Increase Provider Awareness Research Articles

Improving Hepatitis C Screening in the Primary Care Outpatient Setting for Individuals Belonging to the Birth Cohort 1945-1965

Hepatitis C virus (HCV) affects millions of individuals in the United States. Because of the asymptomatic nature of early illness, many individuals infected with HCV are unaware of their disease status. Measures to increase HCV screening are essential to diagnose early asymptomatic disease, before the onset chronic illness. A quality improvement study was conducted to increase provider awareness of and adherence to HCV screening recommendations. This resulted in an increase in HCV screening among asymptomatic individuals born between 1945 and 1965 (birth cohort 1945-1965). Although this study focused on birth cohort testing, implementation of similar initiatives may increase screening in larger populations.

Using Preventive Health Alerts in the Electronic Health Record Improves Hepatitis C Virus Testing Among Infants Perinatally Exposed to Hepatitis C.

Perinatal exposure to hepatitis C virus (HCV) is a major public health issue, and poor testing rates leave many children with infection unidentified. We sought to use the electronic health record (EHR) to promote guideline-directed HCV testing among infants born to mothers with HCV infection in an urban, safety-net hospital system. Our study population was identified using our EHR database, Epic. Children were included in the study if they had perinatal HCV exposure, were 18 months to 18 years of age and had at least 1 encounter in a primary or urgent care clinic during the study period. Our study included retrospective (October 2011 to February 2015) and prospective (February 2015 to May 2018) arms. Our EHR-based intervention was initiated in the prospective arm and recommended a one-time HCV antibody test at or after the age of 18 months using a health maintenance reminder. The health maintenance reminder activated a point-of-care alert and a linked HCV testing order set in all prespecified encounters during the intervention period. Median time to appropriate HCV testing decreased from 96.2 months preintervention to 9.1 months postintervention (P < 0.0001), and rate of completed antibody testing increased from 14% to 61% (P < 0.0001). Among children with perinatal HCV exposure, using a point-of-care alert within the EHR significantly increased the HCV antibody testing rate in accordance with American Academy of Pediatrics (AAP) recommendations. More effective EHR-based interventions combined with increased provider awareness of appropriate HCV testing in perinatally exposed infants is imperative.

Abstract 19: Impacts of the Million Hearts® Cardiovascular Disease Risk Reduction Model on the Initiation or Intensification of Statins and Anti-hypertensive Medications: A Pragmatic, Cluster-randomized Trial

Introduction: The Million Hearts® Cardiovascular Disease (CVD) Risk Reduction Model pays providers for measuring cardiovascular risk among their Medicare beneficiaries and for reducing risk among their high-risk patients. The Centers for Medicare and Medicaid Services (CMS) is testing whether this model can improve cardiovascular care and reduce the incidence of first-time heart attacks and strokes over 5 years. This study assesses whether, in its first 2 years, the model (1) increased use of CVD medications among those with elevated blood pressure or cholesterol, and (2) increased provider awareness of CVD risks among their patients. Methods: In this pragmatic, cluster-randomized trial, CMS enrolled 516 organizations (primary and specialty practices, health centers, and hospitals) throughout the country and assigned half to the intervention group. Organizations enrolled beneficiaries (age 40-79 without a prior CVD event) during routine office visits. We linked enrollment and clinical data with Medicare Part D claims and estimated impacts as intervention-control differences in outcomes. We surveyed one randomly selected provider in each organization about their use of risk CVD stratification (70% response rate). Results: The intervention and control organizations enrolled 300,550 Medicare beneficiaries. In both groups, 18% of enrollees were high risk per CMS definitions (≥30% or higher risk of a heart attack or stroke in the next 10 years), 40% were medium risk (15-30% risk), and the remainder were low risk (&lt;15% risk). While almost all high-risk enrollees were taking anti-hypertensive medications or statins at baseline, most (90%) had elevated blood pressure, cholesterol, or both. High-risk enrollees in the intervention group were 4 percentage points more likely than control enrollees (28 vs 24%, p&lt;0.001) to initiate or intensify statins or anti-hypertensive medications within 6 months of enrollment. When including the larger medium-risk group—for whom CMS does not separately pay for CVD risk reduction—rates of initiation or intensification were 3 percentage points higher in the intervention versus control groups (23 vs 20%, p&lt;0.001). According to the survey, intervention group providers were much more likely than control group providers to risk assess at least half of their Medicare patients (71 vs 39%, p&lt;0.001). Most intervention group providers (73%) said that their greater use of risk stratification helped them better identify beneficiaries at risk of CVD events. Conclusions: The Million Hearts model significantly improved use of CVD medications among high-risk enrollees, mainly through intensification, and had positive spillover to the much larger medium risk group. These improvements were likely driven, at least partly, by providers become more aware of their patients’ CVD risk through greater use of risk stratification.

Overlap Between Irritable Bowel Syndrome Diagnosis and Endometriosis in Adolescents

Gastroenterologic symptoms often are reported by adults with endometriosis, leading to unnecessary diagnostic tests or complicated treatment. We investigated associations between endometriosis and irritable bowel syndrome (IBS) in adolescents and whether concurrent pain disorders affect these. We collected data from within The Women's Health Study: Adolescence to Adulthood, which is a US longitudinal study of premenopausal females with and without endometriosis. Our study cohort included participants younger than 21 years enrolled from 2012 to 2018. Participants completed an extensive health questionnaire. Those with IBS based on a self-reported diagnosis or meeting Rome IV diagnostic criteria were considered cases and those without IBS were controls. Subjects without concurrent gastrointestinal disorders or missing pain data (n= 323) were included in the analyses. We calculated adjusted odds ratios using unconditional logistic regression. More adolescents with endometriosis (54 of 224; 24%) had comorbid IBS compared with adolescents without endometriosis (7 of 99; 7.1%). The odds of IBS was 5.26-fold higher among participants with endometriosis than without (95% CI, 2.13-13.0). In girls with severe acyclic pelvic pain, the odds of IBS was 35.7-fold higher in girls without endometriosis (95% CI, 4.67-272.6) and 12-fold higher in girls with endometriosis (95% CI, 4.2-36.3), compared with no/mild pain. For participants with endometriosis, each 1-point increase in acyclic pain severity increased the odds of IBS by 31% (adjusted odds ratio, 1.31; 95% CI, 1.18-1.47). In an analysis of data from a longitudinal study of girls and women with and without endometriosis, we found significant associations between endometriosis and IBS, and a linear relationship between acyclic pelvic pain severity and the odds of IBS. Increased provider awareness and screening for IBS and endometriosis will improve patient outcomes and increase our understanding of these complex disorders.

Quality of life perceptions amongst patients co-infected with Visceral Leishmaniasis and HIV: Aqualitative study from Bihar, India.

BackgroundCo-infection with Visceral Leishmaniasis (commonly known as Kala Azar, KA) and Human Immunodeficiency Virus (HIV) is increasingly being diagnosed among patients in Bihar. This qualitative study is the first assessment of self-reported quality of life among patients co-infected with KA-HIV in the Asian context.MethodsWe conducted semi-structured, in-depth interviews and adopted an inductive thematic analysis to generate evidence on the quality of life of patients co-infected with KA and HIV. Patients were purposively sampled until saturation was attained.ResultsWe found that patients highly valued income or livelihood potential and health as indicators of a good quality life, and routinely went into debt accessing care in the private setup. This was due to perceptions of poor quality of care in the government setup and a lack of knowledge regarding available government services at the district level. KA symptoms were often misdiagnosed in the private sector as seasonal fever, while care providers found it difficult to disentangle the clinical symptoms of KA and HIV; hence, patients presented late to district hospitals. Patients perceived a high level of stigma, largely due to their HIV status, and routinely reported that HIV had “destroyed” their life.ConclusionsInadequate social support and referral pathways that were not conducive to patient needs negatively impacted patients’ quality of life. The dual burden of poverty interacting with the severity and chronicity of KA-HIV co-infection means financial support, increased community engagement, and collaborative decision making are crucial for co-infected patients. Increased provider awareness of co-infection and effective stigma-reduction interventions should be integrated to ensure that appropriate and effective access to care is possible for this vulnerable population. A sustainable long-term strategy requires a people-centered approach wherein the perceptions and life circumstances of patients are taken into account in the medical decision making process.

Long-Term Outcomes and Associations With Major Adverse Limb Events After Peripheral Artery Revascularization

BackgroundLong-term cardiovascular and limb outcomes after revascularization for peripheral artery disease and, in particular, prognosis after post-procedure major adverse limb events (MALE) are not well-studied. ObjectivesThis study sought to describe outcomes after peripheral revascularization and assess relationships between post-procedure MALE hospitalization and subsequent events. MethodsPatients undergoing peripheral artery revascularization between January 1, 2009, and September 30, 2015, in the Premier Healthcare Database were examined for the co-primary outcomes of interest, composite myocardial infarction (MI) or stroke and composite major amputation or peripheral revascularization. Multivariable adjusted Cox proportional hazards models with post-procedure MALE hospitalization included as a time-dependent covariate were developed to estimate hazard ratios for outcomes. ResultsAmong 393,017 revascularized patients followed for a median of 2.7 years (interquartile range: 1.3 to 4.4 years), the cumulative incidence of MI or stroke was 9.8% and that of major amputation or peripheral revascularization was 41.9%. A total of 50,750 patients (12.9%) had at least 1 post-procedure MALE hospitalization. In time-dependent covariate adjusted models, post-procedure MALE hospitalization was associated with greater risk of subsequent MI or stroke (hazard ratio: 1.34; 95% confidence interval: 1.28 to 1.40) and major amputation or peripheral revascularization (hazard ratio: 8.13; 95% confidence interval: 7.96 to 8.29). After peripheral revascularization with or without post-procedure MALE hospitalization, risk of limb events increased rapidly post-procedure and more slowly after the first year, whereas cardiac risk increased steadily during follow-up. ConclusionsRevascularized peripheral artery disease patients face earlier limb and later cardiovascular ischemic risk that is heightened among patients with post-procedure MALE hospitalization. Increased provider awareness of these long-term risks may guide efforts to improve post-procedural outcomes.

PrEParing for Preexposure Prophylaxis.

In 2012 the Food and Drug Administration (FDA) approved Truvada (emtricitabine [FTC] 200 mg/tenofovir disoproxil fumarate [TDF] 300 mg) for preexposure prophylaxis (PrEP) against HIV. There was a substantial decline in new HIV diagnoses which has since stabilized. The plateau is thought to be because preventative efforts are not reaching high-risk groups. About 1.2 million adults in the United States could benefit from PrEP but only 80,000 individuals are taking it. This article aims to increase provider awareness of PrEP so primary care providers feel confident discussing risk reduction options, initiating, and monitoring PrEP. A case based approached is used to achieve the objective. Target populations, baseline labs, follow up labs and monitoring parameters, and side effects of medication will be reviewed. Patient counseling with regards to dosing, administration, side effects and adverse events will be discussed. HIV prevention is an integral public health goal. PrEP is a way to achiveeve continued reduction in HIV incidence. PCPs should be offering PrEP to at risk individuals. Many nurse practitioners work as primary care providers, this article hopes to increase the confidence of PCPs in prescribing PrEP to those who would benefit from it.

Therapeutic Plasma Exchange (PLEX) in Thrombotic Microangiopathy (TMA): Experiences of an Inner-City Hospital over a Decade

Introduction: There are multiple mechanisms of occurrence of TMA. Some of the etiologies are associated with high morbidity and mortality, but there are very subtle differences in presentation. A high index of suspicion is recommended for thrombotic thrombocytopenic purpura (TTP) due to the time sensitive nature of treatment initiation and poor outcomes associated with delay in treatment. Due to this, treatment with PLEX is often initiated empirically before diagnostic test results are available. We aim to report the management and outcomes of TMA along with the predictive value of the PLASMIC score in our patient population, over a 10-year period in an inner-city safety net hospital. Methods: This is a single center observational study including patients who underwent PLEX for a diagnosis of TMA, due to concern for TTP between January 2009 and May 2019 at an inner-city safety net hospital. Patients were identified from blood bank records and data was collected by review of electronic medical record. We excluded patients &amp;lt;18 years old and who received PLEX for indications other than that described previously. Data was collected until death or last follow-up. Statistical analysis was done using STATA. Results: A total of 40 patients met the inclusion criteria. Of these, 57.5% (n=23) were male, 17.5% (n=7) had a known malignancy and 15% (n=6) had human immunodeficiency virus infection. Study population was predominantly African American and Hispanic- comprising 75% (n=30) and 17.5% respectively- which differentiates our study from other validation studies for the PLASMIC score. Symptoms at presentation to emergency department, time to initiation of PLEX from presentation, and lab parameters before and after PLEX are shown in the attached table. ADAMTS13 activity level is available in 65% (n=26) patients, 57.7% of which were sent before initiation of PLEX. Average number of PLEX sessions during the admission was 9.4 (range: 2-30). As part of treatment, 85% (n=34) received steroids and 17.5% (n=7) received hemodialysis. 5 patients received rituximab and 2 received eculizumab. Final diagnoses included TTP in 62.5% (n=25), complement mediated TMA in 5% (n=2), drug induced TMA in 10% (n=4), TMA from sepsis or rheumatological condition in 15% (n=6), bone marrow suppression due to chemotherapy in 5% (n=2) and unsure in 2.5% (n=1). Average length of stay was 22.2 days (range: 6-85 days). Of the total 40 patients, 7.5% (n=3) died on the same admission, 10% (n=4) died after discharge and 3 were readmitted for repeat PLEX. Duration of follow-up after discharge ranged from 9 to 3319 days (mean 1102.6 days). We retrospectively estimated the PLASMIC score at the time of presentation for all the patients. Amongst the patients eventually diagnosed with TTP, 50% had a PLASMIC score of &amp;gt;5 and 70.83% had a score ≥5 at the time of presentation. Among non-TTP TMA, 25% had a score of &amp;gt;5 and 62.5% had a score ≥5. The sensitivity, specificity and positive predictive value of PLASMIC score for prediction of final diagnosis of TTP was calculated for all patients who met inclusion criteria and is shown in the attached table. Of those who underwent PLEX in the setting of TMA for the concern of TTP, only about a third were started on PLEX within 24 hours. Conclusion:Among our study population, only about a third were started on PLEX within 24 hours which is concerning and highlights the need for quality improvement initiatives to increase provider awareness and decrease time to PLEX. Final diagnosis of TTP was made in 62.5% of the patients but notably, the performance of PLASMIC score in our patient population was inferior compared to prior validation studies. One possible explanation for this could be the difference in baseline patient demographics, with our patients belonging mostly to minority groups. There is a need for further studies with derivation and validation cohorts in this patient population to derive a scoring system that is more predictive. Table Disclosures No relevant conflicts of interest to declare.

Atypical Mycobacterial Infections After Plastic Surgery Procedures Abroad: A Multidisciplinary Algorithm for Diagnosis and Treatment.

The recent rise in medical tourism, especially for cosmetic procedures, has been mirrored by an increase in the incidence of infections with Mycobacterium abscessus, which is an atypical mycobacterium that is ubiquitous in aquatic environments. M. abscessus soft tissue infections arise from the use of improperly sterilized water and surgical equipment during surgical procedures, and these infections have devastating consequences if not promptly treated. M. abscessus infections are notoriously difficult to diagnose and properly treat, and therefore, we illustrate a typical case presentation and provide a comprehensive diagnostic and treatment algorithm. Of the patients who have presented to our hospital for treatment of cutaneous M. abscessus infections, a representative patient's story was included to illustrate the typical presentation and treatment timeline. The current literature on M. abscessus infections was reviewed, and this literature and the clinical experience of our plastic surgery and infectious disease teams were used in the creation of a diagnostic and treatment algorithm for M. abscessus infections. M. abscessus infections can have an incubation period of months, and the classic presenting signs include purulent drainage, violaceous nodules, and subcutaneous abscesses at the site of a recent surgery. A key finding is persistence of the infection despite debridement and empiric antibiotic treatment. Cultures grown on mycobacterial-specific growth media are considered the diagnostic criterion standard, but high clinical suspicion is enough to warrant the initiation of treatment. Treatment itself consists of surgical drainage and debridement in combination with multidrug antibiotic regimens that typically include amikacin, a macrolide, and a carbapenem or cephalosporin antibiotic, with the option for macrolide and fluoroquinolone maintenance therapy. M. abscessus cutaneous infections present with unique history and physical examination findings and often require complex diagnostic workups and treatment plans. Increased provider awareness of the management and potential complications of M. abscessus is crucial to the improvement patient outcomes, as is a multidisciplinary approach that incorporates primary care providers, pathologists, plastic surgeons, and infectious disease specialists.

Utilization and Cost of Mammography Screening Among Commercially Insured Women 50 to 64 Years of Age in the United States, 2012-2016.

Background: In recent years, most insurance plans eliminated cost-sharing for breast cancer screening and recommended screening intervals changed, and newer modalities-digital mammography and breast tomosynthesis-became more widely available. The objectives of this study are to examine how these changes affected utilization, frequency, and costs of breast cancer screening among commercially insured women, and to understand factors associated with utilization and frequency of screening. Materials and Methods: This study used commercial insurance claims data for women 50 to 64 years of age, continuously enrolled in commercial insurance plans during 2012-2016. Results: Of the 685,737 eligible women, 20% were not screened, 40% received annual screening, 24% received biennial screening, and 16% were screened less frequently than recommended during the time period examined. Sociodemographic factors such as age <60 years, rurality, and fee-for-service insurance were associated with low screening utilization. Patients who received annual screening incurred ∼1.78 times higher costs compared to those who received biennial screening during the study period. Digital mammography was the most costly and commonly used modality along with computer-aided detection. Conclusions: Evidence-based interventions to promote screening among women who are screened less frequently are needed along with interventions to move toward biennial screening rather than annual screening. Increasing provider awareness regarding breast cancer screening rates and frequency among various sociodemographic groups is essential to guide provider recommendations and shared decision making. The results of this study can guide targeted public health interventions to reduce barriers to screening, and can also serve as inputs for economic analyses of screening interventions and programs.

Healthcare disparities in rheumatology: the role of education at a global level.

All fields of medicine are victim to health inequity worldwide, including rheumatology. While the health system is a key proponent to health access for all, other social determinants of health also impact world health. We describe herein the current state of global healthcare disparities in rheumatology and attempts at optimizing graduate medical education and resources for optimized healthcare, international research collaborations and a future of universal health equity. We performed a comprehensive search through Pubmed using the following keywords: healthcare disparities, medical education, access to care, community health.Key Points• Healthcare disparities are ubiquitous globally, including the field of rheumatology.• The heterogeneity of global healthcare disparities emphasizes the importance of addressing unmet needs at a regional level.• A standardized approach to incorporating healthcare disparities education in the medical field is lacking. Intervening at this level provides a foundation of increasing provider awareness of regional healthcare disparities so as to establish a framework of addressing such disparities in a culturally competent manner.

2560 Small Bowel Carcinoid Causing Chronic Anemia

INTRODUCTION: Carcinoids are a relatively rare tumor that are often discovered incidentally. If symptoms are present, they may include abdominal pain, carcinoid syndrome, and occasionally bleeding. CASE DESCRIPTION/METHODS: A 59-year-old woman was admitted for bloody bowel movements. Past medical history includes hypertension and morbid obesity. She had chronic microcytic iron deficiency anemia and was evaluated in 2015 with EGD, colonoscopy, and capsule endoscopy. EGD was normal with no bleeding source, colonoscopy showed blood throughout colon without diverticulosis or AVMs, and capsule endoscopy revealed a jejunal ulcer. At presentation, vital signs were stable. Laboratory profile revealed iron deficiency anemia with hemoglobin 7.3 g/dL. Colonoscopy revealed a medium-sized mass in terminal ileum with oozing present and appearance concerning for carcinoid tumor. The mass was tattooed and a clip was placed. CT showed 2.1 cm mass in ileum as well as 1.9 cm enhancing lymph node concerning for metastasis. She underwent laparoscopic small bowel resection with removal of ileal mass and was noted to have multiple lesions along small bowel concerning for metastasis and grossly enlarged mesenteric lymph nodes, which were also removed. Pathology showed well-differentiated grade 1 neuroendocrine tumor with a lymph node positive for metastasis. Patient is scheduled to follow-up with oncology to determine treatment plan. DISCUSSION: Carcinoids are relatively rare with an incidence of 4.7 per 100,000 with rising incidence due to increased detection on endoscopy and imaging as well as increased provider awareness. They can arise in the gastrointestinal tract, lung, and genitourinary tract and are relatively slow growing and less aggressive than other cancers. Within the gastrointestinal tract, most carcinoids are found in the small intestine, rectum, and stomach, while small bowel carcinoids are commonly located in the ileum. Small intestine carcinoid tumors have been characterized as more aggressive in nature and commonly metastasize to lymph nodes or the liver. They require multidisciplinary evaluation with gastroenterologists, oncologists, and surgeons. In our case, the patient had chronic anemia many years prior and had undergone work-up prior to presenting with hematochezia. Previous evaluation showed a jejunal ulcer thought to be due to NSAID use. However, she continued to have iron deficiency anemia. This case illustrates the importance of repeat endoscopic evaluation in cases of persistent iron deficiency anemia.

AUTOIMMUNE BRAIN DISORDERS: BEYOND THE BASICS

Child and adolescent psychiatrists often are the first clinicians to evaluate patients with the abrupt onset of neuropsychiatric symptoms. The diagnosis of autoimmune encephalitis (AE) must be included in the differential for patients with acute-onset multidomain impairment (cognitive decline, personality changes, psychosis, catatonia, etc.). We aim to increase provider awareness of the broader differential for autoimmune brain disorders when considering a clinical diagnosis of AE. Providers will become equipped to participate in collaborative care treatment models for patients with autoimmune brain disorders.

State Strategies to Address Opioid Use Disorder Among Pregnant and Postpartum Women and Infants Prenatally Exposed to Substances, Including Infants with Neonatal Abstinence Syndrome.

Since 1999, the rate of opioid use disorder (OUD) has more than quadrupled, from 1.5 per 1,000 delivery hospitalizations to 6.5 (1), with similar increases in incidence of neonatal abstinence syndrome (NAS) observed for infants (from 2.8 per 1,000 live births to 14.4) among Medicaid-insured deliveries (2). CDC's response to the opioid crisis involves strategies to prevent opioid overdoses and related harms by building state capacity and supporting providers, health systems, and payers.* Recognizing systems gaps in provision of perinatal care and services, CDC partnered with the Association of State and Territorial Health Officials (ASTHO) to launch the Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative Learning Community (OMNI LC). OMNI LC supports systems change and capacity building in 12 states.† Qualitative data from participating states were analyzed to identify strategies, barriers, and facilitators for capacity building in state-defined focus areas. Most states focused on strategies to expand access to and coordination of quality services (10 of 12) or increase provider awareness and training (nine of 12). Fewer states focused on data, monitoring, and evaluation (four of 12); financing and coverage (three of 12); or ethical, legal, and social considerations (two of 12). By building capacity to strengthen health systems, state-identified strategies across all focus areas might improve the health trajectory of mothers, infants, and families affected by the U.S. opioid crisis.

Updates on HIV nonoccupational postexposure prophylaxis.

Adolescents and young adults continue to contribute to new HIV infections despite improved antiretroviral regimens and HIV preexposure and postexposure prophylaxis (PrEP and PEP). Knowledge about nonoccupational HIV PEP (nPEP) is relevant and important for all pediatricians as adolescents present under a variety of circumstances disclosing past sexual activity. nPEP is effective in preventing HIV infection, and newer regimens have been shown to increase compliance amongst users, have less side effects, and lead to less HIV resistance. Yet, research on physician prescription practices shows a lack of knowledge regarding appropriate HIV nPEP medication regimens, dosing, and follow-up recommendations. Updated national guidelines are available to providers who may be unfamiliar with indications and drug regimens for nPEP. Studies also provide different strategies to increase nPEP use and compliance among patients as well as ways to increase provider awareness of appropriate nPEP prescription. Research of HIV nPEP shows that it is effective when used correctly, but there needs to be increased education and awareness to increase provider prescription and patient use as well as institutional changes to help patients complete the full course of medication.

Environmental factors affecting self-management of chronic hepatitis B from the patients' perspective.

To explore factors affecting self-management experiences of patients with chronic hepatitis B within their social and cultural environments. Many cases of hepatitis B are not detected until they are in end-stage liver disease. Despite an increasing trend of indicating a lack of health awareness as the reason, studies have rarely referred to the personal, social and cultural environmental constraints from patients' perspectives. A descriptive qualitative study. Forty-seven adults diagnosed with chronic hepatitis B were interviewed in a private area of a hospital clinic in Taiwan in 2018. Four open-ended questions relating to care self-management included the following: disease detection; disease control; preventive care; and perceptions of screening and follow-ups. Data were examined using content analysis. This study also adhered to the consolidated COREQ guidelines. Five main themes emerged: personal experiences, awareness of occupational health, the availability of conventional treatment, cultural beliefs about health care and family roles. Findings of note were that some participants became aware that they had never known the difference between follow-up for hepatitis B and regular adult/labourer health checks due to a lack of information within their living environment. Many participants added alternative treatments to their self-management strategies and others frequently ignored follow-up appointments because of different cultural health beliefs. Patients' disease self-management perceptions are driven by dynamic influences suggesting that development of policies integrating personal, family, social and cultural environmental factors could enhance individual screening and subsequent health behaviours of patients with chronic hepatitis B. Adding person-centred case management of hepatitis B could enhance patients' adherence to follow-up. Attention should be given to increasing provider awareness of the influence of their own attitude and communication on patients' participation in self-management.

Managing Immuno-Oncology Toxicity: Top 10 Innovative Institutional Solutions.

Expanded use of immuno-oncology (IO) therapy to treat cancer has led to an increased frequency of novel toxicities known as immune-related adverse events (irAEs). Delayed recognition of IO toxicity can be life-threatening or even fatal. To address this issue, intervention is possible at three levels: patients, medical providers, and institutions. Patients and the medical community need institutional safeguards in place to promote swift recognition, assessment, and treatment of IO toxicity. Patients receiving IO therapy must be educated to identify the drugs they have received and to recognize potential IO toxicity, and they must know how to report symptoms. Medical providers must be able to reliably identify that patients have received IO therapy as well as recognize rare or subtle symptoms of IO toxicity. Institutions can establish guidelines and order sets to standardize the treatment of patients receiving IO therapy with irAEs, including the complex management of steroid-refractory irAEs. Additional interventions at an institutional level include identification of IO toxicity champions (subspecialists with expertise in IO toxicity), creating immunotherapy-specific tumor boards and lecture series to educate clinicians and staff, and establishing research programs to evaluate IO toxicity. IO therapy and toxicity experiences must be published and shared with both oncology and nononcology providers in the local, national, and international medical community. These efforts aim to improve patient-related outcomes, increase provider education and awareness, and build institutional safety standards for our oncology patients.

A systematic review of interventions to improve uptake of pertussis vaccination in pregnancy.

BackgroundMaternal pertussis vaccination has been introduced in several countries to prevent pertussis morbidity and mortality in infants too young to be vaccinated. Our review aimed to systematically collect and summarize the available evidence on the effectiveness of interventions used to improve pertussis vaccination uptake in pregnant women.MethodsWe conducted a systematic search of MEDLINE/PubMed, PMC and CINAHL. Before and after studies and those with a concurrent control group were considered for inclusion. Standardized effect sizes were described as the ratio of the odds to be vaccinated in the intervention group compared with the standard care group and absolute benefit increase (ABI) were calculated.ResultsSix studies were included in the review, of which three were randomized controlled trials (RCTs). Strategies to improve uptake were focused on healthcare providers, pregnant women, or enhancing vaccine access. Healthcare provider interventions included provider reminder, education, feedback and standing orders. Interventions directed at pregnant women focused solely on education. Observational studies showed: (1) the provision of maternal pertussis vaccination by midwives at the place of antenatal care has improved uptake of pertussis vaccine during pregnancy from 20% to 90%; (2) introduction of an automated reminder within the electronic medical record was associated with an improvement in the pertussis immunization rate from 48% to 97%; (3) an increase in prenatal pertussis vaccine uptake from 36% to 61% after strategies to increase provider awareness of recommendations were introduced. In contrast to these findings, interventions in all three RCTs (2 involved education of pregnant women, 1 had multi-component interventions) did not demonstrate improved vaccination uptake.ConclusionsBased on the existing research, we recommend incorporating midwife delivered maternal immunization programs at antenatal clinics, use of a provider reminder system to target unvaccinated pregnant women and include maternal pertussis immunization as part of standard antenatal care.

Lower Urinary Tract Symptoms and Urinary Bother Are Common in Patients Undergoing Elective Cervical Spine Surgery.

Lower urinary tract symptoms (LUTS) and urinary bother have been reported in adults undergoing surgery and have been associated with urinary tract infections, longer hospital stays, increased surgical costs, and decreased patient satisfaction. Previous reports indicate that up to one in two patients with lumbar spine pathology have moderate-to-severe LUTS, but little is known about LUTS in patients with cervical spine conditions. (1) What is the prevalence of moderate-to-severe LUTS and clinically relevant urinary bother among patients undergoing elective cervical spine surgery? (2) Does the presence of myelopathy affect frequency of moderate-to-severe LUTS or clinically relevant urinary bother among patients undergoing elective cervical spine surgery? (3) Do MRI findings of spinal cord injury or compression correlate with presence and severity of LUTS? We performed a cross-sectional study using clinical data collected from adult patients undergoing elective cervical spine surgery. Over an approximately 30-month period, we approached all patients who were evaluated in the preoperative clinic before undergoing elective cervical spine surgery. Of the 257 approached, 242 participated (94%). Study participants ranged in age from 34 to 83 years with a mean age of 58 years (SD 12). There were 108 males (45%) and 134 females (55%). A validated questionnaire, the International Prostate Symptom Score (IPSS), was used to identify LUTS. The IPSS score ranges from 0 to 35 points with LUTS presence defined as a score of ≥ 8 and LUTS severity categorized as mild (IPSS 0-7), moderate (IPSS 8-19), or severe (IPSS 20-35). Quality of life resulting from urinary bother is scored 0 to 6 with scores ≥ 4 considered clinically relevant urinary bother. Patients were grouped into a myelopathy group and a nonmyelopathy group based on diagnosis as assigned by the operating surgeon. MRIs were analyzed by one spine surgeon to identify the presence of cord signal, number of levels with cord compression (mm), and a calculated compression ratio score with cord compression and with compression ratio among patients with myelopathy. The prevalence of moderate LUTS in our patient sample was 40% (97 of 242; 95% confidence interval [CI], 34%-47%). The prevalence of severe LUTS in our patient sample was 8% (19 of 242; 95% CI, 5%-12%). Clinically relevant urinary bother was reported in 18% of patients (41 of 228; 95% CI, 13%-24%). After adjustment for age and sex, the odds of moderate-to-severe LUTS among patients with myelopathy was greater than that observed in patients without myelopathy (adjusted odds ratio, 2.0; p = 0.015). The prevalence of clinically relevant urinary bother was higher in patients with myelopathy (30% [26 of 88]) compared with those with no myelopathy (11% [15 of 140]; p < 0.001). With the numbers available, among patients with myelopathy, there was no difference in distribution of LUTS symptom severity or IPSS score according to cord signal presence (50% [23 of 46]) and absence (65% [31 of 48]; p = 0.153), number of levels with compression (70% [seven of 10 with four levels]; 59% [13 of 22 with three levels]; 51% [19 of 37] with two levels; and 60% [15 of 25] with one level; p = 0.730), millimeters of cord compression (r = 0.02; p = 0.854), or compression ratio (r = 0.09; p = 0.413). Nearly half of all patients undergoing elective cervical spine surgery had moderate-to-severe LUTS. This is more than double the prevalence that has been reported in a community-dwelling adult population. These symptoms can impair quality of life, lead to surgical complications (urinary retention or incontinence), and may be mistaken for cauda equina, prompting potentially unnecessary imaging and studies. Given that urinary bother is reported less frequently than LUTS, patients may be less likely to seek care for urinary symptoms before undergoing surgery. Therefore, it is important to increase provider awareness of the high prevalence of LUTS. Level III, prognostic study.

Nationwide Procedural Trends for Renal Trauma Management.

To characterize national trends in procedural management of renal trauma. Management of renal trauma has evolved to favor a more conservative approach. For patients requiring intervention, there is a paucity of information to characterize the nature of procedural therapy administered. A retrospective cross-sectional analysis was performed using data contained within the National Trauma Data Bank. The National Trauma Data Bank is a voluntary data repository managed by the American College of Surgeons, containing data regarding trauma admissions at 747 level I to V trauma centers throughout the United States and Canada. Participants included any patient with renal trauma requiring intervention from 2002 to 2012. They were identified according to International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, with codes 866.00 through 866.03 for blunt renal trauma, and codes 866.10 through 866.13 for penetrating trauma. Cases were separated into those requiring nephrectomy, renorrhaphy, or endovascular repair based on ICD-9 procedure code. The number of cases performed each year and yearly trends as measured by linear regression. A total of 4296 cases were reported during the study period. Of these cases, 2635 involved blunt trauma and 1661 involved penetrating injury. There was a significant increase in the percentage of cases managed by endovascular means for both blunt and penetrating trauma (R = 0.92, P < 0.01; and R = 0.86, P < 0.01, respectively). This was primarily at the expense of nephrectomy, with cases showing significant decline in both groups. National trends for procedural management of renal trauma are toward less invasive interventions. These trends suggest favorable change towards renal preservation and decreased morbidity, potentially facilitated, in part, by improved radiographic staging and endovascular techniques, and also increased provider awareness of the safety and value of conservative management.