New Strategies in Clinical Guideline Delivery: Randomized Trial of Online, Interactive Decision Support Versus Guidelines for Human Immunodeficiency Virus Treatment Selection by Trainees.

BACKGROUND: Support for clinicians in human immunodeficiency virus (HIV) medicine is critical given national HIV-provider shortages. The US Department of Health and Human Services (DHHS) guidelines are comprehensive but complex to apply for antiretroviral therapy (ART) selection. Human immunodeficiency virus antiretroviral selection support and interactive search tool (HIV-ASSIST) (www.hivassist.com) is a free tool providing ART decision support that could augment implementation of clinical practice guidelines. METHODS: We conducted a randomized study of medical trainees at Johns Hopkins University, in which participants were asked to select an ART regimen for 10 HIV case scenarios through an electronic survey. Participants were randomized to receive either DHHS guidelines alone, or DHHS guidelines and HIV-ASSIST to support their decision making. ART selections were graded "appropriate" if consistent with DHHS guidelines, or concordant with regimens selected by HIV experts at 4 academic institutions. RESULTS: Among 118 trainees, participants randomized to receive HIV-ASSIST had a significantly higher percentage of appropriate ART selections compared to those receiving DHHS guidelines alone (percentage of appropriate responses in DHHS vs HIV-ASSIST arms: median [Q1, Q3], 40% [30%, 50%] vs 90% [80%, 100%]; P < .001). The effect was seen for all case types, but most pronounced for complex cases involving ART-experienced patients with ongoing viremia (DHHS vs HIV-ASSIST: median [Q1, Q3], 0% [0%, 33%] vs 100% [66%, 100%]). CONCLUSIONS: Trainees using HIV-ASSIST were significantly more likely to choose appropriate ART regimens compared to those using guidelines alone. Interactive decision support tools may be important to ensure appropriate implementation of HIV guidelines. CLINICAL TRIALS REGISTRATION: NCT04080765.

Evaluating the Concordance of Clinician Antiretroviral Prescribing Practices and HIV-ASSIST, an Online Clinical Decision Support Tool.

BACKGROUND: Individualized selection of antiretroviral (ARV) therapy is complex, considering drug resistance, comorbidities, drug-drug interactions, and other factors. HIV-ASSIST (www.hivassist.com) is a free, online tool that provides ARV decision support. HIV-ASSIST synthesizes patient and virus-specific attributes to rank ARV combinations based upon a composite objective of achieving viral suppression and maximizing tolerability. OBJECTIVE: To evaluate concordance of HIV-ASSIST recommendations with ARV selections of experienced HIV clinicians. DESIGN: Retrospective cohort study. PATIENTS: New and established patients at the Johns Hopkins Bartlett HIV Clinic and San Francisco Veterans Affairs HIV Clinic completing clinic visits were included. Chart reviews were conducted of the most recent clinic visit to generate HIV-ASSIST recommendations, which were compared to prescribed regimens. MAIN MEASURES: For each provider-prescribed regimen, we assessed its corresponding HIV-ASSIST "weighted score" (scale of 0 to 10 +, scores of < 2.0 are preferred), rank within HIV-ASSIST's ordered listing of ARV regimens, and concordance with the top five HIV-ASSIST ranked outputs. KEY RESULTS: Among 106 patients (16% female), 23 (22%) were ARV-naïve. HIV-ASSIST outputs for ARV-naïve patients were 100% concordant with prescribed regimens (median rank 1 [IQR 1-3], median weighted score 1.1 [IQR 1-1.2]). For 18 (17%) ARV-experienced patients with ongoing viremia, HIV-ASSIST outputs were 89% concordant with prescribed regimens (median rank 2 [IQR 1-3], median weighted score 1 [IQR 1-1.2]). For 65 (61.3%) patients that were suppressed on a current ARV regimen, HIV-ASSIST recommendations were concordant 88% of the time (median rank 1 [IQR 1-1], median weighted score 1.1 [IQR 1-1.6]). In 18% of cases, HIV-ASSIST weighted score suggested that the prescribed regimen would be considered "less preferred" (score > 2.0) than other available alternatives. CONCLUSION: HIV-ASSIST is an educational decision support tool that provides ARV recommendations concordant with experienced HIV providers from two major academic centers for a diverse set of patient scenarios.

Copper in Cultured Shrimp Litopenaeus vannamei and Its Reduction in Hepatopancreas After Exposure to Sublethal Nitrite Levels.

This research was to evaluate the load and mobility of Cu in juvenile Litopenaeus vannamei after exposure (48 h) to sublethal concentration of nitrite (5.3 mg/L NO2--N) at a salinity of 3.0 g/L. The hypothesis is that such exposure causes a Cu mobility in the tissues of shrimp. The Cu concentration in exoskeleton, hepatopancreas, muscle and hemolymph in the control group were 38.9 ± 3.0, 2478 ± 256, 11.9 ± 0.2 µg/g (dw) and 95.4 ± 19.1 µg/mL, while in the nitrite exposure, were 46.0 ± 0.1, 1546 ± 173, 11.3 ± 0.3 µg/g (dw) and 118.2 ± 10.5 µg/mL, respectively. Only hepatopancreas exhibited a significant (p < 0.05) reduction (37.6%) between the control and the nitrite exposure. This is evidence that nitrite has a significant effect on Cu accumulation in hepatopancreas when shrimp are exposed to sublethal levels in a salinity of 3 g/L. Results confirm the hypothesis that Cu mobility was only significant in hepatopancreas.

Acute Toxicity of Ammonia, Nitrite and Nitrate to Shrimp Litopenaeus vannamei Postlarvae in Low-Salinity Water.

Shrimp farming in low salinities waters is an alternative to increasing production, and counteracting disease problems in brackish and marine waters. However, in low-salinity waters, toxicity of nitrogen compounds increases, and there is no available data of its acute toxicity in shrimp postlarvae. This study determined the acute toxicity of ammonia, nitrite and nitrate in Litopenaeus vannamei postlarvae in 1 and 3 g/L salinity, as well as the safety levels. The LC50 confirms that nitrite is more toxic than ammonia and nitrate in low salinity waters, and that its toxicity increases with a decrease in salinity. The safe levels estimated for salinities of 1 and 3 g/L were 0.54 and 0.81 mg/L for total ammonia-N, 0.17 and 0.25 mg/L for NO2-N, and 5.6 and 21.5 mg/L for NO3-N, respectively.