Clinic In Houston Research Articles

Abstract PO2-10-01: Discrimination, Trust, and Pain Outcomes Among Black Women with Early-Stage Breast Cancer After Mastectomy

Abstract BACKGROUND Differences in perception, assessment, communication, and management of pain contribute to racial/ethnic pain disparities in breast cancer (BC). We previously found that Black women (BW) reported higher pain severity and interference with life after breast surgery compared to White women after adjusting for type of surgery and other potential confounders. Racial/ethnic inequities persist despite prior trials to improve disparate pain outcomes. This is likely because multiple factors contribute to pain expression, and structural factors affect the ability to control pain adequately. Perceived discrimination is associated with mistrust of medical providers. These factors are known to affect clinical outcomes, but their impact on pain has been understudied. In this preliminary analysis, we examine medical discrimination, trust in physician, and pain outcomes among BW with early-stage breast cancer after mastectomy. METHODS We surveyed BW with stage 0-III breast cancer who had mastectomy < 2 years of study enrollment at Baylor St. Luke’s Medical Center or Harris Health Smith Clinic in Houston, TX. Participants completed a demographic survey as well as the Brief Pain Inventory (BPI), Discrimination in Medical Settings Scale (DMS), and Trust in Physician Scale (TPS). In the BPI, participants reported their pain severity (PS) on a 0-10 scale at its worst, least, and on average. They reported pain interference with life (PI) from 0-10, types of pain treatments, and % relief from pain treatments. DMS and TPS questions were assessed on 5-point Likert scale. We performed chart review to obtain baseline clinical data related to BC diagnosis and treatment and comorbidities. We summarized patients’ baseline demographic and clinical information using descriptive statistics. PI and DMS were scored as a mean of the total items of each survey. We created mean Trust and Mistrust scores using means of the TPS questions related to each category. RESULTS Of the 37 BW surveyed, 36 (97.3%) were non-Hispanic. 23 (62.2%) had HR+ BC, and 2 (6.7%) had HER2+ disease. 26 (70.3%) women received chemotherapy, 10 (27%) received radiation therapy, and 17 (45.9%) received endocrine therapy. 26 (70.3%) women had > 1 comorbidity; the mean (SD) number reported was 1.3 (1.1). Mean BMI was 30.9 (6.6). 10 (29.4%) women completed high school, and 8 (23.5%) completed some college. 19 (55.9%) had a household income < $25,000, and 11 (32.4%) had private health insurance. Mean worst PS was 4.2 (3.1), and mean average PS was 3.6 (2.9). Mean composite PI score was 2.7 (2.7). 11 (29.7%) women were taking opioids for pain, 17 (45.9%) were taking non-opioid analgesics, and 3 (8.1%) were receiving non-medication treatments. Mean % pain relief with treatment was 52.3% (38.3). Mean DMS score was 1.2 (0.6). Mean composite TPS Trust and Mistrust scores were 4.4 (0.7) and 1.8 (1.0), respectively. CONCLUSION BW may continue to experience pain requiring opioid and/or non-opioid analgesics up to 2 years following mastectomy. Study participants reported relatively low levels of discrimination and high levels of trust on average. We are currently enrolling additional participants in the Emory Healthcare System and Grady Memorial Hospital in Atlanta, GA. After enrolling at least 80 total patients, we will determine the association between DMS and pain outcomes among participants adjusting for demographic, socioeconomic, and clinical factors as well as assess TPS as a potential mediator in the causal pathway between DMS and PS. Citation Format: Demetria Smith-Graziani, Yichun Cao, Jeffrey Switchenko, Mothaffar Rimawi, Abenaa Brewster. Discrimination, Trust, and Pain Outcomes Among Black Women with Early-Stage Breast Cancer After Mastectomy [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-10-01.

AB001. Disparities in healthcare: Spanish-speakers at a pediatric clinic in Houston, Texas

AB001. Disparities in healthcare: Spanish-speakers at a pediatric clinic in Houston, Texas

Determining a urinary-specific antibiogram and risk factors of trimethoprim/sulfamethoxazole, ciprofloxacin and multidrug resistance among Enterobacterales in primary care.

Risk factors for ciprofloxacin or MDR in primary care urine specimens are not well defined. We created a primary care-specific antibiogram for Escherichia coli isolates from cases with complicated and uncomplicated urinary tract infection (UTI) and evaluated risk factors for ciprofloxacin, trimethoprim/sulfamethoxazole and MDR among Enterobacterales. We conducted a cross-sectional study to determine resistance and risk factors by collecting urine cultures from all patients (≥18 years) presenting with provider-suspected UTI at two primary care, safety-net clinics in Houston, TX, USA between November 2018 and March 2020. Among 1262 cultures, 308 cultures grew 339 uropathogens. Patients with Enterobacterales (n = 199) were mostly female (93.5%) with a mean age of 48.5 years. E. coli was the predominant uropathogen isolated (n = 187/339; 55%) and had elevated trimethoprim/sulfamethoxazole (43.6%) and ciprofloxacin (29.5%) resistance, low nitrofurantoin (1.8%) resistance, and no fosfomycin resistance. Among E. coli, 10.6% were ESBL positive and 24.9% had MDR. Birth outside the U.S.A., prior (2 year) trimethoprim/sulfamethoxazole resistance, and diabetes mellitus were associated with trimethoprim/sulfamethoxazole resistance. Prior (60 day) fluoroquinolone use, prior ciprofloxacin resistance and both diabetes mellitus and hypertension were strongly associated with ciprofloxacin resistance. Prior fluoroquinolone use and a history of resistance to any studied antibiotic were associated with MDR, while pregnancy was protective. We found elevated resistance to UTI-relevant antimicrobials and novel factors associated with resistance; these data can be incorporated into clinical decision tools to improve organism and drug concordance.

Delays in Hepatitis A vaccination in people with HIV in Houston, Texas between 2010 and 2018

BackgroundStudies have demonstrated low hepatitis A virus (HAV) vaccination rates among persons with HIV (PWH). MethodsWe conducted a retrospective study of persons entering HIV care at two clinics in Houston, Texas between 2010 and 2018. We defined those eligible for HAV vaccination as those who had no history of HAV vaccination and had a negative anti-HAV IgG at entry to care. Kaplan-Meier curves summarized time to receipt of HAV vaccines. The proportions of patients who received 1 and 2 HAV vaccines at 6, 12, and 24 months were estimated. Cox proportional hazards regression evaluated associations between patient characteristics and vaccination. Significant factors were included in a multivariable Cox proportional hazards model. ResultsOf 6,515 patients, 1372 were eligible for HAV vaccination. Of eligible patients, 29.2 % received 1 HAV vaccination at 6 months, 37.1 % at 12 months, and 47.8 % at 24 months. At 6 months, 10 % received 2 HAV vaccinations, 21.1 % at 12 months, and 33.4 % at 24 months. In multivariable analysis, men who have sex with men (adjusted HR 1.35, 95 % CI 1.06, 1.73) or those who had CD4 count ≥ 200 cells/µl (adjusted HR 2.52, 95 % CI 1.89, 3.37) had their second vaccination sooner than those who were not men who have sex with men or who had CD4 counts < 200 cells/µl, respectively. Patients > 50 years of age had their second vaccination sooner than those aged 30–50 years (adjusted HR 1.47, 95 % CI 1.08, 1.99). Those with active substance history had a longer time to second vaccination compared to those with no substance use history (adjusted HR 0.57, 95 % CI 0.40, 0.82). ConclusionsHAV vaccination rates were low and highlight the need for effective solutions to address HAV immunization gaps in PWH, especially among young patients, those with active substance use disorders, and those with significant immunocompromise.

Design and protocol of a clinic-based comparative effectiveness randomized controlled trial to determine the feasibility and effectiveness of food prescription program strategies in at-risk pediatric populations

BackgroundProduce prescription programs are gaining traction in the U.S.; however, data on the impact of such approaches in pediatric populations are limited. The purpose of our clinic-based comparative effectiveness randomized controlled trial (CE RCT) is to evaluate the preliminary effectiveness of two produce prescription strategies (at-home delivery and grocery store vouchers) implemented by the Brighter Bites non-profit organization in improving obesity-related health outcomes and dietary behaviors among low-income 5–12-year-olds in Houston, Texas. This paper presents the study design, intervention components, and the study measures. MethodsParticipants (n = 150) are being recruited from two pediatric clinics in Houston, Texas. Child eligibility criteria are aged 5–12 years, Medicaid recipients, body-mass index (BMI) percentile ≥85 and living within 10 miles of a Brighter Bites distribution site. Following consent and baseline measures, children are randomized into one of three arms: (1) Bi-weekly $25 vouchers redeemable for produce at stores (n = 50), (2) Bi-weekly produce delivery to participants' homes through DoorDash (n = 50), and (3) wait-list usual care controls (n = 50). Intervention participants also receive Brighter Bites nutrition education materials. Main child outcome measures are BMI z-scores, blood pressure, hemoglobin A1c, liver panels, and lipid panels. Other outcomes including household food insecurity, child diet quality, and home nutrition environment will be collected through parent surveys. Outcome measures are collected at baseline and post-intervention. Process evaluation will measure program dosage, reach, acceptability, and feasibility. ConclusionsOur paper presents the design and next steps to ensure the successful implementation of a produce prescription program in a pediatric clinic setting.

Delays in Hepatitis B Immunization Series Completion in People With Human Immunodeficiency Virus.

Studies have demonstrated low hepatitis B virus (HBV) vaccine series completion among persons with human immunodeficiency virus (HIV). We conducted a retrospective record review of persons entering HIV care at 2 clinics in Houston, Texas, between 2010 and 2018. Kaplan-Meier curves summarized time to receipt of HBV vaccines for those eligible for vaccination. We estimated the proportions of patients who had received 1, 2, or 3 HBV vaccine doses at 12 and 24 months after entry to care. A Prentice Williams and Peterson total time model was used to evaluate associations between patient characteristics and time to vaccination. Of the 5357 patients who entered care, 2718 were eligible for HBV vaccination. After 2 years of follow-up, 51.2% of those eligible had received 1 HBV vaccine, 43.2% had received 2, and 28.4% received 3 vaccines. With adjustment for significant cofactors, patients whose CD4 cell count was ≥200/μL (adjusted hazard ratio [aHR], 1.43 [95% confidence interval (CI), 1.29-1.59]) and transgender patients (1.49 [1.08-2.04]) received any given vaccine dose sooner than those with CD4 cell counts <200/μL or cisgender patients, respectively. Compared with non-Hispanic whites, Hispanic patients were vaccinated sooner (aHR, 1.28 [95% CI, 1.07-1.53]). Those with an active substance use history had a significantly longer time to vaccination than those with no substance use history (aHR, 0.73 [95% CI, .62-.85]). Strategies are needed to increase HBV vaccine completion rates in our study population, particularly among those with CD4 cell counts <200/μL or with a substance use disorder.

Microalbuminuria in Perinatally HIV-Infected Children and Adolescents in the United States.

The kidney is a common target for human immunodeficiency virus (HIV), making renal disease a common noninfectious complication of HIV. Microalbuminuria is an important marker that can detect early renal damage. Timely detection of microalbuminuria is important to initiate renal management and stop the progression of renal dysfunction in people with HIV. Limited data are available about renal abnormalities in people with perinatal HIV infection. The objective of this study was to determine the prevalence of microalbuminuria in a cohort of perinatally HIV-infected children and young adults receiving combination antiretroviral therapy and investigate correlations between microalbuminuria and clinical and laboratory findings. This was a retrospective study of 71 patients with HIV followed in an urban pediatric HIV clinic in Houston, Texas, between October 2007 and August 2016. Demographic, clinical, and laboratory data were compared between subjects with persistent microalbuminuria (PM) and those without. PM is defined as a microalbumin-to-creatinine ratio ≥30 mg/g on at least 2 occasions separated by at least 1 month. Sixteen of 71 patients (23%) met the definition of PM. In univariate analysis, patients with PM had significantly higher CD8+ T-cell activation and lower CD4+ T-cell nadir. Multivariate analysis demonstrated increased microalbuminuria to be independently associated with older age and CD8+ T-cell activation measured as CD8+HLA-DR+ T-cell percentage. Older age and increased activation of CD8+HLA-DR+ on T cells correlate with presence of microalbuminuria in this cohort of HIV-infected patients.

MiR-124-3p target genes identify globus pallidus role in suicide ideation recovery in borderline personality disorder

Borderline personality disorder (BPD) is characterized by patterns of unstable affect, unstable interpersonal relationships, and chronic suicidal tendencies. Research on the genetics, epigenetics, and brain function of BPD is lacking. MicroRNA-124-3p (miR-124-3p) was recently identified in a Genome-Wide Association Study as likely associated with BPD. Here, we identified the anatomical brain expression of genes likely modulated by miR-124-3p and compared morphometry in those brain regions in BPD inpatients vs. controls matched for psychiatric comorbidities. We isolated lists of targets likely modulated by miR-124-3p from TargetScan (v 8.0) by their preferentially conserved targeting (Aggregate PCT > 0.99, see Supplementary Table 1). We applied Process Genes List (PGL) to identify regions of interest associated with the co-expression of miR-124-3p target genes. We compared the gray matter volume of the top region of interest co-expressing those genes between BPD inpatients (n = 111, 46% female) and psychiatric controls (n = 111, 54% female) at The Menninger Clinic in Houston, Texas. We then correlated personality measures, suicidal ideation intensity, and recovery from suicidal ideation with volumetrics. Gene targets of miR-124-3p were significantly co-expressed in the left Globus Pallidus (GP), which was smaller in BPD than in psychiatric controls. Smaller GP volume was negatively correlated with agreeableness and with recovery from suicidal ideation post-treatment. In BPD, GP volume may be reduced through miR-124-3p regulation and suppression of its target genes. Importantly, we identified that a reduction of the GP in BPD could serve as a potential biomarker for recovery from suicidal ideation.

Clinical factors and diagnoses associated with inappropriate urine-culture ordering in primary care

Background: Inappropriate urine-culture ordering is associated with increased antibiotic prescribing in myriad care environments, including acute and long-term care. In primary care, where urinary tract infections (UTIs) are commonly encountered, the appropriateness of urine-culture ordering has not been well described. We examined the appropriateness of urine-culture ordering and factors associated with inappropriate urine-culture ordering in primary care. Methods: We conducted a secondary analysis of data from a previous prospective study that included patients aged ≥18 years presenting with provider-suspected UTI with an accompanying urine culture at 2 safety-net, primary-care clinics in Houston, Texas, between November 2018 and March 2020. Patients with complicated or uncomplicated UTI were included, but those with a urinary catheter and pregnant females were excluded. Urine cultures were considered appropriate if the patient had an evidence-based symptom of UTI (ie, dysuria, frequency, urgency, hematuria, fever, chills, costovertebral angle tenderness, suprapubic, pelvic, or flank pain, or nephrolithiasis) as a diagnostic code or listed in providers’ free-text documentation. Diagnostic codes for symptoms that were not evidence based were grouped into categories based on body system, visit type (eg, routine visit), or sign or symptom clusters. We evaluated the relationships among demographic and clinical factors, the clinic visited, and non–evidence-based diagnostic codes with inappropriately ordered cultures. Results: We examined 870 cultures from 807 patients. Overall, 61.5% of patients were Hispanic (61.5%) and 23% were African American or Black. Also, 70.6% were women; the mean age was 49.2 years (SD, 14.6); and the mean Elixhauser score was 1.9 (SD, 5.4). Among the 870 cultures, 210 (24%) were ordered inappropriately. Dysuria (n = 289), frequency (n = 129), and UTI or cystitis (n = 117) were the most common, evidence-based codes among appropriate cultures. In the adjusted model, the nonteaching clinic (aOR, 6.33) and diagnostic codes comprising the following categories were associated with inappropriate culturing: acute lower back pain (aOR, 5.42), cardiac-related visits (aOR, 2.41), urinary incontinence (aOR, 4.46), routine health visits (aOR, 3.66), urine characteristics (aOR, 14.32), voiding difficulties (aOR, 3.88), and well-woman visits with a gynecological exam or family planning aspect (aOR, 12.27) (all P &lt; .05). Conclusions: This research highlights potential gaps or miscues in provider behavior related to urine culture ordering, and unveiled problematic culturing related to urine characteristics and to routine visits, especially of a gynecological nature. This information can be incorporated into diagnostic stewardship interventions to address misconceptions, and to further explore the reasoning or processes wherein urine cultures are ordered for routine visits.Financial support: NIAID UM1AI104681Disclosure: None

Obesity in Pediatric Congenital Heart Disease: The Role of Age, Complexity, and Sociodemographics.

The prevalence of obesity in children with congenital heart disease (CHD) is greater than 25%, putting these patients at-risk for increased surgical morbidity and mortality. Our goal was to determine the association between CHD complexity, sociodemographic factors, and obesity. Our hypothesis was that among CHD patients, the odds of obesity would be highest in older children with simple CHD, and in all children with a lower socioeconomic status. We conducted a retrospective cohort study, reviewing electronic medical records of children aged 2-17years from over 50 outpatient pediatric clinics in Houston, TX. Children were classified as simple or moderate/complex CHD, and obesity was defined by BMI ≥ 95th percentile for age and sex. Logistic regression was used to determine the association between sociodemographic factors and CHD complexity with obesity. We identified 648 CHD and 369,776 non-CHD patients. Children with simple CHD had a similar odds of obesity as non-CHD children. Children with CHD had a higher prevalence of obesity if they were older, male, Black, Hispanic, and publicly insured. Children with moderate/complex CHD had lower odds of obesity [OR 0.24 (95% CI 0.07-0.73)], however their predicted probability of obesity approached that of the general population as they aged. Additionally, there was an incremental relationship with poverty and obesity [1.01 (1.01-1.01)]. Awareness of which patients with CHD are at highest risk of obesity may help in targeting interventions to assist at-risk patients maintain a healthy lifestyle.

Disparities in healthcare: Spanish-speakers at a pediatric clinic in Houston, Texas

Disparities in healthcare: Spanish-speakers at a pediatric clinic in Houston, Texas

Effect of a Medical-Legal Partnership on Mental Health and Utilization: A Randomized Controlled Trial in Primary Care.

Context: Family physicians lack resources to effectively intervene on health-harming legal needs (HHLNs), despite growing calls to address social determinants of health. One promising model is the medical-legal partnership (MLP), which embeds legal screening and referral in clinics, but more evidence is needed prior to broader implementation. Objective: To examine whether an MLP reduces stress, depression, and medical overutilization. Study design: Randomized controlled trial. Setting: Urban, primary care clinic in Houston. Population studied: Low-income individuals, aged 18 or older, who are English or Spanish speaking with positive screens for HHLNs. Intervention: Randomization to an MLP referral or 6-month waitlist. Outcome measures: The primary outcome was perceived stress at 6 months (Perceived Stress Scale (PSS); 0-40 range). Secondary outcomes were depression (Center for Epidemiologic Studies Depression Scale (CES-D); 0-60 range), anxiety (Generalized Anxiety Disorder scale (GAD-7); 0-21 range) and self-reported emergency department, urgent care, and hospital visits. Assessments occurred at 3, 6, and 9 months. Analysis: Generalized linear modeling was used to fit each outcome at 6-months as a function of MLP group, controlling for baseline. Bayesian statistical inference with weakly informative priors and a 75% posterior probability (PP) threshold was used to identify noteworthy differences. Results: One hundred sixty individuals were randomized to intervention (80) and control (80) groups. Analyses did not find meaningful group differences for emergency department visits, urgent care visits, or CES-D. Being in the intervention group was associated with lower PSS scores (18.8 vs. 19.9; PP = 75%) but higher hospitalizations (0.4 vs. 0.3; PP = 78%) and GAD-7 scores (10.3 vs. 6.7; PP=90%). Conclusion: Findings in this trial of an MLP referral were mixed. At 6 months, participants who received an MLP referral appeared to be less stressed but also reported higher anxiety and more hospitalizations.

Testing the accuracy of autofluorescence device in diagnosing oral potentially malignant disorders among people with HIV seeking dental care.

Although many studies have assessed the diagnostic accuracy of autofluorescence in oral potentially malignant disorders (OPMDs), there has been a paucity of such information in high-risk populations. Our study thereby tested the accuracy of using autofluorescence in the oral examination of suspicious lesions among patients seeking care at an HIV-specialized dental clinic in Houston, Texas. We performed a prospective single-arm design in which forty-four (44) HIV-infected individuals seeking dental care at a specialized-HIV dental clinic were recruited. Each subject had their oral cavity examined under conventional lighting and then used a fluorescence light-based handheld device (OralID®). Biopsy was obtained from unresolved suspicious OPMDs at the 15-day follow-up, and histopathological analysis was conducted. The oral lesions, not the patient, were treated as the unit of analysis. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated using SPSS. The results showed that OPMDs could be identified with a sensitivity of 90%, a specificity of 18%, an NPV of 86%, a PPV of 24% using the fluorescence light-based handheld device, with a diagnostic accuracy of 55%. Despite the low specificity, fluorescence light can complement clinical oral cancer screening and aid identification of OPMDs during biopsy procedures. Our findings suggest that autofluorescence devices could supplement clinical oral examination and aid the identification of OPMDs during biopsy procedures, potentially improving oral cancer screening among HIV-positive patients seeking care.

S1356 Correlation Between Systemic Inflammatory Markers and Evidence of Metastatic Disease in Patients With Hepatocellular Carcinoma

Introduction: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. A wide variety of scoring systems such as Albumin-Bilirubin (ALBI), Platelet-Album-Bilirubin (PALBI), Monocyte-to-Lymphocyte ratio (MLR), and Neutrophil-Lymphocyte Ratio (NLR) along with tumor characteristics (tumor size, count, and vascular invasion) have been proposed as prognostic indicators. The aim of our study was to determine the correlation, if any between these scoring systems and evidence of metastatic disease at diagnosis in patients with HCC. Methods: A cross-sectional study was conducted at Liver Associates of Texas Hepatology clinics in Houston, Texas. Included were patients diagnosed with HCC between January 2014 and December 2021. Demographic data, chronic liver disease, cirrhosis status, and evidence of metastatic disease at diagnosis were recorded. Laboratory parameters including serum albumin, total bilirubin, platelet count, absolute lymphocyte, neutrophil, and monocyte counts were collected for each patient at the time of diagnosis. The diagnosis of HCC was established by Magnetic Resonance Imaging (MRI). Albumin-Bilirubin (ALBI) score, Platelet-Albumin-Bilirubin (PALBI) score, Monocyte-to-Lymphocyte ratio (MLR), and Neutrophil-to-Lymphocyte ratio (NLR) were calculated by mathematical formulas previously described in the literature. A binomial logistic regression model was performed with the different scores and ratios as independent variables, and evidence of metastatic disease as the dependent variable. A p-value of less than 0.05 was considered significant. (Figure) Results: 231 patients were identified with HCC. The mean age was 69 years old. 72.3% were male. 38.1% white, 21.6% Hispanic, 13.4% African American, 13.4% Asian/Pacific Islander, and 13.4% unspecified ethnicity. Out of the 231, all except one patient had cirrhosis; hepatitis C was the most common cause of cirrhosis (59.7%) followed by NASH (17.7%). 17.3% of the patients had evidence of metastatic disease at diagnosis. Patients with metastatic disease at diagnosis had a higher NLR (OR: 1.64 [1.18 – 2.29], p = 0.003). However, interestingly, patients with metastatic disease at diagnosis had a lower MLR (OR: 0.11 [0.01 – 0.77], p = 0.027). (Table) Conclusion: Our study suggests that patients with metastatic disease at diagnosis had a higher NLR, hence this ratio is a promising non-invasive prognostic parameter for patients with HCC. However, further studies need to be performed to validate our results. Table 1. - Correlation among different steatosis scores and ratios with the evidence of metastatic disease at diagnosis in patients with HCC OR p value 95% CI ALBI score 8.99 0.141 (0.48 – 166.95) PALBI score 0.59 0.219 ( 0.25 – 1.36) MLR 0.11 0.027* (0.01 – 0.77) NLR 1.64 0.003* (1.18 – 2.29) ALBI= Albumin-Bilirubin; PALBI= Platelet-Albumin-Bilirubin; MLR= Monocyte to Lymphocyte Ratio; NLR= Neutrophil to Lymphocyte Ratio; OR= Odds Ratio; * = Statistically significant to the 95% CI; CI = Confidence Interval. Figure 1.: Positive correlation between NLR and metastatic disease in patients with HCC.

Prevalence and predictors of urine culture contamination in primary care: A cross-sectional study

BackgroundAntimicrobial resistance is a global health threat. To slow resistance and preserve antibiotics, stewardship interventions are increasingly promoted and mandated. Urine cultures are the most common microbiological test in the outpatient setting. Contamination most likely occurs during urine collection from surrounding vaginal, perineal, and epidermal flora. Sample contamination can lead to incorrect diagnosis, unnecessary or inappropriate treatment, poor patient outcomes, and higher costs. Therefore, ensuring proper collection of urinary samples serves as a prime diagnostic stewardship target, one that international nursing societies increasingly endorse as an opportunity for nurse involvement. ObjectivesDetermine the prevalence, predictors, and antibiotic prescribing associated with contaminated urine cultures in primary care clinics. DesignCross-sectional study. SettingTwo adult safety-net clinics in Houston, Texas. Participants1265 clinical encounters among 1114 primary care patients. MethodsWe reviewed charts from office visits among patients who had a urine culture ordered between November 2018 and March 2020. Patient demographics, culture results and prescription orders were captured for each visit. Culture results were defined as no growth, contaminated (i.e., mixed flora, non-uropathogens, or ≥3 bacterial species isolated), or low-count (102–105 colony forming units (CFU)/mL) or high-count (>105 CFU/mL) uropathogen-positive. We performed multinomial logistic regression to identify predictors independently associated with contaminated cultures. ResultsOur study evaluated 1265 cultures from 1114 patients that were primarily female (84 %), of Hispanic/Latino (74.4 %) or Black/African American (18.9 %) race/ethnicity with a mean age of 43 years. Out of 1265 urine cultures, 264 (20.9 %) had no growth, 694 (54.9 %) were contaminated, 159 (12.6 %) were low-count positive, and 148 (11.7 %) were high-count positive. Female sex, pregnancy, and obesity were associated with contaminated cultures (multinomial adjusted odds ratios: 15.89, 14.34, 1.93, respectively; 95 % confidence intervals: 10.25–24.61, 8.03–25.61, 1.32–2.81, respectively). Antibiotic prescribing was significantly higher among symptomatic patients with contaminated cultures compared to those with no growth. ConclusionUrine culture contamination occurred frequently in our clinics, and obesity, female sex and pregnancy were independent risk factors for contamination. The association of pregnancy and contamination is particularly concerning as pregnant females are routinely screened and treated for asymptomatic bacteriuria in the United States. Culture contamination may obscure underlying uropathogens, leading to pyelonephritis or potential neonatal infection if untreated. Conversely, overtreatment of false positive bacteriuria could lead to adverse effects from antibiotics and increased risk for antibiotic resistance. As nurses play a prominent role in patient education, diagnostic stewardship interventions may want to utilize nurses' educational capabilities to improve urine culture collection. Tweetable abstract55 % of urine cultures collected in primary care clinics were contaminated, revealing a major opportunity for nurse-driven diagnostic stewardship interventions.

Creating a Collaborative Trauma-Informed Interdisciplinary Citywide Victim Services Model Focused on Health Care for Survivors of Human Trafficking.

Although human trafficking is recognized as a public health issue, research on the health effects of human trafficking and best intervention practices is limited. We describe 2 citywide collaborative victim services models, the THRIVE (Trafficking, Healthcare, Resources, and Interdisciplinary Victim Services and Education) Clinic at the University of Miami and Jackson Health System in Miami, Florida, and the Greater Houston Area Pathways for Advocacy-based, Trauma-Informed Healthcare (PATH) Collaborative at Baylor College of Medicine, CommonSpirit Health, and San Jose Clinic in Houston, Texas, funded in part by the Office for Victims of Crime, which focus on trauma-informed health care delivery for victims of human trafficking. From June 2015 through September 2021, the THRIVE Clinic served 214 patients with an average age of 28.7 years at the time of their first visit. From October 2017 through September 2021, the PATH Collaborative received 560 suspected trafficking referrals, 400 of which screened positive for labor or sex trafficking. These models serve as a framework for replication of interdisciplinary practices to provide health care for this unique population and preliminary information about the strategies put in place to assist victims during their recovery. Key lessons include the importance of a citywide needs assessment, patient navigators, interdisciplinary care, and building community partnerships to ensure safe housing, transportation, identification, health insurance, vocation services, input from survivors, peer-to-peer mentorship, and medical-legal services. Further research is needed to understand the detrimental health effects of trafficking and the health care needs of victims. In addition, a need exists to develop optimal models of care for recovery and reintegration for this patient population and to address public health, legal, and medical policies to ensure access to and sustainability of comprehensive, trauma-informed, interdisciplinary victim services.

Impact of the COVID-19 pandemic on visual outcomes of diabetic macular edema patients at a tertiary care veterans affairs center.

PurposeThere are limited studies on factors that impacted retina clinic patient outcomes during the COVID-19 pandemic. We aimed to evaluate visual and anatomic outcomes in patients with diabetic macular edema (DME) requiring anti-VEGF injections at the veterans’ affairs tertiary care eye clinic in Houston, TX.MethodsPatient volume from April 2020 was compared to that of April 2019 to determine attendance changes. To evaluate outcomes, we reviewed patients with DME who had scheduled appointments during April 2020. We tracked changes in central foveal thickness (CFT) and Snellen visual acuity (VA) measurements. Patient outcomes were classified as poor (defined as worsening VA or CFT at follow-up) or good (no worsening of either at follow-up). Regression analysis identified characteristics associated with poor outcomes.ResultsTo prevent the spread of COVID-19, patients were called to reschedule clinic appointments. Attendance frequency decreased from 523 patients in April 2019 to 246 patients in April 2020. 134 patients met inclusion criteria (mean age of 64.7 ± 8.8 years). 19/134 of patients were seen on schedule, 89/134 had delayed appointments (average follow-up interval of 115.2 ± 50.0 days), and 26/134 were lost to follow-up. Patients with delayed appointments had higher odds of poor outcome at follow-up compared to patients seen on schedule (OR = 4.03, 95% CI: 1.14–16.92, p = 0.04). Patient’s baseline visual acuity, macular thickness, comorbidities, and diabetic retinopathy severity, and demographics did not affect visual outcome at follow-up.ConclusionsOn average, patients were rescheduled to a visit 2.4 months later than their usual visit. Over half these patients experienced worsening of vision or edema. This demonstrates that lapses in care result in worsening of DME. However, there is no clear association between baseline characteristics and risk of disease progression.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40200-022-01049-5.

Outpatient antibiogram and predictors of ciprofloxacin and trimethoprim-sulfamethoxazole resistant urinary tract infections.

Context: Rising antibiotic resistance has transcended hospital boundaries and impacted individuals with community acquired urinary tract infections (UTI). Scant data on antibiotic resistance in outpatient settings exists and most studies in the United States (U.S.) have identified predictors of resistance in acute-care settings. Objective: Determine the antibiogram among Escherichia coli isolates and factors associated with ciprofloxacin and trimethoprim-sulfamethoxazole (TMP-SMX) resistant gram-negative urinary isolates. Study Design: Retrospective cohort study. Setting: Two primary care, safety-net clinics in Houston, TX between 11/2018 and 3/2020. Population studied: Patients aged 18 and older presenting with provider suspected uncomplicated or complicated UTI. Outcome measures: Resistance and predictors of resistance to UTI-relevant antibiotics. Results: Among 1265 cultures collected, 372 (28.4%) were positive. We detected E. coli (50.3%) and Group B Streptococcus (18.6%) most frequently. Our patient population consisted mostly of Hispanic (75.7%) females (92.5%) born outside the U.S. (67.3%) with a mean age of 47. Among patients with E. coli isolated (n=189), antibiotic resistance was highest to ampicillin (63%), TMP-SMX (44%), ciprofloxacin (31%), and cefazolin (30%); no or low resistance against amikacin (0%), fosfomycin (0%), and nitrofurantoin (2.7%) was detected. Approximately 12% of E. coli isolates were extended-spectrum beta-lactamase positive. Having a prior UTI caused by a TMP-SMX resistant gram-negative organism and being born outside the U.S increased the odds of TMP-SMX resistance by 3.71 (95% confidence interval: 1.6-9.2) and 3.08 (95% CI: 1.6-6.3), respectively. Having a complicated UTI (odds ratio (OR): 3.58; 95% CI: 1.1-12.1), prior fluoroquinolone use (OR: 6.81; 95% CI: 1.7-34.1) and a prior UTI with ciprofloxacin resistance (OR: 7.84; 95% CI: 3.2-20.7) increased the odds of having a ciprofloxacin resistance. Conclusion: The Infectious Disease Society of America cautions against prescribing an antibiotic if regional resistance exceeds 20%. We constructed an antibiogram and found resistance surpassed this threshold for TMP-SMX and ciprofloxacin and identified factors associated with resistance to these agents. Assessing these characteristics during clinical decision making may improve antibiotic-organism susceptibility concordance in primary care.

Acceptability and feasibility of video-based coaching to enhance clinicians\u2019 communication skills with patients

BackgroundDespite a growing call to train clinicians in interpersonal communication skills, communication training is either not offered or is minimally effective, if at all. A critical need exists to develop new ways of teaching communication skills that are effective and mindful of clinician time pressures. We propose a program that includes real-time observation and video-based coaching to teach clinician communication skills. In this study, we assess acceptability and feasibility of the program using clinician interviews and surveys.MethodsThe video-based coaching intervention targets five patient-centered communication behaviors. It uses trained communication coaches and live feed technology to provide coaching that is brief (less than 15 min), timely (same day) and theory-informed. Two coaches were trained to set up webcams and observe live video feeds of clinician visits in rooms nearby. As coaches watched and recorded the visit, they time stamped illustrative clips in real time. Video clips were a critical element of the program. During feedback sessions, coaches used video clips to promote discussion and self-reflection. They also used role play and guided practice techniques to enforce new tips. Clinicians included residents (n = 15), fellows (n = 4), attending physicians (n = 3), and a nurse practitioner (n = 1) at two primary care clinics in Houston, Texas. We administered surveys to clinicians participating in the program. The survey included questions on quality and delivery of feedback, and credibility of the coaches. We also interviewed clinicians following the intervention. We used rapid analysis to identify themes within the interviews.ResultsSurvey measures showed high feasibility and acceptability ratings from clinicians, with mean item scores ranging from 6.4 to 6.8 out of 7 points. Qualitative analysis revealed that clinicians found that 1) coaches were credible and supportive, 2) feedback was useful, 3) video-clips allowed for self-reflection, 4) getting feedback on the same day was useful, and 5) use of real patients preferred over standardized patients.ConclusionsVideo-based coaching can help clinicians learn new communication skills in a way that is clinician-centered, brief and timely. Our study demonstrates that real-time coaching using live feed and video technology is an acceptable and feasible way of teaching communication skills.

The Effect of Initial Patient Experiences and Life Stressors on Predicting Lost to Follow-Up in Patients New to an HIV Clinic.

We conducted a prospective cohort study of 450 patients new to an HIV clinic in Houston, TX, to examine the roles of life stressors and initial care experiences in predicting being lost to follow-up in the first year of care. Patients completed a self-administered survey following their initial provider visit. In logistic regression models, patients who reported better experiences with the HIV provider at the first visit were less likely to be lost to follow-up at 6months (aOR = 0.866, p = 0.038) and 12months (aOR = 0.825, p = 0.008). Patients with a higher burden of stressful life events were more likely to be lost to follow-up at 6months (aOR = 1.232, p = 0.037) and 12months (aOR = 1.263, p = 0.029). Assessments of patient experience and life stressors at the initial visit have potential to predict patients at risk of dropping out of care.