Postoperative Outcomes Associated with the Timing of Surgery After SARS-CoV-2 Infection.

OBJECTIVE: Examine the association between prior SARS-CoV-2 infection, interval from infection to surgery, and adverse surgical outcomes. SUMMARY BACKGROUND DATA: Earlier series have reported worse outcomes for surgery after COVID-19 illness, and these findings have led to routinely deferring surgery seven weeks after infection. METHODS: We created a retrospective cohort of patients from US Veterans Health Administration facilities nationwide, April 2020-September 2022, undergoing surgical procedures. Primary outcomes were 90-day all-cause mortality and 30-day complications. Within surgical procedure groupings, SARS-CoV-2 infected and uninfected patients were matched in a 1:4 ratio. We categorized patients by two-week intervals from SARS-CoV-2 positive test to surgery. Hierarchical multilevel multivariable logistic regression models were used to estimate the association between infection to surgery interval versus no infection and primary endpoints. RESULTS: We identified 82,815 veterans undergoing eligible operations (33% general, 27% orthopedic, 13% urologic, 9% vascular), of whom 16,563 (20%) had laboratory confirmed SARS-CoV-2 infection prior to surgery. The multivariable models demonstrated an association between prior SARS-CoV-2 infection and increased 90-day mortality (odds ratio (OR) 1.42, 95% CI 1.08, 1.86) and complications (OR 1.32, 95% CI 1.11, 1.57) only for patients having surgery within 14 days of infection. ASA-stratified multivariable models showed that the associations between increased 90-day mortality (OR 1.40, 95% CI 1.12, 1.75) and complications (OR 1.73, 95% CI 1.34, 2.24) for patients having surgery within 14 days of infection were confined to those with ASA 4-5. CONCLUSIONS: In a contemporary surgical cohort, patients with prior SARS-CoV-2 infection only had increased post-operative mortality or complications when they had surgery within 14 days after positive test. These findings support revising timing recommendations between surgery and prior SARS-CoV-2 infection.

Characteristics Associated with Spirometry Guideline Adherence in VA Patients Hospitalized with Chronic Obstructive Pulmonary Disease.

BACKGROUND: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends at least annual spirometry for patients with chronic obstructive pulmonary disease (COPD). Since spirometry acquisition is variable in clinical practice, identifying characteristics associated with annual spirometry may inform strategies to improve care for patients with COPD. METHODS: We included veterans hospitalized for COPD at Veterans Health Administration (VHA) facilities from 10/2012 to 09/2015. Our primary outcome was spirometry within 1 year of COPD hospitalization. Patient demographics, health factors, and comorbidities as well as practice and geographic variables were identified using Corporate Data Warehouse; provider characteristics were obtained from the Survey of Healthcare Experiences of Patients. We used logistic regression with a random intercept to account for potential clustering within facilities. RESULTS: Spirometry was completed 1 year before or after hospitalization for 20,683/38,148 (54.2%) veterans across 114 facilities. Patients with spirometry were younger, (mean=67.2 years (standard deviation (SD)=9.3) vs. 69.4 (10.3)), more likely non-white (21.3% vs. 19.7%), and more likely to have comorbidities (p<0.0001 for asthma, depression, and post-traumatic stress disorder). Pulmonary clinic visit was most strongly associated with spirometry (odds ratio (OR)=3.14 [95% confidence interval 2.99-3.30]). There was no association for facility complexity. In a secondary analysis including provider-level data (3862 patients), results were largely unchanged. There was no association between primary care provider age, gender, or type (physician vs. advanced practice registered nurse vs. physician assistant) and spirometry. CONCLUSION: In a cohort of high-risk COPD patients, just over half completed spirometry within 1 year of hospitalization. Pulmonary clinic visit was most strongly associated with 1-year spirometry, though provider variables were not. Spirometry completion for high-risk COPD patients remains suboptimal and strategies to improve post-hospitalization care for patients not seen in pulmonary clinic should be developed to ensure guideline concordant care.

Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU.

Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.

Dexamethasone in hospitalised COVID-19 patients not on intensive respiratory support.

BACKGROUND: Dexamethasone decreases mortality in coronavirus disease 2019 (COVID-19) patients on intensive respiratory support (IRS) but is of uncertain benefit if less severely ill. We determined whether early (within 48 h) dexamethasone was associated with mortality in patients hospitalised with COVID-19 not on IRS. METHODS: We included patients admitted to US Veterans Affairs hospitals between 7 June 2020 and 31 May 2021 within 14 days after a positive test for severe acute respiratory syndrome coronavirus 2. Exclusions included recent prior corticosteroids and IRS within 48 h. We used inverse probability of treatment weighting (IPTW) to balance exposed and unexposed groups, and Cox proportional hazards models to determine 90-day all-cause mortality. RESULTS: Of 19 973 total patients (95% men, median age 71 years, 27% black), 15 404 (77%) were without IRS within 48 h. Of these, 3514 out of 9450 (34%) patients on no oxygen received dexamethasone and 1042 (11%) died; 4472 out of 5954 (75%) patients on low-flow nasal cannula (NC) only received dexamethasone and 857 (14%) died. In IPTW stratified models, patients on no oxygen who received dexamethasone experienced 76% increased risk for 90-day mortality (hazard ratio (HR) 1.76, 95% CI 1.47-2.12); there was no association with mortality among patients on NC only (HR 1.08, 95% CI 0.86-1.36). CONCLUSIONS: In patients hospitalised with COVID-19, early initiation of dexamethasone was common and was associated with no mortality benefit among those on no oxygen or NC only in the first 48 h; instead, we found evidence of potential harm. These real-world findings do not support the use of early dexamethasone in hospitalised COVID-19 patients without IRS.

Wellness and Coping of Physicians Who Worked in ICUs During the Pandemic: A Multicenter Cross-Sectional North American Survey.

OBJECTIVES: Few surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic. DESIGN: Cross-sectional survey using four validated instruments. SETTING: Sixty-two sites in Canada and the United States. SUBJECTS: Attending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures. CONCLUSIONS: Despite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness.

Evidence of Racial Disparities in the Lung Cancer Screening Process: a Systematic Review and Meta-Analysis.

BACKGROUND: Annual lung cancer screening (LCS) with low-dose chest computed tomography for high-risk individuals reduces lung cancer mortality, with greater reduction observed in Black participants in clinical trials. While racial disparities in lung cancer mortality exist, less is known about disparities in LCS participation. We conducted a systematic review to explore LCS participation in Black compared with White patients in the USA. METHODS: A systematic review was conducted through a search of published studies in MEDLINE, PubMed, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied-Health Literature Database, from database inception through October 2020. We included studies that examined rates of LCS participation and compared rates by race. Studies were pooled using random-effects meta-analysis. RESULTS: We screened 18,300 titles/abstracts; 229 studies were selected for full-text review, of which nine studies met inclusion criteria. Studies were categorized into 2 groups: studies that reported the screening rate among an LCS-eligible patient population, and studies that reported the screening rate among a patient population referred for LCS. Median LCS participation rates were 14.4% (range 1.7 to 62.6%) for eligible patient studies and 68.5% (range 62.6 to 88.8%) for referred patient studies. The meta-analyses showed screening rates were lower in the Black compared to White population among the LCS-eligible patient studies ([OR]=0.43, [95% CI: 0.25, 0.74]). However, screening rates were the same between Black and White patients in the referred patient studies (OR=0.94, [95% CI: 0.74, 1.19]). DISCUSSION: Black LCS-eligible patients are being screened at a lower rate than White patients but have similar rates of participation once referred. Differences in referrals by providers may contribute to the racial disparity in LCS participation. More studies are needed to identify barriers to LCS referral and develop interventions to increase provider awareness of the importance of LCS in Black patients. Trial Registry PROSPERO; No.: CRD42020214213; URL: http://www.crd.york.ac.uk/PROSPERO.

Embracing the Diversity of Latinx Communities to Promote Vaccinations.

While vaccine hesitancy is well documented in the literature among the Latinx community, little attention or effort is given to the nuances among the members of individual communities, such as country of origin, immigration status, generational status, primary language, race, age, sex, gender, or rural residence and how these complexities affect vaccine messaging and uptake. We have evidence that this heterogeneity causes differences in access to healthcare, attitudes towards vaccines, and degree of health disparities. In this review we will describe their impact on vaccination rates in the Latinx community, highlighting missed opportunities for public health outreach, and how targeted messaging could improve vaccine uptake.

Does pulmonary subspecialty referral from primary care affect the adherence to vaccination recommendations in COPD patients?

The importance of vaccinations for COPD patients has been previously described. However, there is still a gap between guideline recommendations and the implementation of preventive care delivery for these patients. Specially, the rise of SARS-CoV-2 pandemic has made the significance of vaccination adherence more critical to address. Our study showed that referral to pulmonary clinic is associated with increased odds of receiving influenza (OR = 1.97, [95% CI 1.07, 3.65]) and pneumococcal vaccinations (PCV13 OR = 3.55, [1.47, 8.54]; PPSV23 OR = 4.92, [1.51, 16.02]). These data suggest that partnerships between primary care physicians and pulmonologists can potentially improve the vaccination rates for patients with COPD.

Polypharmacy and frailty among persons with HIV.

Polypharmacy is associated with frailty in the general population, but little is known about polypharmacy among persons living with HIV (PLWH) on antiretroviral (ARV) therapy. We determined the association between polypharmacy and an adapted frailty-related phenotype (aFRP) via a cross-sectional study in FY 2009 of 1762 PLWH on ARV with suppressed viral load and 2679 uninfected participants in the Veterans Aging Cohort Study. The primary predictor was number of chronic outpatient non-ARV medications using pharmacy fill/refill data. The outcome was self-report of four aFRP domains: shrinking, exhaustion, slowness, low physical activity. Frailty was defined as reporting 3-4 domains while pre-frailty was 1-2. Frailty was uncommon (2% PLWH, 3% uninfected); a larger proportion demonstrated any aFRP domain (31% PLWH, 41% uninfected). Among PLWH and uninfected, median chronic non-ARV medications was 6 and 16 respectively if having any aFRP domain, and 4 and 10 when without aFRP domains. In adjusted analyses, each additional chronic non-ARV medication conferred an 11% increased odds of having any aFRP domain in PLWH (OR [95% CI] = 1.11 [1.08, 1.14]), and a 4% increase in those uninfected (OR [95% CI] = 1.04 [1.03, 1.04]). The stronger association between polypharmacy and frailty in PLWH warrants further study and potential deprescribing of medications.

Development and validation of case-finding algorithms to identify prosthetic joint infections after total knee arthroplasty in Veterans Health Administration data.

PURPOSE: To determine the positive predictive values (PPVs) of ICD-9, ICD-10, and current procedural terminology (CPT)-based diagnostic coding algorithms to identify prosthetic joint infection (PJI) following knee arthroplasty (TKA) within the United States Veterans Health Administration. METHODS: We identified patients with: (1) hospital discharge ICD-9 or ICD-10 diagnosis of PJI, (2) ICD-9, ICD-10, or CPT procedure code for TKA prior to PJI diagnosis, (3) CPT code for knee X-ray within ±90 days of the PJI diagnosis, and (4) at least 1 CPT code for arthrocentesis, arthrotomy, blood culture, or microbiologic procedure within ±90 days of the PJI diagnosis date. Separate samples of patients identified with the ICD-9 and ICD-10-based PJI diagnoses were obtained, stratified by TKA procedure volume at each medical center. Medical records of sampled patients were reviewed by infectious disease clinicians to adjudicate PJI events. The PPV (95% confidence interval [CI]) for the ICD-9 and ICD-10 PJI algorithms were calculated. RESULTS: Among a sample of 80 patients meeting the ICD-9 PJI algorithm, 60 (PPV 75.0%, [CI 64.1%-84.0%]) had confirmed PJI. Among 80 patients who met the ICD-10 PJI algorithm, 68 (PPV 85.0%, [CI 75.3%-92.0%]) had a confirmed diagnosis. CONCLUSIONS: An algorithm consisting of an ICD-9 or ICD-10 PJI diagnosis following a TKA code combined with CPT codes for a knee X-ray and either a relevant surgical procedure or microbiologic culture yielded a PPV of 75.0% (ICD-9) and 85.0% (ICD-10), for confirmed PJI events and could be considered for use in future pharmacoepidemiologic studies.

COVID-19 Healthcare Inequity: Lessons Learned from Annual Influenza Vaccination Rates to Mitigate COVID-19 Vaccine Disparities.

The COVID-19 pandemic has infected 33 million Americans and resulted in more than 600,000 deaths as of late Spring 2021. Black, Indigenous, and Latinx (BIL) people are disproportionately infected, hospitalized, and dying. Effective vaccines were rapidly developed and have been widely available in the United States since their initial rollout in late 2020-early 2021 but vaccination rates in BIL communities have remained low compared with non-BIL communities. Limited access to the vaccine, lack of customized information, and mistrust of the medical system, all contribute to vaccine hesitancy and low vaccination rates. Regrettably, COVID-19 is not the only vaccine-preventable illness with racial/ethnic inequities. Similar inequities are seen with the seasonal influenza vaccine. We review the racial/ethnic health disparities in COVID-19 illness and vaccination rates and what inequities contribute to these disparities. We use evidence from the seasonal influenza vaccination efforts to inform potential strategies to attenuate these inequities. The development of effective and sustainable strategies to improve vaccination rates and reduce factors that result in health inequities is essential in managing current and future pandemics and promoting improved health for all communities.

Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study.

BACKGROUND: There is growing concern that racial and ethnic minority communities around the world are experiencing a disproportionate burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19). We investigated racial and ethnic disparities in patterns of COVID-19 testing (i.e., who received testing and who tested positive) and subsequent mortality in the largest integrated healthcare system in the United States. METHODS AND FINDINGS: This retrospective cohort study included 5,834,543 individuals receiving care in the US Department of Veterans Affairs; most (91%) were men, 74% were non-Hispanic White (White), 19% were non-Hispanic Black (Black), and 7% were Hispanic. We evaluated associations between race/ethnicity and receipt of COVID-19 testing, a positive test result, and 30-day mortality, with multivariable adjustment for a wide range of demographic and clinical characteristics including comorbid conditions, health behaviors, medication history, site of care, and urban versus rural residence. Between February 8 and July 22, 2020, 254,595 individuals were tested for COVID-19, of whom 16,317 tested positive and 1,057 died. Black individuals were more likely to be tested (rate per 1,000 individuals: 60.0, 95% CI 59.6-60.5) than Hispanic (52.7, 95% CI 52.1-53.4) and White individuals (38.6, 95% CI 38.4-38.7). While individuals from minority backgrounds were more likely to test positive (Black versus White: odds ratio [OR] 1.93, 95% CI 1.85-2.01, p < 0.001; Hispanic versus White: OR 1.84, 95% CI 1.74-1.94, p < 0.001), 30-day mortality did not differ by race/ethnicity (Black versus White: OR 0.97, 95% CI 0.80-1.17, p = 0.74; Hispanic versus White: OR 0.99, 95% CI 0.73-1.34, p = 0.94). The disparity between Black and White individuals in testing positive for COVID-19 was stronger in the Midwest (OR 2.66, 95% CI 2.41-2.95, p < 0.001) than the West (OR 1.24, 95% CI 1.11-1.39, p < 0.001). The disparity in testing positive for COVID-19 between Hispanic and White individuals was consistent across region, calendar time, and outbreak pattern. Study limitations include underrepresentation of women and a lack of detailed information on social determinants of health. CONCLUSIONS: In this nationwide study, we found that Black and Hispanic individuals are experiencing an excess burden of SARS-CoV-2 infection not entirely explained by underlying medical conditions or where they live or receive care. There is an urgent need to proactively tailor strategies to contain and prevent further outbreaks in racial and ethnic minority communities.

Underutilization of Pulmonary Function Testing in Veterans Hospitalized for Chronic Obstructive Pulmonary Disease Exacerbation: Who are We Missing?

Pulmonary function testing (PFT) is required to diagnose chronic obstructive pulmonary disease (COPD) but is completed for only 30-50% of patients with the disease. We determined patient factors associated with decreased likelihood for PFT acquisition (i.e. underutilization) in the United States Veterans Affairs (VA) health care system.We performed a retrospective analysis of Veterans who survived a VA-based COPD hospitalization between 2012 and 2015. COPD was identified using International Classification of Disease (ICD)-9 codes. Our primary outcome was PFT acquisition, using Current Procedural Terminology (CPT) codes any time prior to the index hospitalization. We compared patients with and without PFTs and used logistic regression to identify associations with PFT underutilization.Of the 48,888 Veterans included, 78% underwent PFTs prior to hospitalization. Patients without PFTs were younger and more likely to be: women (4.2% vs. 3.6%; p = 0.01), nonwhite (22% vs. 19%; p < 0.0001), and current smokers (66% vs 61%; p < 0.0001). PFT acquisition was less likely in Veterans with alcohol and drug use disorders. Using logistic regression, Veterans who were women (Odds Ratio (OR) = 1.17 [95% confidence limit 1.03-1.32]), nonwhite (OR 1.12 [1.06-1.20]), and with a history of alcohol (OR = 1.07 [1.00-1.14]) or drug use disorders (OR = 1.15 [1.06-1.24]) were less likely to undergo PFTs.Though most Veterans hospitalized for COPD had PFTs prior to admission, PFTs are underutilized in Veterans who are: women, younger, nonwhite, and have alcohol or drug use disorders. These groups may be "at-risk" for delayed diagnosis or substandard COPD quality care.

Accuracy of electronic health record data for the diagnosis of chronic obstructive pulmonary disease in persons living with HIV and uninfected persons.

PURPOSE: No prior studies have addressed the performance of electronic health record (EHR) data to diagnose chronic obstructive pulmonary disease (COPD) in people living with HIV (PLWH), in whom COPD could be more likely to be underdiagnosed or misdiagnosed, given the higher frequency of respiratory symptoms and smoking compared with HIV-uninfected (uninfected) persons. METHODS: We determined whether EHR data could improve accuracy of ICD-9 codes to define COPD when compared with spirometry in PLWH vs uninfected, and quantified level of discrimination using the area under the receiver-operating curve (AUC). The development cohort consisted of 350 participants who completed research spirometry in the Examinations of HIV Associated Lung Emphysema (EXHALE) study, a pulmonary substudy of the Veterans Aging Cohort Study. Results were externally validated in 294 PLWH who performed spirometry for clinical indications from the University of Washington (UW) site of the Centers for AIDS Research Network of Integrated Clinical Systems cohort. RESULTS: ICD-9 codes performed similarly by HIV status, but alone were poor at discriminating cases from non-cases of COPD when compared with spirometry (AUC 0.633 in EXHALE; 0.651 in the UW cohort). However, algorithms that combined ICD-9 codes with other clinical variables available in the EHR-age, smoking, and COPD inhalers-improved discrimination and performed similarly in EXHALE (AUC 0.771) and UW (AUC 0.734). CONCLUSIONS: These data support that EHR data in combination with ICD-9 codes have moderately good accuracy to identify COPD when spirometry data are not available, and perform similarly in PLWH and uninfected individuals.

Increased Echocardiographic Pulmonary Pressure in HIV-infected and -uninfected Individuals in the Veterans Aging Cohort Study.

RATIONALE: The epidemiology and prognostic impact of increased pulmonary pressure among HIV-infected individuals in the antiretroviral therapy era is not well described. OBJECTIVES: To examine the prevalence, clinical features, and outcomes of increased echocardiographic pulmonary pressure in HIV-infected and -uninfected individuals. METHODS: This study evaluated 8,296 veterans referred for echocardiography with reported pulmonary artery systolic pressure (PASP) estimates from the Veterans Aging Cohort study, an observational cohort of HIV-infected and -uninfected veterans matched by age, sex, race/ethnicity, and clinical site. The primary outcome was adjusted mortality by HIV status. MEASUREMENTS AND MAIN RESULTS: PASP was reported in 2,831 HIV-infected and 5,465 HIV-uninfected veterans (follow-up [mean ± SD], 3.8 ± 2.6 yr). As compared with uninfected veterans, HIV-infected veterans with HIV viral load greater than 500 copies/ml (odds ratio, 1.27; 95% confidence interval [CI], 1.05-1.54) and those with CD4 cell count less than 200 cells/µl (odds ratio, 1.28; 95% CI, 1.02-1.60) had a higher prevalence of PASP greater than or equal to 40 mm Hg. As compared with uninfected veterans with a PASP less than 40 mm Hg, HIV-infected veterans with a PASP greater than or equal to 40 mm Hg had an increased risk of death (adjusted hazard ratio, 1.78; 95% CI, 1.57-2.01). This risk persisted even among participants without prevalent comorbidities (adjusted hazard ratio, 3.61; 95% CI, 2.17-6.01). The adjusted risk of mortality in HIV-infected veterans was higher at all PASP values than in uninfected veterans, including at values currently considered to be normal. CONCLUSIONS: HIV-infected people with high HIV viral loads or low CD4 cell counts have a higher prevalence of increased PASP than uninfected people. Mortality risk in HIV-infected veterans increases at lower values of PASP than previously recognized and is present even among those without prevalent comorbidities. These findings may inform clinical decision-making regarding screening and surveillance of pulmonary hypertension in HIV-infected individuals.

Dedicated Afternoon Rounds for ICU Patients' Families and Family Satisfaction With Care.

OBJECTIVE: It was hypothesized that adding dedicated afternoon rounds for patients' families to supplement standard family support would improve overall family satisfaction with care in a neuroscience ICU. DESIGN: Pre- and postimplementation (pre-I and post-I) design. SETTING: Single academic neuroscience ICU. PATIENTS: Patients in the neuroscience ICU admitted for longer than 72 hours or made comfort measures only at any point during neuroscience ICU admission. INTERVENTION: The on-service attending intensivist and a neuroscience ICU nursing leader made bedside visits to families to address concerns during regularly scheduled, advertised times two afternoons each week. MEASUREMENTS AND MAIN RESULTS: One family member per patient during the pre-I and post-I periods was recruited to complete the Family Satisfaction in the ICU 24 instrument. Post-I respondents indicated whether they had participated in the afternoon rounds. For primary outcome, the mean pre-I and post-I composite Family Satisfaction in the ICU 24 scores (on a 100-point scale) were compared. A total of 146 pre-I (March 2013 to October 2014; capture rate, 51.6%) and 141 post-I surveys (October 2014 to December 2015; 47.2%) were collected. There was no difference in mean Family Satisfaction in the ICU 24 score between groups (pre-I, 89.2 ± 11.2; post-I, 87.4 ± 14.2; p = 0.6). In a secondary analysis, there was also no difference in mean Family Satisfaction in the ICU 24 score between the pre-I respondents and the 39.0% of post-I respondents who participated in family rounds. The mean Family Satisfaction in the ICU 24 score of the post-I respondents who reported no participation trended lower than the mean pre-I score, with fewer respondents in this group reporting complete satisfaction with emotional support (75% vs. 54%; p = 0.002), coordination of care (82% vs. 68%; p = 0.03), and frequency of communication by physicians (60% vs. 43%; p = 0.03). CONCLUSIONS: Dedicated afternoon rounds for families twice a week may not necessarily improve an ICU's overall family satisfaction. Increased dissatisfaction among families who do not or cannot participate is possible.

Minority Men Who Have Sex with Men Demonstrate Increased Risk for HIV Transmission.

Black and Hispanic (minority) MSM have a higher incidence of HIV than white MSM. Multiple sexual partners, being under the influence of drugs and/or alcohol during sex, having a detectable HIV-1 RNA, and non-condom use are factors associated with HIV transmission. Using data from the Veterans Aging Cohort Study, we consider minority status and sexual orientation jointly to characterize and compare these factors. White non-MSM had the lowest prevalence of these factors (p < 0.001) and were used as the comparator group in calculating odds ratios (OR). Both MSM groups were more likely to report multiple sex partners (white MSM OR 7.50; 95 % CI 5.26, 10.71; minority MSM OR 10.24; 95 % CI 7.44, 14.08), and more likely to be under the influence during sex (white MSM OR 2.15; 95 % CI 1.49, 3.11; minority MSM OR 2.94; 95 % CI 2.16, 4.01). Only minority MSM were more likely to have detectable HIV-1 RNA (OR 1.87; 95 % CI 1.12, 3.11). Both MSM groups were more likely to use condoms than white non-MSM. These analyses suggest that tailored interventions to prevent HIV transmission among minority MSM are needed, with awareness of the potential co-occurrence of risk factors.

Alcohol-Related Diagnoses and All-Cause Hospitalization Among HIV-Infected and Uninfected Patients: A Longitudinal Analysis of United States Veterans from 1997 to 2011.

Individuals with HIV infection are living substantially longer on antiretroviral therapy, but hospitalization rates continue to be relatively high. We do not know how overall or diagnosis-specific hospitalization rates compare between HIV-infected and uninfected individuals or what conditions may drive hospitalization trends. Hospitalization rates among United States Veterans were calculated and stratified by HIV serostatus and principal diagnosis disease category. Because alcohol-related diagnoses (ARD) appeared to have a disproportional effect, we further stratified our calculations by ARD history. A multivariable Cox proportional hazards model was fitted to assess the relative risk of hospitalization controlling for demographic and other comorbidity variables. From 1997 to 2011, 46,428 HIV-infected and 93,997 uninfected patients were followed for 1,497,536 person-years. Overall hospitalization rates decreased among HIV-infected and uninfected patients. However, cardiovascular and renal insufficiency admissions increased for all groups while gastrointestinal and liver, endocrine, neurologic, and non-AIDS cancer admissions increased among those with an alcohol-related diagnosis. After multivariable adjustment, HIV-infected individuals with an ARD had the highest risk of hospitalization (hazard ratio 3.24, 95 % CI 3.00, 3.49) compared to those free of HIV infection and without an ARD. Still, HIV alone also conferred increased risk (HR 2.08, 95 % CI 2.04, 2.13). While decreasing overall, risk of all-cause hospitalization remains higher among HIV-infected than uninfected individuals and is strongly influenced by the presence of an ARD.