Eran Bellin

Rates of and risk factors for Trichomoniasis among pregnant inmates in New York city

Background: Trichomonas vaginalis is a common pathogen that is associated with adverse pregnancy outcomes and may serve as a cofactor in human immunodeficiency virus (HIV) transmission. Goal: To define the epidemiology of trichomoniasis in a population of newly incarcerated pregnant women in New York City. Study Design: Prospective study of 213 pregnant prisoners attending prenatal clinic. Patients participated in an interview regarding sexual and drug‐related behaviors, and underwent direct culture for T. vaginalis in addition to routine testing for syphilis, gonorrhea, and chlamydia. Results: The prevalence of trichomoniasis was 46.9%. On univariate analysis, there was a significant association between trichomoniasis and older age, crack use, prostitution, known HIV infection, and positive serological test for syphilis. Multivariate analysis showed a significant association of trichomoniasis with crack use and positive serological test for syphilis. Conclusions: Trichomoniasis is highly prevalent in pregnant prisoners in New York City. The extent of disease observed may justify a formal program of testing and treatment and emphasizes the urgent need for harm reduction education and expanded HIV counseling and testing services in this high‐risk population.

Democratizing information creation from health care data for quality improvement, research, and education-the Montefiore Medical Center Experience.

The National Research Council recently reviewed the capabilities of health care software implemented in the United States and described a health care information technology chasm that is threatening the medical communitys ability to meet the health care quality goals enumerated in Institute of Medicine reports. Among the critical gaps is the inability of health care software systems to allow users to convert data into meaningful information supporting quality improvement, analysis, and research. In this article, the authors describe the Montefiore Medical Centers decade-long experience developing software for the purpose of converting data into useful information and integrating software use into the clinical culture. The program at Montefiore could serve as a potential national model.

Development of an electronic medical record-based algorithm to identify patients with unknown HIV status

Individuals with unknown HIV status are at risk for undiagnosed HIV, but practical and reliable methods for identifying these individuals have not been described. We developed an algorithm to identify patients with unknown HIV status using data from the electronic medical record (EMR) of a large health care system. We developed EMR-based criteria to classify patients as having known status (HIV-positive or HIV-negative) or unknown status and applied these criteria to all patients seen in the affiliated health care system from 2008 to 2012. Performance characteristics of the algorithm for identifying patients with unknown HIV status were calculated by comparing a random sample of the algorithms results to a reference standard medical record review. The algorithm classifies all patients as having either known or unknown HIV status. Its sensitivity and specificity for identifying patients with unknown status are 99.4% (95% CI: 96.5–100%) and 95.2% (95% CI: 83.8–99.4%), respectively, with positive and negative predictive values of 98.7% (95% CI: 95.5–99.8%) and 97.6% (95% CI: 87.1–99.1%), respectively. Using commonly available data from an EMR, our algorithm has high sensitivity and specificity for identifying patients with unknown HIV status. This algorithm may inform expanded HIV testing strategies aiming to test the untested.

Preliminary development of a clinical decision rule for acute aortic syndromes

OBJECTIVE Patients with suspected acute aortic syndromes (AAS) often undergo computed tomography (CT) with negative results. We sought clinical and diagnostic criteria to identify low-risk patients, an initial step in developing a clinical decision rule. METHODS We retrospectively identified all adults presenting to our emergency department (ED) from January 1, 2006, to August 1, 2010, who underwent CT angiography for suspected AAS without prior trauma or AAS. A total of 1465 patients met inclusion criteria; a retrospective case-controlled review (ratio 1:4) was conducted. Cases were diagnosed with aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, or ruptured aneurysm. RESULTS Of the patients who underwent CT, 2.7% (40/1465) had an AAS; 2 additional cases were diagnosed after admission (ED miss rate, 5% [2/42]). Patients with AAS were significantly older than controls (66 vs 59 years; P = .008). Risk factors included abnormal chest radiograph (sensitivity, 79% [26/33]; specificity, 82% [113/137]) and acute chest pain (sensitivity, 83% [29/35]; specificity, 71% [111/157]). None of the 19 patients with resolved pain upon ED presentation had AAS. These data support a 2-step rule: first screen for ongoing pain; if present, screen for acute chest pain or an abnormal chest radiograph. This approach achieves a 54% (84/155) reduction in CT usage with a sensitivity for AAS of 96% (95% confidence interval, 89%-100%), negative predictive value of 99.8% (99.4%-100%), and a false-negative rate of 1.7% (1/84). CONCLUSIONS Our results demonstrate a need to safely identify patients at low risk for AAS who can forgo CT. We developed a preliminary 2-step clinical decision rule, which requires validation.

A computerized reminder system improves compliance with Papanicolaou smear recommendations in an HIV care clinic.

Current guidelines call for Papanicolaou (Pap) smear screening of HIV-infected women at least annually. After the initiation of a weekly computer based Pap smear reminder list in an HIV care clinic, the prevalence of scheduled women with up-to-date Pap smears was calculated for the one-year project period and was compared to the prevalence preceding the project. The prevalence of scheduled women with up-to-date Pap smears increased from 61.4% to 73.2% (P <0.001) during the project period. Including Pap smears that were performed elsewhere, the final up-to-date Pap smear rate was 82.7%. The improved rate of up-to-date Pap smears showed no sign of attenuation over time. A computerized report generated from data in the hospital information system increased rates of compliance with Pap smear screening recommendations. Creative utilization of hospital data environments may be an inexpensive route to improved compliance with practice guidelines.

Tuberculosis in Correctional Facilities: The Tuberculosis Control Program of the Montefiore Medical Center Rikers Island Health Services

“Recognizing that prisons disproportionately confine sick people, with mental illness, substance abuse, HIV disease among other illnesses; and that prisoners are subject to further morbidity and mortality in these institutions, due to lack of access and/or resources for health care, overcrowding, violence, emotional deprivation, and suicide ....( APHA) condemns the social practice of mass imprisonment.’’

Is time-slice analysis superior to total hospital length of stay in demonstrating the effectiveness of a month-long intensive effort on a medicine service?

To control the upward spiral of healthcare costs, hospitals seek to implement efficiency interventions whose benefits are frequently assessed by reductions in average inpatient length of stay (LOS). However, average hospital LOS is a crude metric when trying to assess the utility of an intervention focussed on a particular service or over a specific time window. It cannot isolate the time or place of the intervention from the full duration of a patients hospital visit, which may include more than 1 hospital service or extend beyond the interventions time window. At Montefiore Medical Center, a new analytic method was used to describe a month-long effort to improve care efficiency in a hospital teaching service. Using an extension of the Cox proportional hazard model (S-plus), we were able to analyze the contribution of only those patient-days that took place during the time window of interest on the service of interest, eliminating the contamination of the “non intervention days.” Having built the appropriate model, we were then able to graph the behavior of the groups with and without the intervention and calculate the models expected average LOS, controlling for the appropriate variables. By comparing this method with a conventional average LOS analysis, we demonstrate the superiority of using this “time slice” method over the conventional analysis of LOS.

Ventricular Myocardial Fat: An Unexpected Biomarker for Long-term Survival?

PurposeTo examine the association between myocardial fat, a poorly understood finding frequently observed on non-contrast CT, and all-cause mortality in patients with and without a history of prior MI.Materials and methodsA retrospective cohort from a diverse urban academic center was derived from chronic myocardial infarction (MI) patients (n = 265) and three age-matched patients without MI (n = 690) who underwent non-contrast chest CT between 1 January 2005-31 December 2008. CT images were reviewed for left and right ventricular fat. Electronic records identified clinical variables. Kaplan-Meier and Cox proportional hazard analyses assessed the association between myocardial fat and all-cause mortality. The net reclassification improvement assessed the utility of adding myocardial fat to traditional risk prediction models.ResultsMortality was 40.1% for the no MI and 71.7% for the MI groups (median follow-up, 6.8 years; mean age, 73.7 ± 10.6 years). In the no MI group, 25.7% had LV and 49.9% RV fat. In the MI group, 32.8% had LV and 42.3% RV fat. LV and RV fat was highly associated (OR 5.3, p < 0.001). Ventricular fat was not associated with cardiovascular risk factors. Myocardial fat was associated with a reduction in the adjusted hazard of death for both the no MI (25%, p = 0.04) and the MI group (31%, p = 0.018). Myocardial fat resulted in the correct reclassification of 22% for the no MI group versus the Charlson score or calcium score (p = 0.004) and 47% for the MI group versus the Charlson score (p = 0.0006).ConclusionsPatients with myocardial fat have better survival, regardless of MI status, suggesting that myocardial fat is a beneficial biomarker and may improve risk stratification.Key Points• Myocardial fat is commonly found on chest CT, yet is poorly understood• Myocardial fat is associated with better survival in patients with and without prior MI and is not associated with traditional cardiovascular risk factors• This finding may provide clinically meaningful prognostic value in the risk stratification of patients

The pharmacoeconomic impact of antimicrobial therapy for peptic ulcer disease in a large urban jail

PurposeTo determine the pharmacoeconomic impact of antimicrobial treatment of peptic ulcer disease (PUD) in a large urban jail.Patients and MethodsRetrospective comparison of PUD-related pharmacy and laboratory expenditures over a 2-year period before and after the institution of a PUD treatment protocol with the priority ofHelicobacter pylori eradication for inmates in Rikers Island Correctional Facility.ResultsAfter the protocol was adopted, total pharmacy-related and laboratory-related expenses for PUD care decreased by 40.2%, and expenditures for ranitidine declined by 52.2%. There was an increase in spending for antimicrobial agents andH. pylori antibody testing, but this was insignificant compared to the savings generated by decreased ranitidine usage. Annual savings in our facility as a result of this intervention were

System and method for monitoring patient care

123,449.ConclusionsModern therapeutic strategies for PUD aimed at eradicatingH. pylori can result in significant savings in the institutional setting; these savings are largely attributable to the decreased usage of histamine-2 receptor antagonists.