Alignment of Ending the HIV Epidemic Priority Jurisdictions With Availability of HIV Service Organizations: An Ecological Study.

We sought to describe and quantify the association between HIV service organization availability, HIV burden, and HIV awareness and prevention in the 57 priority jurisdictions selected as part of the U.S. Ending the HIV Epidemic initiative. On average, jurisdictions with more per capita organizations had more people living with HIV, more individuals aware of their positive status, and more individuals prescribed PrEP (b = 0.3; 95% CI [0.2, 0.5] for each additional case per 1,000 people in the first metric, and b = 0.3; 95% CI [0.2, 0.4] and b = 0.1; 95% CI [< 0.1, 0.1], respectively, for each percentage point change in the second two metrics), accounting for jurisdiction size. Several jurisdictions were outliers in the modeled associations and may reflect comparatively better, or worse, performance than similar jurisdictions. This information can assist in evaluating resource allocation and determining whether availability translates to accessibility.

Data Quality in Electronic Health Record Research: An Approach for Validation and Quantitative Bias Analysis for Imperfectly Ascertained Health Outcomes Via Diagnostic Codes.

It is incumbent upon all researchers who use the electronic health record (EHR), including data scientists, to understand the quality of such data. EHR data may be subject to measurement error or misclassification that have the potential to bias results, unless one applies the available computational techniques specifically created for this problem. In this article, we begin with a discussion of data-quality issues in the EHR focusing on health outcomes. We review the concepts of sensitivity, specificity, positive and negative predictive values, and demonstrate how the imperfect classification of a dichotomous outcome variable can bias an analysis, both in terms of prevalence of the outcome, and relative risk of the outcome under one treatment regime (aka exposure) compared to another. This is then followed by a description of a generalizable approach to probabilistic (quantitative) bias analysis using a combination of regression estimation of the parameters that relate the true and observed data and application of these estimates to adjust the prevalence and relative risk that may have existed if there was no misclassification. We describe bias analysis that accounts for both random and systematic errors and highlight its limitations. We then motivate a case study with the goal of validating the accuracy of a health outcome, chronic infection with hepatitis C virus, derived from a diagnostic code in the EHR. Finally, we demonstrate our approaches on the case study and conclude by summarizing the literature on outcome misclassification and quantitative bias analysis.

Retrospective Comparison of Patients ≥ 80 Years With Atrial Fibrillation Prescribed Either an FDA-Approved Reduced or Full Dose Direct-Acting Oral Anticoagulant.

Direct-acting oral anticoagulants (DOACs) represent the standard for preventing stroke and systemic embolization (SSE) in patients with atrial fibrillation (AF). There is limited information for patients ≥ 80 years. We report a retrospective analysis of AF patients ≥ 80 years prescribed either a US Food and Drug Administration (FDA)-approved reduced (n = 514) or full dose (n = 199) DOAC (Dabigatran, Rivaroxaban, or Apixaban) between January 1st, 2011 (first DOAC commercially available) and May 31st, 2017. The following multivariable differences in baseline characteristics were identified: patients prescribed a reduced dose DOAC were older (p < 0.001), had worse renal function (p = 0.001), were more often prescribed aspirin (p = 0.004) or aspirin and clopidogrel (p < 0.001), and more often had new-onset AF (p = 0.001). SSE and central nervous system (CNS) bleed rates were low and not different (1.02 vs 0 %/yr and 1.45 vs 0.44 %/yr) for the reduced and full dose groups, respectively. For non-CNS bleeds, rates were 10.89 vs 4.15 %/yr (p < 0.001, univariable) for the reduced and full doses, respectively. The mortality rate was 6.24 vs 1.75 %/yr (p = 0.001, univariable) for the reduced and full doses. Unlike the non-CNS bleed rate, mortality rate differences remained significant when adjusted for baseline characteristics. Thus, DOACs in patients ≥ 80 with AF effectively reduce SSE with a low risk of CNS bleeding, independent of DOAC dose. The higher non-CNS bleed rate and not the mortality rate is explained by the higher risk baseline characteristics in the reduced DOAC dose group. Further investigation of the etiology of non-CNS bleeds and mortality is warranted.

Predictors of range of motion restrictions in children with spastic cerebral palsy: A registry-based study.

BACKGROUND: Although children with spastic cerebral palsy (CP) commonly present with restricted passive range of motion (PROM) and contractures, knowledge about the child's characteristics that increase the risk of development of restricted PROM is limited. Identifying children who are more likely to develop contractures is important for early detection and the provision of appropriate medical management. This study aims to identify the most commonly restricted PROM of children with spastic CP and (2) to examine the combined effect of a child's age, gender, gross motor functional classification level and CP subtype on the development of restricted PROM in children with spastic CP. METHODS: The PROM of 233 children diagnosed with CP was extracted from the national registry of CP in Jordan (CPUP-Jordan) in addition to information about children's age, gender, level of Gross Motor Function Classification System-Expanded and Revised (GMFCS-E&R) and subtype of CP. The mean age of the participants was 3.73 years (SD = 3.14), 57.5% were males and 80.3% had bilateral spastic CP. Point biserial correlations were calculated between the PROM and the child's variables. Multiple binary logistic regressions were conducted to identify the predictors of PROM. RESULTS: Hip abduction was the most common restricted PROM (57.9%), whereas the hip extension was the least (2.1%). Children with older ages demonstrated more restrictions in knee extension and ankle dorsiflexion; males demonstrated more restriction in hip abduction than females; children with lower GMFCS-E&R levels had more restrictions in hip internal rotation but fewer restrictions in hip abduction and ankle dorsiflexion; and children with bilateral spastic CP had more restrictions in hip abduction than children with unilateral spastic CP. CONCLUSIONS: PROM of the hip, knee and ankle joints of children with spastic CP was predicted by different sets of child characteristics. Implications for health professionals and follow-up registries of children with CP are provided.

School-Based Physical Therapists' Experiences and Perceptions of How Student Goals Influence Services and Outcomes.

Aims: Individualized goals are the foundation for physical therapy services and outcomes. This research describes school-based physical therapists' (PTs) experiences and perceptions of how student goals impact services and outcomes. Methods: Twenty school-based PTs participated in one of five semi-structured focus groups on goal development and use. Therapists were recruited from 113 therapists who participated in a study of school-based physical therapy outcomes. Two researchers conducted thematic analysis of written transcriptions of audio recordings to identify qualitative themes; a third researcher reviewed the analysis. Results: Four themes emerged related to how goals impact services: (1) the nature of services, (2) intervention strategies, (3) teaming, and (4) flexibility of services. Three themes emerged related to how goals impact outcomes: (1) natural linkages among goals, services, and outcomes; (2) goals impact teaming to achieve outcomes; and (3) specifics of the goal matter. Therapists also reported a range of student and environmental factors that impact services and outcomes. Conclusions: Therapists perceive that goals influence services and outcomes in complex ways, especially due to the flexibility and individualization needed in school-based practice. This study helps school-based PTs understand and reflect on how individualized goals influence services and optimize student outcomes.

Knowledge, Attitudes, and Acceptability of Pre-Exposure Prophylaxis among Individuals Living with HIV in an Urban HIV Clinic.

INTRODUCTION: Pre-exposure prophylaxis (PrEP) is an effective tool to reduce HIV transmission. The primary objective of this study was to assess awareness of PrEP by individuals living with HIV (HIV+) and acceptance of its use for their HIV negative (HIV-) partners. METHODS: A cross sectional survey was conducted among individuals living with HIV who received care at an urban HIV clinic between January 2013 and June 2013. The survey examined knowledge, attitudes, and acceptability of PrEP, and perception of transmission risk of HIV. Chi-Square test and Fisher's Exact test were used to compare proportions. RESULTS: Among 206 subjects living with HIV, 15.3% (32) had heard of PrEP. Men who have sex with men (MSM) were more likely to be aware of PrEP than all others (p = 0.003). Once educated about PrEP those who believed PrEP would reduce their partner's risk for HIV were more likely to recommend PrEP to their partner (p<0.001). 92% of all respondents said they would be "extremely likely/likely" to discuss PrEP use with their provider. Of 159 subjects whose main partner was HIV-, MSM (p = 0.007), male participants (p = 0.044), and those who were consistently taking meds (p = 0.049) were more likely to be aware of PrEP. Those who perceived they were at risk of transmitting HIV (p<0.001) and those who were consistently taking meds (0.049) were more likely to agree that PrEP could reduce the risk of HIV to their partners. CONCLUSION: This study illustrates a low awareness of PrEP but once educated the willingness of a cohort of individuals living with HIV to recommend PrEP to their partners. Our findings demonstrate the importance of providers informing their patients living with HIV about PrEP, as these persons are an underutilized link to support the uptake of PrEP by their HIV- partners.

Predictors of Linkage to Care for Newly Diagnosed HIV-Positive Adults.

INTRODUCTION: Linkage to care following a human immunodeficiency virus (HIV) diagnosis is critical. In the U.S. only 69% of patients are successfully linked to care, which results in delayed receipt of antiretroviral therapy leading to immune system dysfunction and risk of transmission to others. METHODS: We evaluated predictors of failure to link to care at a large urban healthcare center in Philadelphia in order to identify potential intervention targets. We conducted a cohort study between May 2007 and November 2011 at hospital-affiliated outpatient clinics, emergency departments (EDs), and inpatient units. RESULTS: Of 87 patients with a new HIV diagnosis, 63 (72%) were linked to care: 23 (96%) from the outpatient setting and 40 (63%) from the hospital setting (ED or inpatient) (p<0.01). Those who were tested in the hospital-based settings were more likely to be black (p=0.01), homeless (p=0.03), and use alcohol or drugs (p=0.03) than those tested in the outpatient clinics. Patients tested in the ED or inpatient units had a 10.9 fold (p=0.03) higher odds of failure to link compared to those diagnosed in an outpatient clinic. When testing site was controlled, unemployment (OR 12.2;p<0.01) and substance use (OR 6.4;p<0.01) were associated with failure to link. CONCLUSION: Our findings demonstrate the comparative success of linkage to care in outpatient medical clinics versus hospital-based settings. This study both reinforces the importance of routine opt-out HIV testing in outpatient practices, and demonstrates the need to better understand barriers to linkage.

Stereotactic body radiotherapy for re-irradiation of lung cancer recurrence with lower biological effective doses.

OBJECTIVE: Few studies have evaluated re-irradiation of lung cancer recurrences with stereotactic body radiotherapy (SBRT). This study evaluates outcomes with SBRT re-irradiation for recurrent lung cancer. METHODS: Two hundred and seventy-eight patients treated with SBRT for lung cancer were retrospectively reviewed. Of those, 26 patients with 29 tumors were re-irradiated with SBRT. Ninety percent of tumors received prior external beam irradiation and 10 % received prior SBRT. Previous median radiation dose was 61.2 Gy with a median 8-month interval from previous radiation. The median re-irradiation SBRT dose was 30 Gy (48 Gy10 biological effective dose (BED)). Endpoints evaluated included local control, overall survival, and progression-free survival. RESULTS: Twenty-five of 29 tumors were evaluable for local control, with 27 tumors (93 %) considered in-field recurrences. In-field crude local control rate was 80 % (20/25) with 1 and 2-year actuarial rates of 78.6 and 65.5 %, respectively. One and 2-year actuarial survival rates were 52.3 and 37.0 %, respectively. One and 2-year actuarial progression-free survival rates were 56.7 and 37.0 %, respectively. Fifty-five percent of patients reported acute/chronic grades 1 and 2 toxicities. No grade 3 or higher toxicities were reported. CONCLUSION: Patients with recurrent lung cancer have limited options. SBRT re-irradiation is tolerable even after a median 61.2 Gy to the re-irradiation site. The lower BED used provided acceptable progression-free survival with low toxicity. Given the poor prognosis with current treatment options, new paradigms for re-treatment should include SBRT-re-irradiation as an adjunct to systemic therapy for in-field lung cancer recurrence.

A Phase II study of anti-epidermal growth factor receptor radioimmunotherapy in the treatment of glioblastoma multiforme.

OBJECT: This single-institution Phase II study tests the efficacy of adjuvant radioimmunotherapy with (125)I-labeled anti-epidermal growth factor receptor 425 murine monoclonal antibody ((125)I-mAb 425) in patients with newly diagnosed glioblastoma multiforme (GBM). METHODS: A total of 192 patients with GBM were treated with (125)I-mAb 425 over a course of 3 weekly intravenous injections of 1.8 GBq following surgery and radiation therapy. The primary end point was overall survival, and the secondary end point was toxicity. Additional subgroup analyses were performed comparing treatment with (125)I-mAb 425 (RIT, 132 patients), (125)I-mAb 425 and temozolomide (TMZ+RIT, 60 patients), and a historical control group (CTL, 81 patients). RESULTS: The median age was 53 years (range 19-78 years), and the median Karnofsky Performance Scale score was 80 (range 60-100). The percentage of patients who underwent debulking surgery was 77.6% and that of those receiving temozolomide was 31.3%. The overall median survival was 15.7 months (95% CI 13.6-17.8 months). The 1- and 2-year survivals were 62.5 and 25.5%, respectively. For subgroups RIT and TMZ+RIT, the median survivals were 14.5 and 20.2 months, respectively. No Grade 3 or 4 toxicity was seen with the administration of (125)I-mAb 425. The CTL patients lacked Karnofsky Performance Scale scores, had poorer survival, were older, and were less likely to receive radiation therapy. On multivariate analysis, the hazard ratios for RIT versus CTL, TMZ+RIT versus CTL, and TMZ+RIT versus RIT were 0.49 (p < 0.001), 0.30 (p < 0.001), and 0.62 (p = 0.008), respectively. CONCLUSIONS: In this large Phase II study of 192 patients with GBM treated with anti-epidermal growth factor receptor (125)I-mAb 425 radioimmunotherapy, survival was 15.7 months, and treatment was safe and well tolerated.

Predictors of resolution of aberrant drug behavior in chronic pain patients treated in a structured opioid risk management program.

OBJECTIVE: To identify demographic and clinical predictors of the resolution of aberrant drug-related behaviors (ADRBs) in a group of patients referred to the Opioid Renewal Clinic (ORC) by their primary care providers (PCPs). ORC is a program supporting PCPs' use of opioids for chronic pain in patients perceived as at risk for opioid abuse or those with demonstrated ADRBs. METHODS: A retrospective chart review was conducted for 195 consecutive subjects referred to the ORC from January 17, 2002 to August 27, 2004, for ADRBs. Binary logistic regression was employed to identify independent predictors of aberrant behavior outcome at 1 year. RESULTS: Of the 195 referred, 45.6% (N = 89) resolved their ADRB at 1 year. Other outcomes, classified as nonresolution of ADRB, self-discharged or discharged by the ORC for inability to adhere to the opioid treatment agreement (N = 86, 44.1%) and acceptance of referral for addiction treatment (N = 20, 10.2%). A history of cocaine abuse increased the odds of failing the program by five times (odds ratio [OR] = 4.97, P = 0.001). Each additional pain diagnosis reduced the odds of failure by 16% (OR = 0.837, P = 0.008). When compared with singles, married individuals were 62% less likely to fail the ORC program (OR = 0.38, P = 0.028). CONCLUSIONS: Nearly half of the patients resolved their aberrant behavior within the ORC. Patients with cocaine abuse were at higher risk for failure, suggesting a need for further research into safe and effective ways to manage pain in this complex subset of patients. Aberrant behaviors tended to resolve in patients with multiple pain locations, possibly because of their desire for relief.

Scapular rotation in swimmers with and without impingement syndrome: practice effects.

PURPOSE: The purpose of this study was to examine the effects of a normal swim practice on the scapular kinematics of swimmers with impingement syndrome and healthy swimmers. METHODS: Twenty swimmers with no known shoulder pathology and 20 swimmers with shoulder impingement syndrome participated in this study. Shoulder strength measurements were made with a hand-held dynamometer. Static scapular upward rotation was measured with an inclinometer with the arm at rest, and at 45, 90, and 135 degrees of humeral elevation. Measurements were made pre- and postswim training. RESULTS: There were no differences in baseline measurements of kinematics between the two groups. After swimming, both groups experienced muscle fatigue as indicated by a significant reduction in force generation. Although swimming practice resulted in no significant differences in scapular kinematics for the healthy swimmers, there were significant decreases in scapular upward rotation in subjects with shoulder impingement. CONCLUSIONS: Abnormal scapular kinematics in swimmers with impingement syndrome may only be observed after an intense swim practice. The examination of swimmers immediately after swimming may provide more information regarding impingement syndrome than a typical clinical exam.

Pagers combined with telephones improve successful follow-up from a pediatric emergency department.

OBJECTIVE: To determine whether there is a significant difference in initial successful contact when attempting follow-up of patients discharged from a pediatric emergency department (ED) using either pagers or the telephone. In addition, to evaluate whether the combination of both pager and telephone follow-up is more successful than telephone follow-up alone when confined to a 2-hour period. DESIGN AND SETTING: A prospective comparison of intervention and control groups taken from convenience samples of patients seen in an ED of an urban, tertiary care children's hospital. PARTICIPANTS: One hundred eighty-five patients whose families had access to both a pager and a telephone (intervention group) and 112 patients whose families had access to only a telephone (control group) were enrolled. INTERVENTION: Before discharging the patient from the ED, the investigators verified a pager number and/or a best contact telephone number for a follow-up telephone call. Participants were divided into 2 groups. The intervention group consisted of caretakers with both pagers and telephones. The control group consisted of caretakers with only telephones. On even calendar days after ED visits, intervention group caretakers were paged initially from 11:00 AM to 11:59 AM. On odd calendar days, intervention group caretakers were telephoned initially from 11:00 AM to 11:59 AM. Successful contact was defined as communication with a family member or guardian over the age of 18. If the caretaker spoke only Spanish, a translator was used. In a crossover design with the intervention group, if contact was unsuccessful after 1 hour, the alternative mode of communication was used at noon. Control group caretakers were telephoned from 11:00 AM to 11:59 AM. If telephone contact was unsuccessful, they were called again 1 hour later. RESULTS: Two hundred forty-six (36%) of 685 of the convenience sample of caretakers had access to both a pager and a telephone. Fifty-two (55%) of 94 intervention caretakers were contacted initially using pagers versus 47 (52%) of 91 intervention caretakers contacted initially by telephones. Overall successful contact of intervention caretakers (telephones and pagers) was 145 (78%) of 185 when confined to a 2-hour time period. In contrast, overall successful contact of control caretakers was 68 (61%) of 112 when confined to a 2-hour time period. Successful contact was greater with the intervention caretakers than with control caretakers (78% vs 61%). CONCLUSIONS: No significant difference in successful contact was seen whether paged or telephoned initially. The combination of both pagers and telephone follow-up was more successful than telephone follow-up alone when confined between 11:00 AM to 1:00 PM.

Emergency department preparedness for the evaluation and treatment of victims of biological or chemical terrorist attack.

This study evaluated the preparedness of Emergency Departments (EDs) in the greater Philadelphia area to evaluate and treat victims of a terrorist biological or chemical agent release. All hospitals with EDs in the survey target area were included. A survey instrument consisting of 38 questions was mailed to the physician director of each ED. Fifty-four of 62 directors returned usable surveys. This represented an overall response rate of 88.5%. Deficiencies in preparedness were identified involving physician training and education, antidote stocking, written policies, interagency agreements, and decontamination facilities. The overall level of preparedness for hospital EDs responding to this survey was low based on a set of predetermined, implicit criteria. Comprehensive plans should be developed and implemented to remedy the identified deficiencies.