Who declines "opt-out" HIV/HCV testing? Experience of an internal medicine resident continuity clinic serving a predominantly Black adult population in South Carolina.

BACKGROUND: Universal "opt-out" human immunodeficiency virus (HIV) or hepatitis C virus (HCV) testing involves testing individuals for HIV or HCV regardless of symptoms, unless they decline. Little is known about the characteristics of individuals who decline. METHODS: We conducted a retrospective, medical record review of adults evaluated at an outpatient clinic in South Carolina. "Opt-out" HIV/HCV testing was implemented in Feb 2019; we reviewed medical records of individuals evaluated in May - July 2019. We excluded individuals who did not meet age-based screening criteria (HIV: 18-65 years; HCV: 18-74 years), had a prior HIV/HCV diagnosis, were tested for HIV/HCV within the preceding 12 months, and whose "opt-out" decision was not documented. We used multivariable logistic regression to estimate adjusted odds ratios (aOR) and 95 % confidence intervals (CI) for "opt-out" decision, with age, sex, race/ethnicity, insurance status, visit type, and genitourinary vs. non-genitourinary chief complaints as predictors. RESULTS: The final analyses included 706 individuals for HIV and 818 for HCV. Most individuals were non-Hispanic Black (77 % and 78 %) and female (66 % and 64 %). The mean ages were 49.1 (±11.9) and 51.9 (±13.2). Nearly one-third of individuals declined HIV and HCV testing (31 % and 30 %). Black males were more likely to decline HIV and HCV testing than Black females (aOR = 1.61 [95 % CI. 1.08 - 2.40] and aOR = 1.50 [95 %CI. 1.04 - 2.16]). CONCLUSION: Despite HIV/HCV testing being the standard of care, approximately one-third of eligible individuals may decline testing, the demographic characteristics of whom may overlap with individuals who are traditionally unaware of their status. MAIN POINT: Despite HIV/HCV testing being the standard of care, approximately one-third of eligible individuals may decline testing, the demographic characteristics of whom may overlap with individuals who are traditionally unaware of their status.

Hepatitis C: Screening changes, treatment advances.

Changing at-risk populations and treatments are reshaping screening and management. Which regimens are best and what factors influence treatment choices?

Medical Student--Reported Outcomes of a Radiation Oncologist--Led Preclinical Course in Oncology: A Five-Year Analysis.

PURPOSE: There is a recognized need for more robust training in oncology for medical students. At our institution, we have offered a core dedicated oncology block, led by a radiation oncologist course director, during the second year of the medical school curriculum since the 2008-2009 academic year. Herein, we report the outcomes of the oncology block over the past 5 years through an analysis of student perceptions of the course, both immediately after completion of the block and in the third year. METHODS AND MATERIALS: We analyzed 2 separate surveys. The first assessed student impressions of how well the course met each of the course's learning objectives through a survey that was administered to students immediately after the oncology block in 2012. The second was administered after students completed the oncology block during the required radiology clerkship in the third year. All questions used a 5-level Likert scale and were analyzed by use of a Wilcoxon signed-rank test. RESULTS: Of the 169 students who took the oncology course in 2012, 127 (75.1%) completed the course feedback survey. Over 73% of students agreed or strongly agreed that the course met its 3 learning objectives. Of the 699 medical students who took the required radiology clerkship between 2010 and 2013, 538 participated in the second survey, for a total response rate of 77%. Of these students, 368 (68.4%) agreed or strongly agreed that the course was effective in contributing to their overall medical education. CONCLUSION: Student perceptions of the oncology block are favorable and have improved across multiple categories since the inception of the course. Students self-reported that a dedicated preclinical oncology block was effective in helping identify the basics of cancer therapy and laying the foundation for clinical electives in oncology, including radiation oncology.

Patient demographic characteristics and disease stage as drivers of disparities in mortality in prostate cancer patients who receive care at a safety net academic medical center.

INTRODUCTION: The purpose of this study was to examine the effect of patient demographic characteristics and tumor stage at diagnosis on mortality in prostate cancer patients who receive care at a safety net, academic medical center with a diverse patient population. PATIENTS AND METHODS: Eight hundred sixty-nine patients were diagnosed with prostate cancer at our institution between August 2004 and October 2011. Patient demographic characteristics were determined as follows: race and/or ethnicity, primary language, insurance type, age at diagnosis, marital status, income (determined by zip code), and American Joint Committee on Cancer (AJCC) tumor stage. Fisher exact or Pearson χ(2) test was used to test for differences in categorical variables. Multivariate logistic regression analysis was performed to identify factors related to mortality recorded at the end of follow-up in March of 2012. RESULTS: Mortality was significantly decreased in patients who spoke Haitian Creole (odds ratio [OR], 0.18; 95% confidence interval [CI], 0.04-0.74; P = .017). Distribution of insurance type, age, income, and prostate-specific antigen level differed between English and Haitian Creole speakers. Increased mortality was observed in patients who were single (OR, 1.99; 95% CI, 1.06-3.73; P = .032), older than 70 (OR, 15.5; 95% CI, 3.03-79.45; P = .001), had Medicaid and/or free care (OR, 4.98; 95% CI, 1.72-14.4; P = .003), or had AJCC stage IV cancer (OR, 9.56; 95% CI, 4.89-18.69; P < .001). There was no significant difference in mortality according to race and/or ethnicity or income in the multivariate-adjusted model. CONCLUSION: In this retrospective study, prostate cancer patients who spoke Haitian Creole had a lower incidence of mortality compared with English speakers. Consistent with similar large-scale studies, being single or having Medicaid and/or free care insurance predicted worse outcomes, reinforcing their roles as drivers of disparities.

Beyond the standard curriculum: a review of available opportunities for medical students to prepare for a career in radiation oncology.

PURPOSE: To review currently available opportunities for medical students to supplement their standard medical education to prepare for a career in radiation oncology. METHODS AND MATERIALS: Google and PubMed were used to identify existing clinical, health policy, and research programs for medical students in radiation oncology. In addition, results publicly available by the National Resident Matching Program were used to explore opportunities that successful radiation oncology applicants pursued during their medical education, including obtaining additional graduate degrees. RESULTS: Medical students can pursue a wide variety of opportunities before entering radiation oncology. Several national specialty societies, such as the American Society for Radiation Oncology and the Radiological Society of North America, offer summer internships for medical students interested in radiation oncology. In 2011, 30% of allopathic senior medical students in the United States who matched into radiation oncology had an additional graduate degree, including PhD, MPH, MBA, and MA degrees. Some medical schools are beginning to further integrate dedicated education in radiation oncology into the standard 4-year medical curriculum. CONCLUSIONS: To the authors' knowledge, this is the first comprehensive review of available opportunities for medical students interested in radiation oncology. Early exposure to radiation oncology and additional educational training beyond the standard medical curriculum have the potential to create more successful radiation oncology applicants and practicing radiation oncologists while also promoting the growth of the field. We hope this review can serve as guide to radiation oncology applicants and mentors as well as encourage discussion regarding initiatives in radiation oncology opportunities for medical students.

Devising the optimal preclinical oncology curriculum for undergraduate medical students in the United States.

A third of women and a near majority of men in the United States will be diagnosed with cancer in their lifetimes. To prepare future physicians for this reality, we have developed a preclinical oncology curriculum that introduces second-year medical students to essential concepts and practices in oncology to improve their abilities to appropriately care for these patients. We surveyed the oncology and education literature and compiled subjects important to students' education including basic science and clinical aspects of oncology and addressing patients' psychosocial needs. Along with the proposed curriculum content, scheduling, independent learning exercises, and case studies, we discuss practical considerations for curriculum implementation based on experience at our institution. Given the changing oncology healthcare landscape, all (new) physicians must competently address their cancer patients' needs, regardless of chosen specialty. A thorough and logically organized cancer curriculum for preclinical medical students should help achieve these aims. This new model curriculum, with accompanying strategies to evaluate its efforts, is essential to update how medical students are educated about cancer.

Jails, HIV testing, and linkage to care services: an overview of the EnhanceLink initiative.

Over 9 million persons in the United States (US) are admitted each year to jails. HIV prevalence among detainees is higher than the general population, which creates a public health need for linking HIV-infected detainees to services during jail and after release. The EnhanceLink initiative was funded as demonstration projects in 10 communities at 20 separate jails across the US. Grantees implemented and evaluated innovative models of HIV testing in jails and linkage of HIV-infected individuals to community services post release. In this paper, we describe services delivered with the EnhanceLink initiative. During 877,119 admission events, 210,267 inmates agreed to HIV testing and 822 new diagnoses of HIV were made. The majority of persons served with transitional services were previously diagnosed before the current incarceration. Cumulatively, 9,837 HIV+ persons were offered linkage and transitional services and 8,056 (82 %) accepted the offer. EnhanceLink demonstrated the feasibility of HIV testing in jail settings and provision of linkage services to enhance continuity of HIV care post-release.

Infected Nonunion of Radius and Ulna - Strategy of Approach.

INTRODUCTION: Infected nonunion of radius and ulna are rare but difficult problems to deal. We report a case of successfully managed infected non-unonion of forearm bones and the reasoning behind strategy of approach to the case. CASE REPORT: 42 year old female presented with history of closed forearm fracture three months back for which she was operated with open reduction and internal fixation using dynamic compression plate. There was pain and fever post-surgery and discharge and wound gape. This was treated with resuturing of the wound and oral antibiotics. She continued to have pain fever and discharge and consulted another surgeon who removed first the radius plate and then the ulna plate sequentially with stabilisation by external fixation. She presented to us at three months post injury with infected nonunion of radius and ulna with loosening of fixators, sequestrum on radiograph and wristdrop. A staged treatment was planned for her. As first stage debridement, antibiotic Calcium Sulphate cement bead insertion and intramedullary flexible nail fixation. She was given iv antibiotics as per culture report. At 3 months post surgery the infection had settled and pellets were resorbed. Double barrel vascularized fibula graft was used to fill the gap and fixation using long locked plates was done. At one year follow up radiographs showed good healing and clinically patient had a good elbow movements and was able to carry out her daily activities. CONCLUSIONS: Proper planning and staged management of such cases helps to achieve goals with good functional outcome.

Fever of unknown origin: is there a role for empiric therapy?

Empiric therapy has little or no role to play in cases of classic fever of unknown origin with three important exceptions: cases that meet criteria for culture-negative endocarditis; cases in which findings or the clinical setting suggests cryptic disseminated tuberculosis (or, occasionally, other granulomatous infections); and cases in which temporal arteritis with vision loss is suspected. Several studies indicate that patients with prolonged, undiagnosed fever of unknown origin generally have a favorable prognosis. A small and largely anecdotal literature suggests a small role for symptomatic use of corticosteroids or nonsteroidal anti-inflammatory agents in highly selected cases.