HIV screening in an urban emergency department: comparison of screening using an opt-in versus an opt-out approach.

OBJECTIVE: We compare outcomes of opt-in and opt-out HIV screening approaches in an urban emergency department. METHODS: This was a 1-year prospective observational study comparing 2 6-month screening approaches. Eligibility for opt-in and opt-out screening was identical: aged 15 years or older, medically stable, and able to complete general consent. During the opt-in phase, triage nurses referred patients to HIV testers stationed at triage, who obtained separate opt-in written consent and performed rapid oral fluid tests. During the opt-out phase, registration staff conducted integrated opt-out consent and then referred patients to HIV testers. We assessed the proportion of potentially eligible patients who were offered screening (screening offer rate), the proportion offered screening who accepted (screening acceptance rate), the proportion who accepted screening and subsequently completed testing (test completion rate), and the proportion of potentially eligible patients who completed testing (overall screening rate) during each phase. RESULTS: For the opt-in versus the opt-out phases, respectively, there were 23,236 potentially eligible patients versus 26,757, screening offer rate was 27.9% versus 75.8% (P<.001), screening acceptance rate was 62.7% versus 30.9% (P<.001), test completion rate was 99.8% versus 74.6% (P<.001), and overall screening rate was 17.4% versus 17.5% (P = .90). CONCLUSION: A significantly higher proportion of patients were offered HIV screening with an opt-out approach at registration. However, this was offset by much higher screening acceptance and test completion rates with the opt-in approach at triage. Overall screening rates with the 2 approaches were nearly identical.

Endometriosis in the Mouse: Challenges and Progress Toward a 'Best Fit' Murine Model.

Endometriosis is a prevalent gynecologic condition associated with pelvic pain and infertility characterized by the implantation and growth of endometrial tissue displaced into the pelvis via retrograde menstruation. The mouse is a molecularly well-annotated and cost-efficient species for modeling human disease in the therapeutic discovery pipeline. However, as a non-menstrual species with a closed tubo-ovarian junction, the mouse poses inherent challenges as a preclinical model for endometriosis research. Over the past three decades, numerous murine models of endometriosis have been described with varying degrees of fidelity in recapitulating the essential pathophysiologic features of the human disease. We conducted a search of the peer-reviewed literature to identify publications describing preclinical research using a murine model of endometriosis. Each model was reviewed according to a panel of ideal model parameters founded on the current understanding of endometriosis pathophysiology. Evaluated parameters included method of transplantation, cycle phase and type of tissue transplanted, recipient immune/ovarian status, iterative schedule of transplantation, and option for longitudinal lesion assessment. Though challenges remain, more recent models have incorporated innovative technical approaches such as in vivo fluorescence imaging and novel hormonal preparations to overcome the unique challenges posed by murine anatomy and physiology. These models offer significant advantages in lesion development and readout toward a high-fidelity mouse model for translational research in endometriosis.

A comparison of HIV testing in the emergency department and urgent care.

BACKGROUND: Although national guidelines recommend universal human immunodeficiency virus (HIV) testing, emergency departments (EDs) may choose to limit testing to certain patients, such as those triaged to urgent care (UC). OBJECTIVE: To compare the results of rapid HIV testing in an urban ED with an affiliated UC. METHODS: This was a retrospective analysis of an HIV testing program that included screening, which was initiated by triage nurses, and diagnostic testing, which was initiated by clinicians. Eligible patients were ≥ 12 years old and medically stable. RESULTS: From April 2005 through December 2006, HIV tests were completed in 6196 (8.3%) of the 74,331 ED visits and 3256 (8.8%) of the 37,169 UC visits. Screening accounted for 5009 (80.8%) of the ED tests and 2914 (89.5%) of the UC tests, and diagnostic testing accounted for the remainder. Eighty (1.3%) of the ED tests and 21 (0.6%) of the UC tests were positive (p = 0.0024). Compared with newly diagnosed HIV-positive ED patients, HIV-positive UC patients were less likely to have CD4 counts < 200 cells/µL (adjusted odds ratio 0.19, 95% confidence interval 0.05-0.65). CONCLUSION: Although the yield of HIV testing is greater among ED patients, UC patients are diagnosed at a less advanced stage of illness.

Results of a rapid HIV screening and diagnostic testing program in an urban emergency department.

STUDY OBJECTIVE: We describe outcomes of a rapid HIV testing program integrated into emergency department (ED) services, using existing staff. METHODS: From April 2005 through December 2006, triage nurses in an urban ED offered HIV screening to medically stable patients aged 12 years or older. Clinicians could also order diagnostic testing according to presenting signs and symptoms and suspicion of HIV-related illness. Nurses obtained consent, performed rapid testing, and disclosed negative test results. Clinicians disclosed positive test results and arranged follow-up. Outcome measures included number and proportion of visits during which screening was offered, accepted, and completed; number of visits during which diagnostic testing was completed; and number of patients with confirmed new HIV diagnosis and their CD4 counts. RESULTS: HIV screening and diagnostic testing were completed in 9,466 (8%) of the 118,324 ED visits (14.2% of the 60,306 unique patients were tested at least once). Screening was offered 45,159 (38.2%) times, accepted 21,626 (18.3%) times, and completed 7,923 (6.7%) times; diagnostic testing was performed 1,543 (1.3%) times. Fifty-five (0.7%) screened patients and 46 (3.0%) of those completing diagnostic testing had confirmed positive HIV test results. Median CD4 count was 356 cells/microL among screened patients and 99 cells/microL among those who received diagnostic testing. CONCLUSION: Although existing staff was able to perform HIV screening and diagnostic testing, screening capacity was limited and the HIV prevalence was low in those screened. Diagnostic testing yielded a higher percentage of new HIV diagnoses, but screening identified greater than 50% of those found to be HIV positive, and the median CD4 count was substantially higher among those screened than those completing diagnostic testing.

A Survey of Family Planning Training, Knowledge, and Practices Among Health Care Providers Within the Military Health System at Joint Base Lewis-McChord.

INTRODUCTION: Within the active duty U.S. military population, the age-adjusted unintended pregnancy rate is higher than the national average. Unplanned pregnancy within the military impacts individual and unit medical readiness. Contraceptive education and availability are means to reduce unintended pregnancy rates; health care providers are key facilitators in provision of contraception. Understanding provider knowledge and practices related to contraceptive provision may identify strengths and gaps in order to provide focal points for sustainment or improvement in family planning practices. The purpose of this study was to assess family planning knowledge, training, and practices among health care providers serving military and dependent beneficiaries within the military health care system at Fort Lewis, Washington. MATERIAL AND METHODS: This was a cross-sectional survey of health care providers on Joint Base Lewis-McChord in Tacoma, Washington who deliver health care services to U.S. uniformed service members and their dependents in varied settings, including outpatient clinics and a tertiary care center. The survey included questions regarding prior contraceptive training, and current contraceptive knowledge and practices. Survey results were evaluated using descriptive and bivariate analyses. The study was approved by both Institutional Review Boards at Emory University and at Madigan Army Medical Center. RESULTS: Overall, 79 eligible health care providers completed the survey. Eighty-six percent of women's health providers consistently ("always or most of the time") provided family planning services to female service members, compared with 38% of primary care providers. Women's health providers were more likely to counsel by method effectiveness and adapt their counseling to consider patients' reproductive life plans. There were no differences between provider type in considering service members' deployment status during contraceptive counseling. Overall, providers identified the correct effectiveness of long-acting contraceptive methods, but tended to overestimate the effectiveness of short-acting methods. CONCLUSIONS: Family planning services available to service members may be improved through enhanced provider education, targeting efficacy-based counseling and identification of barriers to access and provision of long-acting reversible contraceptive methods.

A model recognition switch. Electrochemical control and transduction of imidazole binding by electrode-immobilized microperoxidase-11.

Electrode-immobilized microperoxidase-11 exhibited a titratable potentiometric response to imidazole, demonstrating both molecular recognition and the capability for "switchable" changes in the affinity of an immobilized redox-receptor for a target ligand.

A Comparison of Patient Satisfaction with Emergency Department Opt-In and Opt-Out Rapid HIV Screening.

Study objective. To compare patient satisfaction with emergency department (ED) opt-in and opt-out HIV screening. Methods. We conducted a survey in an urban ED that provided rapid HIV screening using opt-in (February 1, 2007-July 31, 2007) and opt-out (August 1, 2007-January 31, 2008) approaches. We surveyed a convenience sample of patients that completed screening in each phase. The primary outcome was patient satisfaction with HIV screening. Results. There were 207 and 188 completed surveys during the opt-in and opt-out phases, respectively. The majority of patients were satisfied with both opt-in screening (95%, 95% confidence interval [CI] = 92-98) and opt-out screening (94%, 95% CI = 89-97). Satisfaction ratings were similar between opt-in and opt-out phases even after adjusting for age, gender, race/ethnicity, and test result (adjusted odds ratio 1.3, 95% CI = 0.5-3.1). Conclusions. Emergency department patient satisfaction with opt-in and opt-out HIV screening is similarly high.

A comparison of patient acceptance of fingerstick whole blood and oral fluid rapid HIV screening in an emergency department.

BACKGROUND: Although whole blood rapid HIV testing has a greater sensitivity and specificity compared with oral fluid (OF) testing, patients prefer HIV testing using OF specimen collection. Whether patient preference for noninvasive collection methods affects acceptance of HIV screening in clinical practice, however, is unknown. OBJECTIVE: To determine whether patient acceptance of fingerstick whole blood (FWB) and OF rapid HIV screening differs in an emergency department setting. METHODS: From May 1 to June 30, 2007, triage-based testers offered rapid HIV screening to patients. OF and FWB tests were available on alternate days. Eligible patients were medically stable, > or =15 years of age, and not known to be HIV infected. RESULTS: : Two thousand two hundred one patients were referred for HIV screening: 1089 on OF days and 1112 on FWB screening days. Screening rates with OF and FWB were similar (61.9% vs. 59.1%, P = 0.18). Although most reasons why patients declined screening were similar for the groups, the specimen collection method was the primary reason for refusal by 25 patients who declined FWB screening compared with none of the patients who declined OF screening. CONCLUSIONS: Among emergency department patients, the preference for 1 rapid test collection modality over another has a minimal effect on actual screening rates.

Missed opportunities for earlier HIV diagnosis in an emergency department despite an HIV screening program.

In 2005 we implemented an emergency department HIV testing program that emphasized screening by nurses but also allowed for clinician diagnostic testing. We noted that clinicians often ordered tests that proved to be positive on patients who had been missed by screening, while others who tested positive had made previous visits when screening was available, but were not tested. The study objective was to quantify missed screening opportunities and assess the extent to which diagnostic testing contributes to the detection of HIV infection. Triage nurses were to offer screening to medically stable patients 12 years of age or older. Clinicians could order diagnostic testing in patients with signs and symptoms concerning for HIV. Nurses performed rapid HIV tests on oral fluid specimens. Charts of all patients testing positive between April 1, 2005 and November 31, 2006 were reviewed. The 2006 annual census was 75,000 visits with 47% of patients black, 32% Hispanic, 44% female, and 98% 12 years of age or older. Ninety-five patients tested HIV positive; 66 (69.5%) were diagnosed on their first visit but 29 (30.5%) made a total of 59 visits (range, 1-8) before testing positive. Patients were screening eligible during 54 (91.5%) of these 59 visits but screening was not offered during 34 (63.0%) of them, representing missed screening opportunities. On the day of diagnosis, 80 (84.2%) of the 95 patients were screening eligible but 20 (25.0%) of them were not offered screening, representing missed screening opportunities. Diagnostic testing identified HIV in 44 patients; 15 were screening ineligible, 20 were not offered screening, and 9 declined screening. Missed opportunities for earlier diagnosis occurred frequently despite an HIV screening program. Clinician diagnostic testing was an important adjunct to screening.