centers in Denver, CO. Patient demographics, injury severity, times of ED arrival and surgical intervention, and all variables of the Loma Linda Rule and the MRC were obtained. The outcome, emergent intervention (defined as requiring operative intervention by a trauma surgeon within 1 hour of arrival to the ED or performance of cricothyroidotomy or thoracotomy in the ED), was confirmed using standardized abstraction. Sensitivities, specificities, and 95% confidence intervals were calculated.

RESULTS

There were 8,078 patients included, and 47 (0.6%) required emergent intervention. Of the 47 patients, the median age was 11 years (interquartile range [IQR] 7 to 14 years), 70% were male, 30% had penetrating mechanisms, and the median Injury Severity Score (ISS) was 25 (IQR 9 to 41). At the 2 institutions, the Loma Linda Rule had a sensitivity and specificity of 69% (95% CI 45% to 94%) and 76% (95% CI 69% to 83%), respectively, and the MRC had a sensitivity and specificity of 80% (95% CI 70% to 92%) and 81% (95% CI 77% to 85%), respectively.

CONCLUSIONS

Emergent surgical intervention is rare in the pediatric trauma population. Although precision of predictive accuracies of the Loma Linda Rule and MRC were limited by small numbers of outcomes, neither set of criteria appears to be sufficiently accurate to recommend their routine use.

Comparison of enhanced targeted rapid HIV screening using the Denver HIV risk score to nontargeted rapid HIV screening in the emergency department

STUDY OBJECTIVE

A clinical prediction tool, the Denver HIV Risk Score, was recently developed to help identify patients with increased probability of undiagnosed HIV infection. Our goal was to compare targeted rapid HIV screening using the Denver HIV Risk Score to nontargeted rapid HIV screening in an urban emergency department (ED) and urgent care.

METHODS

We used a prospective, before-after design at an urban medical center with an approximate annual census of 110,000 visits. Patients aged 13 years or older were eligible for screening. Targeted HIV screening of patients identified as high-risk by nurses using the Denver HIV Risk Score during medical screening was compared to nontargeted HIV screening offered by medical screening nurses during 2 separate 4-month time periods. The primary outcome was newly diagnosed HIV-infected patients.

RESULTS

28,506 patients presented during the targeted phase, 1,718 were identified as high-risk, and 551 completed HIV testing. Of these, 7 (1.3%, 95% confidence interval [CI] 0.5% to 2.6%) were newly diagnosed with HIV infection. 29,510 patients presented during the nontargeted phase and 3,591 completed HIV testing. Of these, 7 (0.2%, 95% CI 0.1% to 0.4%) were newly diagnosed with HIV infection. Targeted HIV screening was significantly associated with identification of newly diagnosed HIV infection when compared to nontargeted screening, adjusting for patient demographics and payer status (relative risk [RR] 10.4, 95% CI 3.4 to 32.0).

CONCLUSION

Targeted HIV screening using the Denver HIV Risk Score was strongly associated with new HIV diagnoses when compared to nontargeted screening. Although both HIV screening methods identified the same absolute number of newly diagnosed patients, significantly fewer tests were required during the targeted phase to achieve the same effect.

Ultrasound guidance for central venous access by emergency physicians in colorado

Introduction

To survey emergency physicians (EP) regarding the frequency of use of ultrasound guidance for placement of central venous catheters (UGCVC) and to assess their perceptions regarding the technique and barriers to its implementation.

Methods

A 25-question Web-based survey was e-mailed to all members of the Colorado chapter of the American College of Emergency Physicians with a listed e-mail address. A total of 3 reminders were sent to nonresponders.

Results

Responses were received from 116 out of 330 invitations. Ninety-seven percent (n = 112) of respondents indicated they have an ultrasound machine available in their emergency department, and 78% indicated they use UGCVC. Seventy-seven percent (n = 90) agreed with the statement, “Ultrasound guidance is the preferred method for central venous catheter placement in the emergency department.” However, 23% of respondents stated they have received no specific training in UGCVC. Twenty-six percent (n = 28) of respondents stated they felt “uncomfortable” or “very uncomfortable” with UGCVC, and 47% cite lack of training in UGCVC as a barrier to performing the technique.

Conclusion

Although the majority of surveyed EPs feel UGCVC is a valuable technique and do perform it, a significant percentage reported receiving no training in the procedure and also reported being uncomfortable performing it. Nearly half of those surveyed cited lack of training as a barrier to more widespread implementation of UGCVC. This suggests that there continues to be a need for education and training of EPs in UGCVC.

The current state of ultrasound training in canadian emergency medicine programs: perspectives from program directors

OBJECTIVES

There is a paucity of data about emergency ultrasound (EUS) training in emergency medicine (EM) residency programs accredited by the Royal College of Physicians and Surgeons of Canada (Royal College) and the College of Family Physicians of Canada (CFPC). Historically the progress of EUS in Canada has been different from that in the United States. We describe the current state of EUS training in both Royal College and CFPC-EM programs.

METHODS

All Royal College EM program directors and all CFPC-EM program directors were invited to participate in a website-based survey. Main outcome measures were characteristics of currently offered EUS training.

RESULTS

The response rate of the survey was 100% (30/30). EUS is part of the formal residency curriculum in 100% (13/13) of Royal College EM programs and in 88% (15/17) of CFPC-EM programs. EM resident rotations in ultrasound (US) are provided by 77% (10/13) of Royal College programs but only 47% (8/17) of CFPC-EM programs. There are specific requirements for numbers of EUS exams to be completed by graduation in 77% (10/13) of Royal College programs and 47% (8/17) of CFPC-EM programs. EM faculty and residents make clinical decisions and patient dispositions based on their EUS interpretation without a consultative study by radiology in 100% (13/13) of Royal College programs and 88% (15/17) of CFPC-EM programs. However, 69% (9/13) of Royal College programs and 53% (9/17) of CFPC-EM programs have no formal quality assurance program in place.

CONCLUSIONS

EUS training in Canadian EM programs is prevalent, but there are considerable discrepancies among residency programs in scope of training, curricula, determination of proficiency, and quality assurance. These findings suggest variability in both the level and the quality of EUS training in Canada.

Payer status, race/ethnicity, and acceptance of free routine opt-out rapid HIV screening among emergency department patients

OBJECTIVES

We estimated associations between payer status, race/ethnicity, and acceptance of nontargeted opt-out rapid HIV screening in the emergency department (ED).

METHODS

We analyzed data from a prospective clinical trial between 2007 and 2009 at Denver Health. Patients in the ED were offered free HIV testing. Patient demographics and payer status were collected, and we used multivariable logistic regression to estimate associations with HIV testing acceptance.

RESULTS

A total of 31,525 patients made 44, 765 unique visits: 40% were White, 37% Hispanic, 14% Black, 1% Asian, and 7% unknown race/ethnicity. Of all visits, 10 ,237 (23%) agreed to HIV testing; 27% were self-pay, 23% state-sponsored, 18% Medicaid, 13% commercial insurance, 12% Medicare, and 8% another payer source. Compared with commercial insurance patients, self-pay patients (odds ratio [OR] = 1.63; 95% confidence interval [CI] = 1.51, 1.75), state-sponsored patients (OR = 1.64; 95% CI = 1.52, 1.77), and Medicaid patients (OR = 1.24; 95% CI = 1.14, 1.34) had increased odds of accepting testing. Compared with White patients, Black (OR = 1.29; 95% CI = 1.21, 1.38) and Hispanic (OR = 1.17; 95% CI = 1.11, 1.23) patients had increased odds of accepting testing.

CONCLUSIONS

Many ED patients are uninsured or subsidized through government programs and are more likely to consent to free rapid HIV testing.

Derivation and validation of the Denver Human Immunodeficiency Virus (HIV) risk score for targeted HIV screening

Targeted screening remains an important approach to human immunodeficiency virus (HIV) testing. The authors aimed to derive and validate an instrument to accurately identify patients at risk for HIV infection, using patient data from a metropolitan sexually transmitted disease clinic in Denver, Colorado (1996-2008). With multivariable logistic regression, they developed a risk score from 48 candidate variables using newly identified HIV infection as the outcome. Validation was performed using an independent population from an urban emergency department in Cincinnati, Ohio. The derivation sample included 92,635 patients; 504 (0.54%) were diagnosed with HIV infection. The validation sample included 22,983 patients; 168 (0.73%) were diagnosed with HIV infection. The final score included age, gender, race/ethnicity, sex with a male, vaginal intercourse, receptive anal intercourse, injection drug use, and past HIV testing, and values ranged from -14 to +81. For persons with scores of <20, 20-29, 30-39, 40-49, and ≥50, HIV prevalences were 0.31% (95% confidence interval (CI): 0.20, 0.45) (n = 27/8,782), 0.41% (95% CI: 0.29, 0.57) (n = 36/8,677), 0.99% (95% CI: 0.63, 1.47) (n = 24/2,431), 1.59% (95% CI: 1.02, 2.36) (n = 24/1,505), and 3.59% (95% CI: 2.73, 4.63) (n = 57/1,588), respectively. The risk score accurately categorizes patients into groups with increasing probabilities of HIV infection.

Use of kiosks and patient understanding of opt-out and opt-in consent for routine rapid human immunodeficiency virus screening in the emergency department

OBJECTIVES

The objective was to evaluate patient acceptance and understanding of nontargeted opt-out and opt-in rapid human immunodeficiency virus (HIV) screening using computerized kiosks in the emergency department (ED).

METHODS

This study was a prospective quasi-experiment in an urban hospital with an annual ED and urgent care census of 120,000 visits. During medical screening, patients 13 years and older were offered rapid HIV screening using kiosks and opt-out consent (October 2009) or opt-in consent (December 2009). Random time blocks were used to administer structured surveys to evaluate patient understanding of the testing process.

RESULTS

During the opt-out phase, 6,602 were offered testing, and of these 3,993 (61%) did not opt-out and 886 (13%) completed screening. During the opt-in phase, 5,781 were offered testing, and of these 930 (16%) opted-in and 389 (7%) completed screening (absolute difference = 6%, 95% confidence interval [CI] = 5% to 8%). During the opt-out phase, 330 patients completed the survey. Of these, 201 (61%) did not opt-out, but 108 (54%, 95% CI = 47% to 61%) responded that they had not been informed about an HIV test. Of the 84 patients who had been informed, 32 (38%, 95% CI = 28% to 49%) responded that they had not agreed to an HIV test. During the opt-in phase, 416 completed the survey. Of these, 80 (19%) agreed to testing and two (3%, 95% CI = 0.3% to 9%) responded that they had not been informed about an HIV test. Of the 74 patients who had been informed, only two (3%, 95% CI = 0.3% to 9%) responded that they had not agreed to an HIV test.

CONCLUSIONS

Computerized kiosks can be successfully used to perform nontargeted rapid HIV screening in EDs. However, when using this approach, patient understanding of opt-in consent is significantly better than opt-out consent.