San Francisco General Hospital Research Articles

Surgical Professionalism, the White Owl, and Tar Heel Basketball.

The University of North Carolina (UNC) has storied traditions beyond its champion Tar Heel basketball teams. One of its best-and least known off campus-is the white owl, today a lapel pin given to chief residents in surgery at Memorial Hospital in Chapel Hill. Former residents in anesthesia and surgery at the San Francisco General Hospital (SFGH) remember it as a stuffed owl that anesthesia residents brought into the operating room whenever there was an appendectomy for appendicitis and the appendix was normal, an operation familiarly called a negative appendectomy. Standing at the table closing the incision their surgical counterpart endured the imagined smirks of the anesthesiologists behind their masks and the scrub techs and circulating nurses who also knew of the bird's significance. Alumni of the SFGH training programs also remember it as evidence of the good-natured repartee between anesthesia and surgery, teams that worked hard at all hours to serve the injured and disadvantaged populations of the city. In retrospect, the white owl signifies owning one's decisions and mistakes, an essential aspect of surgical professionalism.

448. Disproportionate Burden of COVID-19 on Latinx Residents among Hospitalized Patients at San Francisco’s Public Health Hospital

BackgroundSan Francisco implemented one of the earliest shelter-in-place public health mandates in the U.S., with flattened curves of diagnoses and deaths. We describe demographics, clinical features and outcomes of COVID-19 patients admitted to a public health hospital in a high population-density city with an early containment response.MethodsWe analyzed inpatients with COVID-19 admitted to San Francisco General Hospital (SFGH) from 3/5/2020–5/11/2020. SFGH serves a network of >63,000 patients (32% Latinx/24% Asian/19% African American/19% Caucasian). Demographic and clinical data through 5/18/2020 were abstracted from hospital records, along with ICU and ventilator utilization, lengths of stay, and in-hospital deaths.ResultsOf 157 admitted patients, 105/157 (67%) were male, median age was 49 (range 19-96y), and 127/157 (81%) of patients with COVID-19 were Latinx. Crowded living conditions were common: 60/157 (38%) lived in multi-family shared housing, 12/1578 (8%) with multigenerational families, and 8/157 (5%) were homeless living in shelters. Of 102 patients with ascertained occupations, most had frontline essential jobs: 23% food service, 14% construction/home maintenance, and 10% cleaning. Overall, 86/157 (55%) of patients lived in neighborhoods home to majority Latinx and African-American populations. Overall, 45/157 (29%) of patients needed ICU care, and 26/157 (17%) required mechanical ventilation; 20/26 (77%) of ventilated patients were successfully extubated, and 137/157 (87%) were discharged home. Median hospitalization duration was 4 days (IQR, 2–10), and only 6/157 (4%) patients died in hospital.ConclusionIn San Francisco, where early COVID-19 mitigation was enacted, we report a stark, disproportionate COVID-19 burden on Latinx patients, who accounted for 81% of hospitalizations despite making up only 32% of the patient base and 15% of San Francisco’s total population. Latinx inpatients frequently lived in high-density settings, increasing household risk, and frequently worked essential jobs, potentially limiting the opportunity to effectively distance from others. We also report here favorable clinical outcomes and low overall mortality. However, an effective COVID-19 response must urgently address racial and ethnic disparities.Disclosures All Authors: No reported disclosures

Stephen G. Young

Stephen G. Young

Effects of clinical and environmental factors on bronchoalveolar antibody responses to Pneumocystis jirovecii: A prospective cohort study of HIV+ patients.

BackgroundHumoral immunity plays an important role against Pneumocystis jirovecii infection, yet clinical and environmental factors that impact bronchoalveolar antibody responses to P. jirovecii remain uncertain.MethodsFrom October 2008—December 2011 we enrolled consecutive HIV-infected adults admitted to San Francisco General Hospital (SFGH) who underwent bronchoscopy for suspected Pneumocystis pneumonia (PCP). We used local air quality monitoring data to assign ozone, nitrogen dioxide, and fine particulate matter exposures within 14 days prior to hospital admission. We quantified serum and bronchoalveolar lavage fluid (BALF) antibody responses to P. jirovecii major surface glycoprotein (Msg) recombinant constructs using ELISA. We then fit linear regression models to determine whether PCP and ambient air pollutants were associated with bronchoalveolar antibody responses to Msg.ResultsOf 81 HIV-infected patients enrolled, 47 (58%) were diagnosed with current PCP and 9 (11%) had a prior history of PCP. The median CD4+ count was 51 cells/μl (IQR 15–129) and 44% were current smokers. Serum antibody responses to Msg were statistically significantly predictive of BALF antibody responses, with the exception of IgG responses to MsgC8 and MsgC9. Prior PCP was associated with increased BALF IgA responses to Msg and current PCP was associated with decreased IgA responses. For instance, among patients without current PCP, those with prior PCP had a median 73.2 U (IQR 19.2–169) IgA response to MsgC1 compared to a 5.00 U (3.52–12.6) response among those without prior PCP. Additionally, current PCP predicted a 22.5 U (95%CI -39.2, -5.82) lower IgA response to MsgC1. Ambient ozone within the two weeks prior to hospital admission was associated with decreased BALF IgA responses to Msg while nitrogen dioxide was associated with increased IgA responses.ConclusionsPCP and ambient air pollutants were associated with BALF IgA responses to P. jirovecii in HIV-infected patients evaluated for suspected PCP.

Abstracts from The 35th Annual National Neurotrauma Symposium July 7-12, 2017 Snowbird, Utah.

Abstracts from The 35th Annual National Neurotrauma Symposium July 7-12, 2017 Snowbird, Utah.

HIV-Associated Toxic Epidermal Necrolysis at San Francisco General Hospital.

We sought to characterize recent cases of toxic epidermal necrolysis (TEN) in HIV-infected patients at San Francisco General Hospital (SFGH), a large HIV referral center. This was a retrospective analysis of HIV-infected patients diagnosed with TEN from January 2001 to May 2014 at SFGH. Ten cases of TEN were identified, 50% of which occurred in HIV-infected individuals. Among the HIV-associated cases, causative agents were trimethoprim-sulfamethoxazole (TMP-SMX; n = 2), atovaquone, clindamycin, and fluconazole. No antiretroviral agents were implicated. Although limited by small sample size, our experience is reflective of the well-recognized increased incidence of TEN in HIV-positive patients and suggests that antimicrobial agents, particularly TMP-SMX, are the most common causative agents in this population. As 3 of the 5 HIV-associated TEN cases were caused by potentially inappropriate or unnecessary use of antibiotics, our experience highlights the importance of judicious use of systemic medications in populations susceptible to severe adverse drug reactions.

215. Fostering Leadership in Transitional Youth: The Making of an Adolescent Patient Advisory Board

For several years, the Family Health Center (FHC) at San Francisco General Hospital (SFGH) has had patient advisory boards which have helped select clinic-wide quality improvement projects, provide feedback on new services and programs, and help foster a more patient-centered clinical environment. The Teen and Young Adult Clinic is housed within the FHC, but has not historically had patient representation on these boards. Recognizing the importance of adolescent input to successful youth services, in September, 2013, we formed a committee to establish a Teen and Young Adult patient advisory board. Our vision was to build a board which would foster leadership among its members and provide meaningful input on how better to provide accessible, quality care to our community's youth. The FHC is a Federally Qualified Health Center, and serves as a continuity clinic for the University of California San Francisco (UCSF) Family and Community Medicine Residency Program. A part of the FHC, the Teen and Young Adult clinic cares for diverse, medically underserved adolescents and young adults (age 12-25 years) in San Francisco. After preliminary planning, a medical student working in the clinic did outreach to adolescent medical service providers in San Francisco to get information about existing patient advisory board structures and learn from their experience. Based on their input, we established a basic structure and goals. We then asked providers to recommend patients, age 15-20, who they recommended for the board, and started our outreach with this group. We then recruited a young adult intern to be the advisory board coordinator and successfully advocated for a dedicated health worker to work to help run it. The advisory board's activities are supported by Performance Improvement Program (PIP) incentive funds that provide gift card incentives for teen advisors involved as well as a stipend for our Teen Advisory Board coordinator. Since its inception in March, 2014, the advisory board has been meeting monthly and is now made up young adults. It has been involved in recruitment efforts to expand its size, planning to make the clinic waiting room a more inviting space for its adolescent patients, and input around quality improvement efforts aimed at our young women patients. The Teen and Young Adult Clinic Patient Advisory Board has provided an important new voice at the Family Health Center. Importantly, the board has created a vehicle for promoting young people's engagement and leadership. It has also provided a committed body to help us improve the climate, process, and manner in which we provide care to this group of patients. As the population of transitional youth seeking medical homes increases in the era of the Affordable Care Act, it is all the more important that there are practices providing care that is attentive and responsive to their needs—patient advisory boards are one such means to that end.

An Inpatient Treatment and Discharge Planning Protocol for Alcohol Dependence: Efficacy in Reducing 30-Day Readmissions and Emergency Department Visits

Alcohol dependence results in multiple hospital readmissions, but no discharge planning protocol has been studied to improve outcomes. The inpatient setting is a frequently missed opportunity to discuss treatment of alcohol dependence and initiate medication-assisted treatment, which is effective yet rarely utilized. Our aim was to implement and evaluate a discharge planning protocol for patients admitted with alcohol dependence. The study took place at the San Francisco General Hospital (SFGH), a university-affiliated, large urban county hospital. Learner participants included Internal Medicine residents at the University of California, San Francisco (UCSF) who staff the teaching service at SFGH. Patient participants included inpatients with alcohol dependence admitted to the Internal Medicine teaching service. We developed and implemented a discharge planning protocol for patients admitted with alcohol dependence that included eligibility assessment and initiation of medication-assisted treatment. Rates of medication-assisted treatment increased from 0% to 64% (p value < 0.001). All-cause 30-day readmission rates to SFGH decreased from 23.4% to 8.2% (p value = 0.042). All-cause emergency department visits to SFGH within 30 days of discharge decreased from 18.8% to 6.1% (p value = 0.056). Through implementation of a discharge planning protocol by Internal Medicine residents for patients admitted with alcohol dependence, there was a statistically significant increase in medication-assisted treatment and a statistically significant decrease in both 30-day readmission rates and emergency department visits.

Non-tuberculous mycobacterial infections at San Francisco General Hospital.

The epidemiology of non-tuberculous mycobacteria (NTM) infection is not well defined. We evaluated the trends in incidence of NTM infections at San Francisco General Hospital (SFGH), a large metropolitan county hospital. We performed a retrospective review of microbiologic and clinical records of all patients with a positive NTM culture reported from 1993 to 2001. NTM infection was defined by the isolation of >1 NTM from any clinical specimen. Patients were stratified by human immunodeficiency virus (HIV) status. Univariate and multivariate logistic regression were used to identify factors that were independently associated with NTM infection. Trends over time were assessed using Poisson test for trend. During the study period, 25 736 samples from 7395 patients were cultured for mycobacteria. Of these samples, 2853 (11.1%) from 1345 patients (18.2%) were culture positive for NTM. Patient characteristics associated with infection included younger age (P < 0.001), male gender (P < 0.001), White ethnicity compared with Asian and Hispanic (P < 0.001 and P = 0.01, respectively), and HIV positivity (P < 0.001). Overall, NTM infection at SFGH decreased significantly from 319 cases in 1993 to 59 in 2001 (P < 0.001). Mycobacterium avium was predominant in both HIV-positive and HIV-negative populations (74.5% and 44.6% of isolates, respectively), and Mycobacterium kansasii was the second most common NTM species isolated. The proportion of other NTM species isolated in these groups differed. In contrast to other published studies, time-series analyses show that NTM isolation rates decreased during the study period at SFGH, where NTM was most strongly associated with HIV infection.

High-Dose Methotrexate Is Effective, Safe, and Leads To Durable Responses In Patients With AIDS-Related Primary Central Nervous System Lymphoma Treated During The Era Of Combined Anti-Retroviral Therapy

▪ IntroductionThe use of high-dose methotrexate (HD MTX) as first-line treatment for patients with primary central nervous system lymphoma (PCNSL) has resulted in dramatic improvements in survival and functional status for immunocompetent individuals. However, there is minimal data describing either its efficacy or safety in patients with AIDS-related (AR) PCNSL, a uniformly fatal disease in the era preceding combined anti-retroviral therapy (cART). Furthermore, it is unclear whether HD MTX and cART may be safely co-administered. Here we report our experience in treating patients with AR PCNSL in the pre-cART, cART, and HD MTX eras at San Francisco General Hospital (SFGH). MethodsThe medical records of 93 patients with biopsy-proven, AR PCNSL diagnosed between April 1988 and August 2012 were culled via electronic tumor registry, electronic medical record, and physical chart review. All patients required documentation of biopsy-proven disease for inclusion in this analysis, and all but one patient record originated from SFGH, the exception being an HIV+ individual who received treatment at our university hospital. Patients receiving a diagnosis prior to 1997 were grouped into the pre-cART era as this was the year in which combined anti-retroviral therapy was widely available and incorporated into treatment regimens at SFGH. The HD MTX era began in 2002 at SFGH with its routine use as first-line treatment for PCNSL. ResultsMedian age at diagnosis for the entire cohort (N = 93) was 36 years, and 95% of the patients were male. The majority of diagnoses were made in the pre-cART era (N = 75, or 81%). With regard to histology, all patients were diagnosed with either diffuse large B-cell lymphoma (DLBCL) or large cell lymphoma NOS, and there were no T-cell nor indolent B-cell histologic subtypes recorded. Median CD4 count at diagnosis was 11 (range 0 to 386) for the 37 patients with this data recorded. The median Karnofsky Performance Status (KPS) score at diagnosis was 30 for the entire cohort with no differences between pre-cART or cART eras. A total of 56 patients (60%) suffered from opportunistic infections (OIs) prior to PCNSL diagnoses, and the proportion was higher among the cART era patients (15 of 18, or 83%). Only 14 patients (15%) were on anti-retroviral (ARV) therapy of any kind prior to diagnosis, and while the majority (10/14) of these patients were diagnosed in the cART era, none were compliant or otherwise receiving treatment on a consistent basis.Regarding treatment, of the 57 patients with documented whole-brain XRT (WBXRT) doses, 55 were treated in the pre-HD MTX era (N = 81) and received a median dose of 3100 cGy with a median of 26 days from diagnosis to completion of therapy. Among the 12 patients diagnosed in the era of HD MTX + cART, 10 patients had clinical data available to calculate a median IELSG score of 4. Ten patients in the HD MTX era received a median 7 cycles of HD MTX with a median dose of 8 gm/m2 per cycle; two patients expired prior to receiving any therapy. No patient in this era received WBXRT as part of first line therapy. One patient experienced grade 4 thrombocytopenia, otherwise there were no noted grade 3/4 toxicities. There were 6 complete remissions (CRs) and 2 partial remissions (PRs) for an overall response rate (ORR) of 80% among patients treated with HD MTX. The median post-treatment KPS among patients treated with HD MTX was 80.Finally, the median OS for the entire cohort (N = 93) was 2.2 months. Among patients diagnosed in the pre-cART era (N = 75), median OS was 2 months. Patients diagnosed in the cART era (N = 18) and patients treated with HD MTX in the cART era (N = 10) had median OS of 8.1 and 29.7 months, respectively. Notably, among survivors (N = 6) of patients treated with HD MTX in the cART era, the median OS was 75 months. ConclusionsAR PCNSL was a uniformly and rapidly fatal disease at SFGH between the years 1988 and 1997 with the use of WBXRT as first-line treatment. In contrast, for patients diagnosed with AR PCNSL in the cART era, HD MTX has been safely and effectively administered with concomitant anti-retroviral therapy at similar doses used for immunocompetent patients. Furthermore, such treatment can lead to durable remissions even in patients with a history of non-compliance or sustained periods off cART therapy. Supported by Leukemia and Lymphoma Society and NIH R01CA139-83-01A1.▪ Disclosures:Rubenstein:Genentech: Research Funding; Celgene: Research Funding.

Orthopedic Surgery in the Developing World: Workforce and Operative Volumes in Ghana Compared to Those in the United States

Musculoskeletal disease is a growing burden in low- and middle-income countries (LMICs), yet little research exists to describe the problem. The purposes of this study were to characterize orthopedic surgery in an LMIC and compare the findings to those from a developed country. The study location was the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana. Orthopedic surgeon, resident, and postgraduate training program numbers were compared to analogous data from a developed nation, the United States. Annual surgical volumes were compared to those at a level I trauma center in the United States, the San Francisco General Hospital (SFGH). There were 24 surgeons in Ghana compared to 23,956 in the United States. There were 7 orthopedic residents and 1 residency program in Ghana versus 3,371 residents and 155 residencies in the United States. Annual case volume was 2,161 at KATH and 2,132 at SFGH. Trauma accounted for 95 % of operations at KATH compared to 65 % at SFGH. The proportion of surgeries devoted to severe fractures was 29 % at KATH compared to 12 % at SFGH. Infections comprised 15 % of procedures at KATH and 5 % at SFGH. Annual case volume at a referral hospital in an LMIC is equivalent to that of a level I trauma center in an industrialized country. Total case volume is similar, but the LMIC institution manages a disproportionately large number of trauma cases, severe fractures, and infections. There is a large burden of orthopedic disease in the developing nation, and there are too few providers and training programs to address these conditions.

Targeted Intervention Reduces Use in Frequent Users of Emergency Medical Services

Some of the increase in EMS use is driven by a small group of frequent users. Age, housing status, mental illness, and substance abuse have been identified as contributors to frequent use. Creating EMS-based outreach team could be a cost-effective means of reducing frequent use of EMS. We hoped to determine if engagement by the San Francisco Fire Department's (SFFD) Homeless Outreach and Medical Emergency (HOME) Team is associated with decreased EMS use, and to identify predictors of responsiveness to HOME team intervention. Patients who called EMS four or more times per month were identified from SFFD records and through referrals from EMS providers and EDs. Intervention began with a traditional paramedic assessment. Once patients were determined to not have any immediate medical need, the HOME TEAM Interventional Technique was employed. This includes direct transport to medical detoxification services, San Francisco Sobering Center, Psychiatric Emergency Services at San Francisco General Hospital (SFGH), substance abuse treatment clinics, primary care clinics, and access to case management and housing. We retrospectively analyzed data collected by HOME Team regarding EMS utilization in the 7 months before and after their intervention. Change in mean EMS use was the primary outcome measure. Social and demographic characteristics were gathered from the Department of Public Health EMR. Of the 59 subjects included in the final analysis, 14 subjects (nonresponders) had increased EMS use (mean increase 9.71, STD 9.75), and 45 subjects (responders) had decreased use (mean decrease 16.29, STD 18.88). The mean decrease in EMS use for all subjects was 10.1 calls per 7 months period (95% CI 4.4 - 15.9). None of the predictors were statistically associated with nonresponsiveness. HOME team intervention was associated with decrease in overall EMS use. While the response was not uniform, none of the tested factors predicted nonresponse. However, sample size limitations and high prevalence of some factors may have limited this finding. EMS-based outreach programs have the potential to reduce EMS utilization by frequent users.TablePatient Demographic and Social Characteristics.CharacteristicN = 59Sex, Male68%Mean Age in years (IQR)55 (9)Not Housed38.9% (5 missing)Substance Abuse88.9% (5 missing)Psychiatric History83.0% (6 missing)No primary Care Doctor43.4% (6 missing) Open table in a new tab

Late Presentation of Colorectal Cancer in a Vulnerable Population

We examined colorectal cancer (CRC) stage at presentation and mortality in a vulnerable population compared with nationally representative data. CRC cases were identified from San Francisco General Hospital (SFGH) and the Surveillance Epidemiology and End Results (SEER) database. Fifty-five percent of the SFGH cohort presented with advanced disease, compared with 44% of the SEER cohort. Increased risk of advanced stage at presentation at SFGH compared with SEER was most evident among blacks and Asians. There was weak evidence for worse survival at SFGH compared with SEER overall. This varied by race with poorer survival at SFGH among whites and possibly blacks but some evidence for better survival among Asians. Among CRC patients at SFGH, Asians and Hispanics had better survival than whites and blacks. At SFGH, 44% had a diagnosis of CRC within 1 year of establishing care there. Of those who had established care at SFGH for at least 1 year, only 22% had exposure to CRC screening tests. These findings allow examination of CRC presentation by ethnicity in vulnerable populations and identify areas where access and utilization of CRC screening can be improved.

A Strange New Disease in San Francisco. A Brief History of the City and Its Response to the HIV/AIDS Epidemic

Advancements were made in the understanding of the human immunodeficiency virus (HIV) and the management of patients with the acquired immunodeficiency syndrome (AIDS) in many parts of the United States after such patients were first identified in 1981. Nevertheless, the relatively small city of San Francisco contributed a disproportionate share of them, due largely to the city's inclusive political and community response to the HIV/AIDS epidemic, including the activities of its Department of Public Health and San Francisco General Hospital (SFGH). San Francisco's colorful history, multicultural character, and tradition of tolerance attracted many patients who would develop HIV/AIDS to the city. The same factors underlaid the community's compassionate response when large numbers of these patients needed medical services. These factors also motivated the physicians, nurses, and other health professionals at SFGH who cared for the patients on the world's first inpatient AIDS ward.

Fear of Discovery Among Latino Immigrants Presenting to the Emergency Department

Recent legislation mandating reporting of undocumented immigrants may instill fear of discovery when they access emergency department (ED) services. The objectives of this study were to: 1) characterize the knowledge and beliefs of undocumented Latino immigrants (UDLI) about health care workers' reporting (or nonreporting) of illegal immigrants in the ED, 2) determine whether UDLI fear discovery when presenting to the ED, and 3) determine the nature and sources of this fear. This was a cross-sectional study of UDLI and two comparison groups conducted in two California county EDs, from November 2009 to August 2010. The authors interviewed a convenience sample of adult UDLI, Latino legal residents (LLR), and non-Latino legal residents (NLLR) using a structured instrument in their native language. The main outcome was fear of discovery among UDLI and the sources of that fear. Of 1,224 patients approached, 1,007 (82.3%) were interviewed: 314 UDLI, 373 LLR, and 320 NLLR. The median age was 43 years (interquartile range [IQR] = 31 to 55 years), and 51% were male. UDLIs were less likely to speak English (14%, 95% confidence interval [CI] = 10% to 18%), have health insurance (39%, 95% CI 32% to 44%), or have a regular primary care provider (PCP; 39%, 95% CI = 34% to 45%), compared to LLR (English 56%, 95% CI = 51% to 61%; health insurance 50%, 95% CI = 45% to 55%; regular PCP 51%, 95% = CI 46% to 57%) and NLLR (English 95%, 95% CI = 92% to 97%; health insurance 49%, 95% CI = 43% to 54%; regular PCP 51%, 95% CI = 45% to 56%). Of the 16% of UDLI who stated that nurses and doctors treat undocumented immigrant patients differently than citizens, 41% (95% CI = 29% to 54%) reported less respect given to UDLI by staff. Thirty-two percent of UDLI had heard of Proposition 187, 13% believed hospital staff reported UDLI to immigration authorities, and 9% said they were asked about their citizenship status. Fear of coming to the hospital because of discovery was expressed by 12% (95% CI = 9% to 16%) of UDLI, with 42% (95% CI = 28% to 58%) citing discussions with friends/family, 32% (95% CI = 19% to 47%) citing media and 16% (95% CI = 7% to 30%) citing both as sources of this fear. One in eight of UDLI presenting to the ED express fear of discovery and consequent deportation. Belief that medical staff report UDLI and recent immigration are risk factors for this fear. Family, friends, and media are the primary sources of these concerns.

Using trauma center data to identify missed bicycle injuries and their associated costs

Recently, there has been a 58% increase in the number of observed cyclists in San Francisco. In 2009, 3.2% of commuters were traveling by bicycle in this city, which is well above the national average of less than 1%. Police reports are the industry standard for assessing transportation-related collisions and informing policies and interventions that address the issue. Previous studies have suggested that police reports miss a substantial portion of bicycle crashes not involving motor vehicles. No study to date has explored the health and economic impact of cyclist-only (CO) injuries for adults in the United States. Our objective was to use trauma registry data to investigate possible underrepresentation of certain cyclist injuries and characterize cost. We reviewed hospital and police records for 2,504 patients treated for bicycle-related injuries at San Francisco General Hospital (SFGH). We compared incidence, injury severity, admission rate, and cost of injury for CO and auto-versus-bicycle (AVB) injuries treated at SFGH. We then calculated the cost of injury. Of all bicycle-related injuries at SFGH, 41.5% were CO injuries and 58.5% were AVB injuries. Those with CO injuries were more than four times as likely to be required of hospital admission compared with those with AVB injuries (odds ratio, 4.76; 95% confidence interval, 3.93-5.76; p < 0.0001). From 2000 to 2009, 54.5% of bicycle injuries treated at SFGH were not associated with a police report, revealing that bicycle crashes and injuries are underrecognized in San Francisco. Costs for care were significantly higher for AVB injuries and increased dramatically over time; total cost for CO and AVB injuries were $12.6 and $17.8 million. Based on this study, we conclude that trauma centers can play a key role in future collaborations to define issues and develop prevention strategies for CO crashes. Epidemiologic study, level II.

Interpersonal Processes of Care and Cesarean Delivery in Two Health Care Settings

We examined whether interpersonal processes of care (IPC) were associated with cesarean delivery. We performed a cross-sectional study of 1308 postpartum women at Kaiser Permanente Medical Center in Walnut Creek, CA (KP-WC), and San Francisco General Hospital (SFGH) from 2004 to 2006. Using interview and medical record data, logistic regression analyses estimated the odds of cesarean delivery as a function of IPC domains. After adjustment for demographic and reproductive factors, women at KP-WC who reported higher scores for their provider's "elicitation of patient concerns and responsiveness" were less likely to have delivered by cesarean, whereas women who reported higher scores for "empowerment and self-care" were more likely. At KP-WC, women who reported low English proficiency were less likely to have delivered by cesarean than women who reported high proficiency. At SFGH, none of the IPC measures were significant; however, younger age was associated with a lower risk of cesarean delivery, whereas higher educational attainment was associated with an increased risk. To reduce record-high rates of cesarean delivery, more emphasis should be placed on addressing the nonmedical factors associated with operative delivery.

The Effect of AIDS Clinical Trials Group Protocol 5164 on the Time From Pneumocystis jirovecii Pneumonia Diagnosis to Antiretroviral Initiation in Routine Clinical Practice: A Case Study of Diffusion, Dissemination, and Implementation

Diffusion, dissemination, and implementation of scientific evidence into routine clinical practice is not well understood. The Adult AIDS Clinical Trials Group (ACTG) Protocol 5164 showed that early antiretroviral therapy (ART; ie, within 14 days) after diagnosis of an opportunistic infection improved clinical outcomes, compared with later initiation. Subsequently, the San Francisco General Hospital (SFGH) HIV/AIDS Service performed the SFGH 5164 Initiative to disseminate and implement the findings of ACTG 5164. We evaluated patients who received a diagnosis of Pneumocystis jirovecii pneumonia (PCP) from 1 January 2001 through 30 March 2011. Survival analyses were used to assess changes in the time to initiation of ART after PCP, and logistic regression was used to evaluate changes in the odds of early ART (ie, within 14 days) because of ACTG 5164 and SFGH 5164 Initiative. Among 162 patients, the adjusted hazard of ART initiation increased by 3.05 (95% confidence interval [CI], 1.86-5.02) after ACTG 5164 and by 4.89 (95% CI, 2.76-8.67) after the SFGH Initiative, compared with before ACTG 5164. When compared with before ACTG 5164, the proportion of patients who received ART within the 14 days after PCP diagnosis increased from 7.4% to 50.0% (P < .001) after ACTG 5164 and from 50.0% to 83.0% (P = .02) after the SFGH 5164 Initiative. Diffusion of findings from of a randomized trial changed practice at an academic medical center, but dissemination and implementation efforts were required to establish early ART at acceptable levels. Early ART initiation can be achieved in real-world patient populations.

Methamphetamine use, sexual activity, patient–provider communication, and medication adherence among HIV-infected patients in care, San Francisco 2004–2006

While numerous studies examine methamphetamine use and associated risky sexual behaviors in HIV-uninfected individuals, few studies have surveyed HIV-infected individuals in the health care setting. To assess the frequency and trends of methamphetamine use, sexual activity, injection drug use, patient–provider communication, and medication adherence among HIV-infected persons in care, we administered a one-page anonymous survey in 2004 and 2006. The survey was conducted at the two University of California, San Francisco outpatient HIV clinics: at Moffitt Hospital (Moffitt), serving primarily privately insured patients, and at San Francisco General Hospital (SFGH), a county hospital serving primarily patients who are uninsured or publicly insured. In 2006, 39% of men who have sex with men (MSM), 33% of heterosexual men, and 11% of women reported methamphetamine use in the prior 12 months. Methamphetamine use was significantly associated with an increased number of sex partners among MSM and heterosexual men, and poor anti-retroviral medication adherence. Among MSM, methamphetamine use was more common at the SFGH clinic. Between 2004 and 2006, reported methamphetamine use in the last 12 months decreased among MSM at Moffitt (38 to 20%, p<0.01), but increased at SFGH (40 to 50%, p<0.05). Among methamphetamine users we found a high frequency of injection of methamphetamine, which increased at SFGH from 38 to 55%, p<0.05. Patient–provider communication regarding methamphetamine use has increased from 2004 to 2006 but no significant change has been found for providers asking patients about sexual activity. Overall, we found methamphetamine use to be common among HIV-infected patients in care, and associated with an increased number of sex partners, a high frequency of injection drug use, and poor adherence to anti-retroviral medications. These findings support the need for improved screening and clinic-based interventions to reduce and treat methamphetamine abuse and associated high risk sexual behaviors.

Patient Perspectives with Abbreviated versus Standard Pre-Test HIV Counseling in the Prenatal Setting: A Randomized-Controlled, Non-Inferiority Trial

BackgroundIn the US, an unacceptably high percentage of pregnant women do not undergo prenatal HIV testing. Previous studies have found increased uptake of prenatal HIV testing with abbreviated pre-test counseling, however little is known about patient decision making, testing satisfaction and knowledge in this setting.Methodology/FindingsA randomized-controlled, non-inferiority trial was conducted from October 2006 through February 2008 at San Francisco General Hospital (SFGH), the public teaching hospital of the City and County of San Francisco. A total of 278 English- and Spanish-speaking pregnant women were randomized to receive either abbreviated or standard nurse-performed HIV test counseling at the initial prenatal visit. Patient decision making experience was compared between abbreviated versus standard HIV counseling strategies among a sample of low-income, urban, ethnically diverse prenatal patients. The primary outcome was the decisional conflict score (DCS) using O'Connor low-literacy scale and secondary outcomes included satisfaction with test decision, basic HIV knowledge and HIV testing uptake. We conducted an intention-to-treat analysis of 278 women – 134 (48.2%) in the abbreviated arm (AA) and 144 (51.8%) in the standard arm (SA). There was no significant difference in the proportion of women with low decisional conflict (71.6% in AA vs. 76.4% in SA, p = .37), and the observed mean difference between the groups of 3.88 (95% CI: −0.65, 8.41) did not exceed the non-inferiority margin. HIV testing uptake was very high (97. 8%) and did not differ significantly between the 2 groups (99.3% in AA vs. 96.5% in SA, p = .12). Likewise, there was no difference in satisfaction with testing decision (97.8% in AA vs. 99.3% in SA, p = .36). However, women in AA had significantly lower mean HIV knowledge scores (78.4%) compared to women in SA (83.7%, p<0.01).Conclusions/SignificanceThis study suggests that streamlining the pre-test counseling process, while associated with slightly lower knowledge, does not compromise patient decision making or satisfaction regarding HIV testing.Trial RegistrationClinicalTrials.gov NCT00503308