Single Academic Health Center Research Articles

Endoscopic reversal of roux-en-Y gastric bypass prevents worsening of nutritional outcomes in patients with severe malnutrition

Roux-en-Y gastric bypass (RYGB) can precipitate protein-calorie malnutrition and micronutrient deficiencies. Sonographically guided endoscopic reversal (ER) via deployment of a stent from the gastric pouch to the remnant stomach in RYGB anatomy has emerged as a novel option for increasing both intestinal transit time and absorptive surface area. In this investigation, short-term nutritional outcomes after ER of a RYGB in patients (age ≥ 18) with severe protein-calorie malnutrition from a single academic health center in Minneapolis, Minnesota over a seven-year period (2015-2021) were retrospectively reviewed pre-procedurally, and at six and twelve months post-procedurally. 17 patients underwent ER for severe protein-calorie malnutrition, or dependence on tube feeds (TF) or total parenteral nutrition (TPN). At 6 months post-ER, two patients were no longer malnourished and only on oral nutrition; three patients were liberated from TPN. Laboratory markers of protein-calorie malnutrition, renal function, and micronutrients were not significantly different at six- or twelve-month follow-up (P > 0.05). In all patients, access to the gastric remnant was maintained via stent placement through the gastric pouch or proximal Roux limb throughout the study period and no complications were noted after ER. Despite the small sample size, this investigation revealed that ER of RYGB may prevent progressive deleterious weight loss, and worsening macro- and micro-nutrient deficiencies, though improvement in weight and nutritional parameters was not observed. Overall, ER was found to be a nuanced and safe, advanced technique useful for when remnant access is desired in RYGB patients.

Time and Travel Burden Associated with Hexapod-Assisted Correction of Lower Extremity Deformity

Background: Hexapod devices, colloquially referred to as frames, are powerful tools to correct lower extremity deformity. However, patients who undergo treatment with frames are followed closely to ensure that clinical and radiographic correction are satisfactory. Depending on the size of the state and the number of surgeons that offer frame treatment, patients may need to travel a long distance and frequently, to obtain care. We sought to characterize the number of clinical and surgical encounters, as well as the cumulative driving distance, for frame patients treated at a single academic health center. Methods: All patients treated with a hexapod frame for any etiology by three pediatric orthopaedic surgeons at a single children’s hospital over an 8-year period were investigated. Patients were queried for demographic data, number of non-surgical and surgical clinical encounters and number of days in the frame. Driving distance was calculated from the patients address to the academic health system address. Results: Thirteen patients qualified for inclusion (10 male, 3 female). Mean age at frame application was 14.6 years (range 4-31). Mean time in the frame was 150.5 days (range 90-207). Throughout the course of their frame treatment, patients had a mean of 16 non-surgical (range 5-26) encounters and a mean of 3 (range 2-6) surgical encounters. Mean one-way driving distance between the treating institution and the patient’s home was 77 miles (range 20-212 miles). When two way driving distance was multiplied by the total number of encounters for each patient, the mean distance driven was 2616 miles (range 862-7632 miles). Conclusion: In this cohort of patients with a lower extremity frame, there were on mean 16 non-surgical and 3 surgical encounters, with a mean driving distance during the treatment program of 2600 miles. When agreeing to undertake a hexapod-assisted program for lower extremity pathology, patients should be counseled about the temporal and financial nature of this strategy, so they are aware of the large commitment needed.

Abstract #1402660: Association of Social Vulnerability Index Themes and Pre-Diabetes in Chicago Neighborhoods

Pre-diabetes, defined as a glycosylated hemoglobin between 5.7% and 6.4%, is a common condition that is amenable to intervention to ameliorate progression to diabetes. The distribution of pre-diabetes at the census tract level in diverse urban communities and the neighborhood factors that may influence community pre-diabetes rates are not well understood. The social vulnerability index (SVI) was created by the Centers for Disease Control and Prevention to study how communities may be affected following natural disasters. SVI scores range from 0 to 1 with higher SVI scores representing increased social vulnerability. SVI is composed of four neighborhood level themes — socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. The objective of this proof-of-concept project was to determine the distribution of pre-diabetes in patients from census tracts served by a single academic health center and to understand how census tract SVI scores amongst the four SVI themes may be associated with pre-diabetes. For data available in 2018, pre-diabetes rates varied from 0.5% to 16.7% for 1,203 out of the 1,313 census tracts for which there were at least 25 adult patients seen at Rush University Medical Center. A linear regression model was used to assess the change in SVI theme score with the rate of pre-diabetes. Each 0.1 unit increase in SVI theme score for the socioeconomic status, household composition and disability, and minority status and language themes were associated with a 0.37% (SE = 0.027; p-value < 0.0001), 0.36% (SE = 0.027; p-value < 0.0001), and 0.14% (SE = 0.029; p-value = 0.0045) increase in the rate of pre-diabetes, respectively. However, the housing and transportation theme had a non-significant 0.08% decreased rate of pre-diabetes per 0.1-unit change (SE = 0.029, p-value = 0.07). While there was significant heterogeneity of SVI theme scores and pre-diabetes rates in census tracts served by a single, urban health center, this proof-of-concept work shows a potential relationship between SVI themes and pre-diabetes rates at the census-tract level. If confirmed in future studies, SVI could be a tool for future targeted neighborhood-specific interventions to reduce the health impact of pre-diabetes, such as providing more resources to address disparities in socioeconomic status, household composition and disability, and minority status and language domains.

U.S.-Based Obstetrician/Gynecologists' Experiences with Delivering Care to Women with Female Genital Cutting.

Background: There has been an increase of women living in the United States who have experienced female genital cutting (FGC). However, limited research exists evaluating the experiences of obstetrician/gynecologists delivering care to this patient population. This study aimed to assess the overall experiences, including barriers and facilitators, of U.S.-based obstetrician/gynecologists (OBGYNs) with delivering care to patients with female genital cutting at a single academic health center in the United States. Materials and Methods: This is a qualitative study of OBGYNs at a large, U.S., urban, academic health center. OBGYNs participated in a one-on-one semistructured interview. Thematic analysis using a grounded theory approach was conducted to identify predominating themes regarding the overall experiences, barriers, and facilitators to delivering care to patients with FGC. Results: Analysis of 15 study interviews revealed 4 main themes impacting the ability of OBGYNs to deliver care to patients with FGC: (1) limited educational training on FGC, (2) challenges with identifying that a patient had FGC and with using the World Health Organization classification system, (3) questions regarding "normative" anatomy and reinfibulation after vaginal procedures, and (4) navigating affective responses of patient and self when FGC is encountered. Conclusion: The above findings have practical implications, showing that the limited educational experience and lack of a clear policy on how to manage the care of women with FGC lead to variation and even limitations in how care is delivered to these women. We encourage OBGYN professional societies to consider creating education and policy to aid clinicians in caring for patients with FGC.

S1460 Endoscopic Reversal of Roux-en-Y Gastric Bypass Prevents Worsening of Nutritional Outcomes in Patients With Severe Malnutrition

Introduction: Roux-en-Y gastric bypass (RYGB) can precipitate protein-caloric malnutrition and micronutrient deficiencies. Sonographically guided endoscopic reversal (ER) via deployment of a stent from the gastric pouch to the remnant stomach is emerging as a novel option for increasing intestinal transit time and increasing absorptive surface area. In this investigation, short-term nutritional outcomes after endoscopic reversal for malnutrition were assessed. Methods: Patients (age ≥ 18) who underwent ER of RYGB for malnutrition from a single academic health center in Minneapolis over a 7-year period (2015-2021) were reviewed. Nutrition status (assessed by a registered dietitian (RD) or a gastroenterologist (GI)), mode of nutrition (per oral (PO), tube feed (TF), or total parenteral nutrition (TPN)), weight and body-mass index (BMI) were obtained pre-procedurally, at 6 months, and at one year post-procedurally. Results: Seventeen patients underwent ER for severe protein caloric malnutrition or dependence on TF / TPN. In this cohort, at the time of the ER procedure, median age was 49 [IQR 46, 58] years and median BMI was 25.2 [IQR 21.18, 29.03] kg/m2, 70% of patients were female, and 82% were White, and 96% had health insurance. Weight and BMI were not significantly different at 6-month or at one year follow-up (P >0.05; Figure demonstrates individual weight trends). At 6 months post-ER, 2 patients were no longer malnourished by RD/GI assessment and only on PO nutrition; 3 patients previously on TPN were liberated from TPN. A panel of laboratory values including markers of protein calorie malnutrition (e.g. albumin), renal function (e.g. creatinine and GFR) and micronutrients (e.g. Vitamin B12) were not significantly different at 6-month or at one year follow-up (P >0.05; Table). In all patients, access to the remnant was maintained throughout the study period and no complications were noted after the procedure. Conclusion: ER is a nuanced, advanced technique useful for when remnant access is desired in RYGB patients, and is safe in experienced hands. Despite small sample size, this investigation revealed that ER of RYGB may prevent worsening weight loss, and worsening macro and micro-nutrient deficiencies; though improvement in weight and nutritional parameters was not observed. As ER affords patients a potential alternative to revisional bariatric surgery, further studies are warranted to examine longer-term nutritional and medical outcomes.Figure 1.: Individual weight trends before RYGB Endoscopic Reversal and at 6 months and 1 year following RYGB Endoscopic Reversal Table 1. - Pre-procedure Post-procedure at 6 months Post-procedure at 1 year Malnutrition Status by dietitian or gastroenterologist assessment (n, %) N=17 N=17 N=9 Severe Malnutrition or on TF / TPN 17 (100%) 15 (88%) 8 (89%) Moderate 0 0 0 Non-severe 0 0 0 Not malnourished 0 2 (12%) 1 (11%) Nutrition Route N=17 N=17 N=9 Oral intake (PO) 6 6 2 Tube feeding (TF) 3 6 3 Total parenteral nutrition (TPN) 8 5 4 Weight / Body Mass Index, median (IQR) N=17 N=15 N=9 Weight (Kg) 64.8 (54.3, 78.1) 68.4 (57.9, 83.6) 67.8 (63.0, 71.1) BMI (Kg/m2) 25.2 (21.2, 29.0) 25.1 (23.1, 30.3) 23.2 (20.5, 24.9) Nutritional Laboratory Values, median (IQR) N * N * ** Albumin (g/dL) 2.6 (2.3, 3.1) 2.4 (1.92, 3.05) x Prealbumin (mg/dL) 14 (10, 15) 14 (8, 16) x Hemoglobin (g/dL) 9.4 (8.8, 11.5) 10.6 (8.8, 12.4) x Creatinine (mg/dL) 0.88 (0.62, 0.99) 0.72 (0.66, 1.06) x Glomerular filtration rate (mL/min) 86 (61, 90) 84 (52, 90) x Iron (ug/dL) 59 (29, 71) 34.5 (19, 49.3) x Ferritin (ng/mL) 113 (27.8, 409) 39 (28.5, 114) x Vitamin B12 (pg/mL) 893 (554, 1405) 1271 (731, 1422) x Folate (ng/mL) 6.6 (5.4, 21.4) 10.6 (6.5, 11.8) x Vitamin D (ug/L) 14 (13, 39) 24.5 (14.5, 27.8) x Zinc (ug/dL) 56 (55, 71) 56.5 (48, 62) x *Various different sample size based on lab availabilities.**1 Year nutritional laboratory values not assessed.

Telehealth Use by Age and Race at a Single Academic Medical Center During the COVID-19 Pandemic: Retrospective Cohort Study.

BackgroundDuring the COVID-19 pandemic, many ambulatory clinics transitioned to telehealth, but it remains unknown how this may have exacerbated inequitable access to care.ObjectiveGiven the potential barriers faced by different populations, we investigated whether telehealth use is consistent and equitable across age, race, and gender.MethodsOur retrospective cohort study of outpatient visits was conducted between March 2 and June 10, 2020, compared with the same time period in 2019, at a single academic health center in Boston, Massachusetts. Visits were divided into in-person visits and telehealth visits and then compared by racial designation, gender, and age.ResultsAt our academic medical center, using a retrospective cohort analysis of ambulatory care delivered between March 2 and June 10, 2020, we found that over half (57.6%) of all visits were telehealth visits, and both Black and White patients accessed telehealth more than Asian patients.ConclusionsOur findings indicate that the rapid implementation of telehealth does not follow prior patterns of health care disparities.

Getting Babies Safely Home: A Retrospective Chart Review of Car Safety Seat Tolerance Screening Outcomes

The American Academy of Pediatrics recommends pre-discharge Car Seat Tolerance Screening (CSTS) for all neonates born <37 weeks estimated gestational age (EGA), or otherwise at risk for cardiorespiratory compromise. Screening is burdensome and there remains tremendous variation in testing criteria and methodology. We conducted a retrospective chart review of 1,072 infants who underwent CSTS between 11/2013 and 7/2016 at a single academic health center. CSTS outcomes (failure and, separately, significant cardiorespiratory instability (CRI)), including those not meeting failure thresholds) were analyzed for all infants screened, and for preterm infants by screening location (Neonatal Intensive Care Unit (NICU) and Mother/Baby Unit (MBU)). Logistic regression was used to estimate associations between infant characteristics and CSTS outcomes. Overall incidence of CSTS failure was 9.2%. Among all infants, hemodynamically significant congenital heart disease, apnea, chronic lung disease, and being small for EGA were associated with failure. Additionally, those born ≤28 weeks EGA had 2.4 times greater likelihood of failure than those 34-36 weeks EGA. Among preterm infants in the NICU and MBU, those of earlier EGA were also more likely to fail. Almost half (47.5%) of all preterm infants demonstrated CRI during CSTS. We found high CSTS failure rates, and identified key infant characteristics that were associated with increased likelihood of failure. Significant CRI events were remarkably common. Larger, prospective studies are needed to elucidate risk factors for instability and failure, and define practical criteria for CSTS recommendations.

Inconsistent platelet-rich plasma product from devices cleared by the US FDA: A retrospective review of clinic data

To the Editor: Platelet-rich plasma (PRP) is trending for the treatment of alopecia.1 Data on the consistency of PRP devices approved by the US Food and Drug Administration in clinical settings are lacking. We performed a retrospective review of PRP products from 3 closed 510K-cleared devices used for alopecia at a single academic health center hair clinic (approved by University of Minnesota institutional review board #00005562): Eclipse (Eclipse MedCorp, LLC, The Colony, TX), Emcyte (Emcyte Corp, Fort Meyers, FL), and Selphyl (Factor Medical, LLC, Langhorn, PA).

The Association Between the Frequency of Interruptions in Antibiotic Exposure and the Risk of Health Care-Associated Clostridiodes difficile Infection

BackgroundAlthough antibiotic use is an established risk factor for health care-associated Clostridiodes difficile infection, estimates of the association between infection and antibiotic use vary, depending upon how antibiotic exposure is measured. ObjectivesThe purpose of this study was to explore the association between the frequency of interruptions in antibiotic exposure and the risk of health care-associated C difficile infection. MethodsA retrospective chart review cohort study was conducted of all inpatients between 2011and 2016 from a single academic health center who received at least 1 dose of a systemic antibacterial for a cumulative duration of >3 days and ≤30 days. The measures of antibiotic exposure examined were duration—cumulative total calendar days of antibiotics therapy—and continuity—the frequency of interruptions in antibiotic exposure that was defined as the number of antibiotic treatment courses. ResultsA total of 52,445/227,967 (23%) patients received antibacterial therapy for >3 days and ≤30 days during their hospitalization. Of these, 1161 out of 52,445 (2.21%) were patients with health care-associated C difficile infection. An adjusted multivariable logistic regression analysis revealed that the risk of C difficile increased with longer cumulative days (odds ratio = 2.7; comparison of >12 days to ≤5 days) and fewer interruptions of antibiotic treatment (odds ratio = 0.78; comparison of >3 discrete antibiotic treatment courses to 1 course or continuous antibiotic treatment course; all P values < 0.05). ConclusionsFor patients who received the same number of cumulative days of therapy, the patients who had more frequently interrupted courses of antibiotic therapy were less likely to experience health care-associated C difficile infection. (Curr Ther Res Clin Exp. 2020; 81:XXX–XXX)

1414. Time-to-Completed-Imaging, Survival, and Function in Patients with Spinal Epidural Abscess: Description of a Series of 34 Patients, 2015–2018

BackgroundSpinal epidural abscess (SEA) is a rare and life-threatening infection with increased incidence over the past two decades. Delays in diagnosis cause significant morbidity and mortality among patients. The objective of this study was to describe average time-to-imaging and frequencies of intervention, risk factors, and outcomes among patients with SEA presenting to an emergency department at a single academic health center in Portland, Oregon.MethodsThis retrospective cohort study reviewed data from patients with no prior history of SEAs at a single hospital from October 1, 2015 to April 1, 2018. We report measures of central tendency and frequencies of collected information.ResultsOf the 34 patients included, seven (20%) died or were discharged with plegia during the study period. Four others (11.8%) had motor weakness, and four (11.8%) patients had new bowel or bladder dysfunction at discharge. Those who died or were discharged with plegia (n = 7) had shorter mean time-to-imaging order (20.8 hours vs. 29.2 hours). Patients with a history of intravenous drug use had a longer mean time-to-imaging order (30.2 hours vs. 23.7 hours) vs. those without a history of intravenous drug use. Furthermore, only three (42.9%) of the seven patients who died or acquired plegia presented with the three symptom classic triad of SEA: (1) fever; (2) abnormal neurologic examination or symptoms; and (3) neck or back pain.ConclusionSEA is a potentially deadly infection requiring prompt identification and treatment. This research provides baseline data for potential quality improvement work at the study site. Future research should evaluate multi-center approaches for identifying and intervening to treat SEA, particularly among patients with a history of intravenous drug use. Disclosures All authors: No reported disclosures.

Low dose chloroquine decreases insulin resistance in human metabolic syndrome but does not reduce carotid intima-media thickness

BackgroundMetabolic syndrome, an obesity-related condition associated with insulin resistance and low-grade inflammation, leads to diabetes, cardiovascular diseases, cancer, osteoarthritis, and other disorders. Optimal therapy is unknown. The antimalarial drug chloroquine activates the kinase ataxia telangiectasia mutated (ATM), improves metabolic syndrome and reduces atherosclerosis in mice. To translate this observation to humans, we conducted two clinical trials of chloroquine in people with the metabolic syndrome.MethodsEligibility included adults with at least 3 criteria of metabolic syndrome but who did not have diabetes. Subjects were studied in the setting of a single academic health center. The specific hypothesis: chloroquine improves insulin sensitivity and decreases atherosclerosis. In Trial 1, the intervention was chloroquine dose escalations in 3-week intervals followed by hyperinsulinemic euglycemic clamps. Trial 2 was a parallel design randomized clinical trial, and the intervention was chloroquine, 80 mg/day, or placebo for 1 year. The primary outcomes were clamp determined-insulin sensitivity for Trial 1, and carotid intima-media thickness (CIMT) for Trial 2. For Trial 2, subjects were allocated based on a randomization sequence using a protocol in blocks of 8. Participants, care givers, and those assessing outcomes were blinded to group assignment.ResultsFor Trial 1, 25 patients were studied. Chloroquine increased hepatic insulin sensitivity without affecting glucose disposal, and improved serum lipids. For Trial 2, 116 patients were randomized, 59 to chloroquine (56 analyzed) and 57 to placebo (51 analyzed). Chloroquine had no effect on CIMT or carotid contrast enhancement by MRI, a pre-specified secondary outcome. The pre-specified secondary outcomes of blood pressure, lipids, and activation of JNK (a stress kinase implicated in diabetes and atherosclerosis) were decreased by chloroquine. Adverse events were similar between groups.ConclusionsThese findings suggest that low dose chloroquine, which improves the metabolic syndrome through ATM-dependent mechanisms in mice, modestly improves components of the metabolic syndrome in humans but is unlikely to be clinically useful in this setting.Trial registration ClinicalTrials.gov (NCT00455325, NCT00455403), both posted 03 April 2007

Perioperative Management of Patients with Colovesical Fistula

BackgroundColovesical fistula (CVF) is an uncommon complication of diverticulitis. Substantial heterogeneity exists in the perioperative management of this condition. We seek to evaluate the role of bladder leak testing, closed suction drainage, prolonged bladder catheter usage, and routine postoperative cystogram in the management of CVF. Study DesignThis is a retrospective study from a single academic health center investigation patients undergoing operation for diverticular CVF from 2005 to 2015 (n = 89). ResultsPatients undergoing operative repair for diverticular CVF resection had a mortality of 4% and overall morbidity of 46%. Intraoperative bladder leak test was performed in 36 patients (40%) and demonstrated a leak in 4 patients (11%). No patients with a negative intraoperative bladder leak test developed a urinary leak. Overall, five (6%) patients developed postoperative bladder leak. Three were identified by elevated drain creatinine and two by cystogram. The diagnostic yield of routine cystogram was 3%. All bladder leaks were diagnosed between postoperative day 3 and 7. Of patients with a postoperative bladder leak, none required reoperation and all resolved within 2 months. ConclusionsThere is significant variability in the management of patients undergoing operation for CVF. Routine intraoperative bladder leak test should be performed. Cystogram may add cost and is low yield for routine evaluation for bladder leak after operation for CVF. Urinary catheter removal before postoperative day 7 should be considered.

Electronic cigarette use, knowledge, and perceptions among health professional students

IntroductionOur study evaluated the electronic cigarette (e-cigarette) use, knowledge, and perceptions of health professional students enrolled in one of five colleges at a single academic health center. MethodsA 56-item survey was conducted to examine the use, knowledge, and perceptions of e-cigarettes among health professional students. An e-cigarette knowledge score was calculated according to correct responses to eight true-false survey items, with possible scores ranging from zero to eight points. Regressions were used to determine associations between students’ enrolled college/discipline and e-cigarette knowledge scores and to identify associations between three perception domains (smoking cessation, harm reduction, and enhanced regulation) and e-cigarette use. ResultsOf the 853 students responding, 24.2% reported e-cigarette ever-use. Of e-cigarette ever users, 85.5% had used within the past year, and 23.1% used e-cigarettes for smoking cessation. Participants from the colleges of public health, pharmacy, and nursing had significantly higher knowledge scores, compared to those in allied health. Knowledge scores from college of medicine participants did not differ significantly compared to scores from allied health. Perceptions of using e-cigarettes for smoking cessation, reduced harm compared to tobacco, and reduced e-cigarette regulation were significantly associated with using e-cigarettes. Discussion and conclusionsSelf-reported ever-use of e-cigarettes among health professional students in this sample was 3.5–6 times higher than previously reported among medical and nursing students. Substantial gaps in e-cigarette knowledge exist. Enhancing health professionals’ preparedness to effectively advise patients about the benefits and harms of e-cigarettes is crucial.

Accuracy of Cardiovascular Risk Prediction Varies by Neighborhood Socioeconomic Position

Inequality in health outcomes in relation to Americans' socioeconomic position is rising. First, to evaluate the spatial relationship between neighborhood disadvantage and major atherosclerotic cardiovascular disease (ASCVD)-related events; second, to evaluate the relative extent to which neighborhood disadvantage and physiologic risk account for neighborhood-level variation in ASCVD event rates. Observational cohort analysis of geocoded longitudinal electronic health records. A single academic health center and surrounding neighborhoods in northeastern Ohio. 109793 patients from the Cleveland Clinic Health System (CCHS) who had an outpatient lipid panel drawn between 2007 and 2010. The date of the first qualifying lipid panel served as the study baseline. Time from baseline to the first occurrence of a major ASCVD event (myocardial infarction, stroke, or cardiovascular death) within 5 years, modeled as a function of a locally derived neighborhood disadvantage index (NDI) and the predicted 5-year ASCVD event rate from the Pooled Cohort Equations Risk Model (PCERM) of the American College of Cardiology and American Heart Association. Outcome data were censored if no CCHS encounters occurred for 2 consecutive years or when state death data were no longer available (that is, from 2014 onward). The PCERM systematically underpredicted ASCVD event risk among patients from disadvantaged communities. Model discrimination was poorer among these patients (concordance index [C], 0.70 [95% CI, 0.67 to 0.74]) than those from the most affluent communities (C, 0.80 [CI, 0.78 to 0.81]). The NDI alone accounted for 32.0% of census tract-level variation in ASCVD event rates, compared with 10.0% accounted for by the PCERM. Patients from affluent communities were overrepresented. Outcomes of patients who received treatment for cardiovascular disease at Cleveland Clinic were assumed to be independent of whether the patients came from a disadvantaged or an affluent neighborhood. Neighborhood disadvantage may be a powerful regulator of ASCVD event risk. In addition to supplemental risk models and clinical screening criteria, population-based solutions are needed to ameliorate the deleterious effects of neighborhood disadvantage on health outcomes. The Clinical and Translational Science Collaborative of Cleveland and National Institutes of Health.

Discoid Lupus and Human Immunodeficiency Virus: A Retrospective Chart Review to Determine the Prevalence and Progression of Co-occurrence of these Conditions at a Single Academic Center.

Context:Discoid lupus erythematosus (DLE) and human immunodeficiency virus (HIV) are both disorders of the immune system. The pathophysiology of these diseases varies greatly as DLE is characterized by an overactive immune system that attacks normal host cells, whereas HIV is characterized by an exogenous attack on the immune system that depletes it of key cell types. Although the reason is unknown, co-occurrence of DLE and HIV is rare.Aims:The goal of this study is to determine the prevalence of co-occurrence of DLE and HIV and to determine whether patients with both DLE and HIV share any clinical feature.Subjects and Methods:The medical records of all patients seen within a single academic health center over a 20-year period were reviewed to determine the prevalence of cutaneous lupus, HIV, and co-occurrence of these conditions. The charts of patients diagnosed with both conditions were further reviewed to determine similarities between them.Results:Of the 10,719 patients diagnosed with HIV and 182 patients diagnosed with cutaneous lupus, only 2 patients were diagnosed with both conditions. Both of these patients were diagnosed with DLE several years after being diagnosed with HIV. They had an undetectable HIV viral load, normal CD4 T-cell counts, and were on antiretroviral therapy when diagnosed with DLE.Conclusion:These results confirm that co-occurrence of DLE and HIV is rare. Although our study population was small, findings from these patients suggest that in HIV-positive patients, DLE manifestations occur when their HIV disease activity is minimal.

A randomized controlled pilot trial of the functional assessment screening tablet to engage patients at the point of care.

Healthcare providers play an important role in encouraging healthy behaviors and improving health-related quality of life (HRQoL). They are most effective when they partner with informed, engaged patients. To examine the impact of a new health-information technology intervention (FAST-Feedback) that provides patients with immediate, personalized, guideline-based feedback regarding tobacco use, physical activity, and HRQoL, and encourages patients to initiate discussions regarding these topics with their primary care physician. A pilot, randomized controlled trial clustered by resident physician, with patients as the unit of analysis. Resident physicians and their out-patients in a single academic health center between May and October 2011. Patients received (intervention) or did not receive (control) FAST-Feedback prior to the clinical encounter. Primary outcomes were patient reports of initiating any discussions regarding tobacco use, physical activity, and HRQoL. Subgroup analyses examined patient reports of discussions regarding tobacco use, physical activity, and HRQoL, respectively. Thirty of the 36 eligible resident physicians (83%) agreed to participate; 173 of their 415 eligible patients (42%) expressed interest in the study and 99 (24%) consented to participate. Compared to controls, a higher percentage of intervention patients reported initiating any discussion with their resident physician, although this difference was not statistically significant (40% vs. 27%; p = 0.12). For subgroup analyses regarding specific topics of discussion, patients in the intervention group reported initiating more discussions regarding mental HRQoL than controls (23% vs. 0%; p = 0.02). There was no difference in patient reports of initiating discussions regarding smoking, physical activity or physical HRQoL. Providing patients with immediate, personalized, guideline-based feedback prior to the clinical encounter can increase patient-initiated discussions regarding mental HRQoL. Future work should test FAST-Feedback in a larger population and evaluate the impact on tobacco cessation, increased physical activity, and improvements in HRQoL.

Exploring the Psychometric Properties of the Humanistic Teaching Practices Effectiveness Questionnaire, an Instrument to Measure the Humanistic Qualities of Medical Teachers

To describe the development and psychometric properties of the Humanistic Teaching Practices Effectiveness Questionnaire (HTPE), an instrument that measures the humanistic skills of attending physicians within an academic health center (AHC) department of medicine. From August 2005 through March 2007, the authors distributed the HTPE, along with other standard faculty evaluations, to internal medicine and medicine/pediatrics residents at a single midwestern AHC (the Indiana University School of Medicine), in an effort to assess the instrument's validity and reliability. The data set included 886 completed HTPE questionnaires, representing 73% of the 1,212 administered. Exploratory factor analysis demonstrated a single major factor with high internal consistency reliability. The correlation between the HTPE and routine teaching evaluation tools was low. Interrater reliability was only fair (0.17). Total HTPE scores were not significantly different between female and male attending physicians. The 10-item HTPE provides reliable and valid information on the humanistic teaching practices of internal medicine faculty at a single AHC. The ability to reliably measure these practices provides a framework for understanding and promoting the skills to effectively demonstrate humanism at the bedside and in the clinic. The low correlation between the HTPE and other faculty evaluations suggests that the former measures a unique domain in attending physicians' performance. The HTPE items cluster together as a single construct allowing educators to choose fewer items without compromising reliability; however, moderate interrater reliability indicates that multiple raters are required to produce reliable scores.

The impact of pioglitazone on ADMA and oxidative stress markers in patients with type 2 diabetes

AimsTo determine whether pioglitazone 30mg daily reduces levels of ADMA in adult patients with diabetes, and whether there is improvement in markers of oxidative stress. MethodsProspective randomized cross-over placebo-controlled study of 36 adults age 40–75 years with type 2 diabetes recruited from a single academic health center. Intervention was for 12 weeks, followed by a 4-week wash-out period, followed by a second 12-week cross-over treatment period. The main outcome was comparison of the change in ADMA levels in the two treatment periods. Secondary outcomes included change in NOx and F2-isoprostanes. ResultsThirty-six patients were enrolled in the study, 31 completed the protocol; the study enrollment met the sample size required to detect a change of 18% in levels. There were no differences in ADMA, NOx and F2-isoprostanes levels in the two treatment periods. Non-study medication changes or changes in dose were infrequent, and a statin was added during the study period in only one patient. ConclusionsDespite previous animal data that showed an effect of pioglitazone on ADMA, the current study in human patients did not demonstrate any differences in ADMA, NOx, or F2-isoprostane levels. The results do not favor that pioglitazone has a significant impact on ADMA levels in human patients with diabetes.

Surgeons' performance during critical situations: competence, confidence, and composure

Background Little is known about surgeons' performance during critical situations. We hypothesized that there are methods and techniques used by surgeons that facilitate performance during critical situations. Methods Surgical faculty and senior general surgery residents from a single academic health center were surveyed. Results Twenty-six surgeons participated. With respect to critical situations, the surgeons felt confident (96%), expected to be successful (96%), and most did not find these situations particularly stressful (62%). The majority reported using learned skills (92%) and agree their skills can be taught (82%). Practice and preparation were reported as very important (89%). A majority use pre-emptive visualization (68%). Competence, confidence, composure, preparation, and experience were most commonly listed as characteristics or behaviors that should be encouraged in aspiring surgeons. Anger, panic, indecision, fear, and chaos were the most commonly listed characteristics that should be discouraged. Conclusions Surgeons' response to performance under pressure is complex; however, surgeons report using simple, learned techniques that seem to be targeted toward eliminating the “fight or flight” sympathetic nervous system response.

Safety of Surgeon-Directed Conscious Sedation in Nasal Surgery

Safety of Surgeon-Directed Conscious Sedation in Nasal Surgery