The diagnostic performance of the Visitect Advanced Disease point-of-care CD4 platform: a pragmatic mixed-methods multisite validation, costing, and qualitative analysis.

BACKGROUND: The Visitect CD4 Advanced Disease test (AccuBio, Alva, United Kingdom) is a rapid, semi-quantitative assay that estimates CD4 results above or below 200 cells/µL. We evaluated the performance of the Visitect CD4 assay in semi-urban laboratories in Uganda. METHODS: We performed a pragmatic laboratory validation of the Visitect CD4 platform in four routine HIV clinics in Uganda, nested within a cluster randomized trial evaluating an enhanced package of screening and treatment for persons with advanced HIV disease (NCT05085171). As part of the clinical trial, samples processed on the Visitect CD4 platform were confirmed using another CD4 testing method. We compared the diagnostic performance of the Visitect CD4 platform against the confirmatory method by evaluating the sensitivity, specificity, positive and negative predictive values. RESULTS: Of 1495 venous blood samples that were processed both by the Visitect CD4 test and another confirmatory CD4 platform at clinics in Kampala, Uganda, specificity was 81% (95% CI, 79%-84%) and the positive predictive value was 69% (95% CI, 66%-73%). There were no samples for which the Visitect test was >200 cells/µL and the confirmatory test was ≤200 cells/µL, resulting in a sensitivity of 100%. Among Visitect CD4 tests that were read as <200 cells/µL with confirmatory results >200 cells/µL, the median confirmatory CD4 result was 397 (IQR, 281-590) cells/µL. Specificity varied by clinic ranging from 63% to 99%. CONCLUSIONS: Given variable specificity of the Visitect CD4 Advanced Disease platform, successful implementation will require consideration of clinic context and laboratory staffing.

Mid-Upper Arm Circumference Is a Strong Predictor of Mortality Among Ugandan Adults With HIV-Associated Cryptococcal Meningitis: A Prospective Cohort Study.

Background: Mortality among adults diagnosed with HIV-associated cryptococcal meningitis remains high (24%-40%). We hypothesized that nutritional state, as measured by mid-upper arm circumference (MUAC), is a potentially modifiable risk factor for mortality. Methods: Ugandan adults hospitalized with HIV-associated cryptococcal meningitis had MUAC measurements performed at baseline. We compared MUAC measurements with baseline clinical and demographic variables and investigated associations with survival using Cox regression. Results: Of 433 participants enrolled, 41% were female, the median CD4 T-cell count (interquartile range [IQR]) was 15 (6-41) cells/µL, and 37% were antiretroviral therapy naïve. The median MUAC (IQR) was 24 (22-26) cm, the median weight (IQR) was 53 (50-60) kg, and MUAC correlated with weight (Pearson r = 0.6; P < .001). Overall, 46% (200/433) died during the 18-week follow-up. Participants in the lowest MUAC quartile (≤22 cm) had the highest mortality: 39% (46/118) at 2 weeks and 62% (73/118) at 18 weeks. A baseline MUAC ≤22 cm was associated with an 82% increased risk of 18-week mortality as compared with participants with an MUAC >22 cm (unadjusted hazard ratio, 1.82; 95% CI, 1.36-2.42; P < .001). Following adjustment for antiretroviral therapy status, CD4 count, hemoglobin, amphotericin dose, and tuberculosis status, the adjusted hazard ratio was 1.84 (95% CI, 1.27-2.65; P < .001). As a continuous variable, 18-week mortality was reduced by 10% for every 1-cm increase in MUAC. CSF Th17 immune responses were positively associated with MUAC quartile. Conclusions: MUAC measurement is a simple bedside tool that can identify adults with HIV-associated cryptococcal meningitis at high risk for mortality for whom an enhanced bundle of care, including nutritional supplementation, should be further investigated.

Awareness of peripheral IV catheters among nurses, physicians, and trainees: A prospective cohort study.

BACKGROUND: Peripheral intravenous catheters (PIVs) are the most frequently used invasive device in hospitalized patients. These devices are not benign and are associated with complications. However, clinician awareness of them is variable and poorly understood. METHODS: We conducted a prospective, multicenter, observational point prevalence study to assess awareness of PIV presence among clinicians caring for hospitalized patients in 4 hospitals between May 2018 and February 2019 located in Michigan, USA. We first assessed patients for the presence of a PIV then interviewed their providers. Differences in awareness by provider type were assessed via χ² tests; P < .05 was considered statistically significant. Analyses were performed on Stata MP v16. RESULTS: A total of 1,385 patients and 4,003 providers were interviewed. Nurses had the greatest awareness of overall PIV presence, 98.6%, while attendings were correct 88.1% of the time. Nurses were more likely to correctly assess PIV presence and exact location than physicians (67.7% vs <30% for all others). Awareness of PIV presence did not significantly vary in patients on contact precautions or those receiving infusions. CONCLUSIONS: Given the ubiquity of PIVs and known complications, methods to increase awareness to ensure appropriate care and removal are necessary.

Something's Not Quite Right.

In this narrative medicine essay, a physician recalls that when she presented with a suspected appendicitis as a medical student, she repeatedly requested a confirmation CT scan, which revealed a different diagnosis, and relates her experience with those of many women whose symptoms are not thoroughly checked out.

Understanding refugee and immigrant health literacy and beliefs toward antimicrobial resistance.

Refugee and migrant populations have increased vulnerability to antimicrobial resistance, yet stewardship guidance is lacking. We addressed this gap through a cross-sectional survey, finding that these populations and immigrants from low and middle-income countries had lower health literacy on the issue compared to native-born Americans and those from high-income countries.

Key Factors in Designing the Health System-Community Pathways Program for African American/Black Children and Young Adults.

Many of the ethnic and racial workforce inequities in the United States are present in health care systems. Low representation of African American/Black individuals in the health care system workforce can be traced to a history of exclusionary practices that leave such individuals less likely to pursue health careers. Past research found that low representation is driven by inequities in health, education, and employment that are a result of structural racism. Pathways programs have been identified as one of the methods to increase recruitment, retention, and promotion in health-related career fields for African American/Black individuals. As prior research has shown, these programs recruit and support the graduation of students from underrepresented communities at all educational stages to increase their representation in specific fields. This article describes the development of key factors in framework design for the Health System-Community Pathways Program (HCPP), which aims to increase representation of African American/Black communities in the health care system workforce and improve the quality of their experience in pursuing careers in these fields. The HCPP framework of key factors is informed by an environmental scan, interviews and focus groups, and an expert discussion panel session. The article's authors come from diverse backgrounds; the team included African American/Black physicians and members of other historically marginalized communities. The qualitative research drew insights from diverse African American/Black community stakeholders; the study was reviewed by many stakeholders to ensure that the design of the research and the end product maximally benefits the community on which it focuses.

Awareness of Peripheral Intravenous Catheters Among Nurses, Physicians, and Students.

OBJECTIVES: Peripheral intravenous catheters (PIVCs) are frequently used to meet patients' short-term health care needs. However, many PIVCs are not promptly removed at the completion of treatment, placing patients at risk of avoidable harm from serious complications including local and systemic infection. This study aims to report the proportion and accuracy of health care staff/students awareness of the presence of their patient's PIVC. METHODS: We asked staff/students to recall the presence or absence of a PIVC in a patient under their care, as well as details of the date of insertion and PIVC location. We recorded concordance of responses with direct observations. To achieve this, face-to-face interviews were conducted with clinical staff/students at 2 adult hospitals. RESULTS: Overall, 90% (n = 216) of staff responses (94% of nurses, 100% of nursing students, 76% of medical staff) correctly identified the presence/absence of a PIVC. Clinicians correctly identified the PIVC location 55% (n = 71) of the time. CONCLUSIONS: Health care services must recognize the implications of this lack of awareness and implement and evaluate tailored quality improvement efforts to address this.

Should they stay or should they go? Who benefits from interfacility transfer to a higher-level trauma center following initial presentation at a lower-level trauma center.

BACKGROUND: Interfacility transfer of patients from Level III/IV to Level I/II (tertiary) trauma centers has been associated with improved outcomes. However, little data are available classifying the specific subsets of patients that derive maximal benefit from transfer to a tertiary trauma center. Drawbacks to transfer include increased secondary overtriage. Here, we ask which injury patterns are associated with improved survival following interfacility transfer. METHODS: Data from the National Trauma Data Bank was utilized. Inclusion criteria were adults (≥16 years). Patients with Injury Severity Score of 10 or less or those who arrived with no signs of life were excluded. Patients were divided into two cohorts: those admitted to a Level III/IV trauma center versus those transferred into a tertiary trauma center. Multiple imputation was performed for missing values, and propensity scores were generated based on demographics, injury patterns, and disease severity. Using propensity score-stratified Cox proportional hazards regression, the hazard ratio for time to death was estimated. RESULTS: Twelve thousand five hundred thirty-four (5.2%) were admitted to Level III/IV trauma centers, and 227,315 (94.8%) were transferred to a tertiary trauma center. Patients transferred to a tertiary trauma center had reduced mortality (hazard ratio, 0.69; p < 0.001). We identified that patients with traumatic brain injury with Glasgow Coma Scale score less than 13, pelvic fracture, penetrating mechanism, solid organ injury, great vessel injury, respiratory distress, and tachycardia benefited from interfacility transfer to a tertiary trauma center. In this sample, 56.8% of the patients benefitted from transfer. Among those not transferred, 49.5% would have benefited from being transferred. CONCLUSION: Interfacility transfer is associated with a survival benefit for specific patients. These data support implementation of minimum evidence-based criteria for interfacility transfer. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.