Association of tattooing and hepatitis C virus infection: a multicenter case-control study.

UNLABELLED: Although injection drug use (IDU) and blood transfusions prior to 1992 are well-accepted risk factors for hepatitis C virus (HCV) infection, many studies that evaluated tattooing as a risk factor for HCV infection did not control for a history of IDU or transfusion prior to 1992. In this large, multicenter, case-control study, we analyzed demographic and HCV risk factor exposure history data from 3,871 patients, including 1,930 with chronic HCV infection (HCV RNA-positive) and 1,941 HCV-negative (HCV antibody-negative) controls. Crude and fully adjusted odds ratios (ORs) of tattoo exposure by multivariate logistic regression in HCV-infected versus controls were determined. As expected, IDU (65.9% versus 17.8%; P < 0.001), blood transfusion prior to 1992 (22.3% versus 11.1%; P < 0.001), and history of having one or more tattoos (OR, 3.81; 95% CI, 3.23-4.49; P < 0.001) were more common in HCV-infected patients than in control subjects. After excluding all patients with a history of ever injecting drugs and those who had a blood transfusion prior to 1992, a total of 1,886 subjects remained for analysis (465 HCV-positive patients and 1,421 controls). Among these individuals without traditional risk factors, HCV-positive patients remained significantly more likely to have a history of one or more tattoos after adjustment for age, sex, and race/ethnicity (OR, 5.17; 95% CI, 3.75-7.11; P < 0.001). CONCLUSION: Tattooing is associated with HCV infection, even among those without traditional HCV risk factors such as IDU and blood transfusion prior to 1992.

Relationship Between Provider Experience and Cardiac Performance Measures in Outpatients (from the NCDR).

Compliance with cardiac performance measures for guideline-directed medical therapy remains suboptimal. There is a compelling need to identify modifiable factors that influence compliance rates, so that these factors can be addressed as targets of quality improvement. This study examines the relationship between cardiovascular provider experience and compliance with performance measures for outpatients with coronary artery disease (CAD), heart failure, and atrial fibrillation in the PINNACLE Registry. We hypothesize that providers who have been practicing longer, especially those further out from certification who may not be required to recertify, will have lower compliance rates with key cardiac performance measures. Using clinical data from January 1, 2013 to March 31, 2014 in the PINNACLE Registry, we employed a multilevel hierarchical logistic regression analysis to examine the relationship between cardiac performance measures and provider experience, defined by the number of years since initial cardiology board certification (<10 years vs 10 to 20 years vs ≥20 years). We found a significant difference in compliance in 4 out of 9 outpatient cardiac performance measures between providers with different experience levels. Providers with ≥20 years since certification were less compliant with 3 out of the 4 statistically different performance metrics; however, the absolute difference between performance measures by provider experience level was small. In conclusion, performance on several key cardiovascular quality measures demonstrate a statistically significant negative association with physician experience-level defined by years since initial cardiology certification, but the clinical significance of this finding is unclear.

Swimming With Sharks: Teaching Residents Value-Based Medicine and Quality Improvement Through Resident-Pitched Projects.

BACKGROUND: To create meaningful quality improvement (QI) curricula for graduate medical education (GME) trainees, institutions strive to improve coordination of QI curricula with hospital improvement infrastructure. OBJECTIVE: We created a curriculum to teach residents about QI and value-based medicine (VBM) and assessed curricular effectiveness. METHODS: We designed a 2-week required curriculum for internal medicine residents at a large academic program. After participating in basic skills workshops, trainees developed QI/VBM project ideas with faculty and nonclinical support and pitched them to hospital leaders at the end of the rotation. Pre-post and 1-year follow-up surveys were conducted for residents to self-assess knowledge, attitudes, and skills, participation in QI/VBM projects, and career intentions. We tracked QI/VBM project implementation. RESULTS: In the first 2 years (2017-2018), 92 trainees participated, and 71 of 76 (93%) recommended the curriculum. Surveys (76 of 92, 83%) show improvement in our learning objectives (12%-60% pre to 62%-97% post; P < .001 for all; Cohen's d effect size 0.7-1.2), which are sustained at 1-year follow-up (57%-95%; P < .01). Four of 19 projects have been implemented. At 1 year, 95% of residents had presented a quality/value poster presentation, 44% were involved in QI/VBM beyond required rotations, and 26% plan to pursue careers focused on improving quality, safety, or value. CONCLUSIONS: Our project-based curriculum culminating in a project pitch to hospital leadership was acceptable to GME trainees, improved self-assessed skills sustained at 1 year, and resulted in successfully implemented QI/VBM projects.

Test Selection for Women with Suspected Stable Ischemic Heart Disease.

Ischemic heart disease (IHD) is the leading cause of death and disability among women in the United States. Identifying IHD in women presenting with stable symptoms and stratifying their risk for an IHD event can be challenging for providers, with several different tests available. This article is meant to serve as a practical guide for clinicians treating women with potentially ischemic symptoms. Evidence and American Heart Association (AHA) recommendations regarding test selection are reviewed, with a focus on the information to be gained from each test. We outline suggested courses of action to be taken in the case of a positive or negative test. Regardless of the initial test result, clinicians should view a woman's symptom presentation as an opportunity to review and modify her risk of cardiovascular events.

Health literacy assessment of labeling of pediatric nonprescription medications: examination of characteristics that may impair parent understanding.

OBJECTIVE: Poor quality and variability of medication labeling have been cited as key contributors to medication misuse. We assessed the format and content of labels and materials packaged with common pediatric liquid nonprescription medications. METHODS: Descriptive study. A total of 200 top-selling pediatric oral liquid nonprescription medications (during the 52 weeks ending October 30, 2009) categorized as analgesic, cough/cold, allergy, and gastrointestinal products, with dosing information for children <12 years (representing 99% of U.S. market for these products) were reviewed. The principal display panel (PDP) and FDA Drug Facts panel (side panel) of each bottle, and associated box, if present, were independently examined by 2 abstractors. Outcome measures were content and format of active ingredient information and dosing instructions of the principal display panel and Drug Facts panel. RESULTS: Although almost all products listed active ingredients on the Drug Facts panel (side panel), nearly 1 in 5 (37 [18.5%]) did not list active ingredients on the PDP. When present, mean (SD) font size for PDP active ingredients was 10.7 (5.0), smaller than product brand name (32.1 [15.0]) and flavor (13.1 [4.8]); P < .001. Most products included directions in chart form (bottle: 167 [83.5%], box: 148 [96.1%], P < .001); mean (SD) font size: 5.5 (0.9; bottle), 6.5 (0.5; box), P < .001. Few products expressed dosing instructions in pictographic form: 4 (2.6%) boxes and 0 bottles. Nearly all products included the Food and Drug Administration-mandated sections. CONCLUSIONS: The format and content of labels for nonprescription pediatric liquid medications could be improved to facilitate parent understanding of key medication information, including active ingredient information and dosing instructions.