Moira McNulty

Development of a Conceptual Framework for Understanding Shared Decision making Among African-American LGBT Patients and their Clinicians

ABSTRACTBACKGROUNDEnhancing patient-centered care and shared decision making (SDM) has become a national priority as a means of engaging patients in their care, improving treatment adherence, and enhancing health outcomes. Relatively little is known about the healthcare experiences or shared decision making among racial/ethnic minorities who also identify as being LGBT. The purpose of this paper is to understand how race, sexual orientation and gender identity can simultaneously influence SDM among African-American LGBT persons, and to propose a model of SDM between such patients and their healthcare providers.METHODSWe reviewed key constructs necessary for understanding SDM among African-American LGBT persons, which guided our systematic literature review. Eligible studies for the review included English-language studies of adults (≥ 19 y/o) in North America, with a focus on LGBT persons who were African-American/black (i.e., > 50 % of the study population) or included sub-analyses by sexual orientation/gender identity and race. We searched PubMed, CINAHL, ProQuest Dissertations & Theses, PsycINFO, and Scopus databases using MESH terms and keywords related to shared decision making, communication quality (e.g., trust, bias), African-Americans, and LGBT persons. Additional references were identified by manual reviews of peer-reviewed journals’ tables of contents and key papers’ references.RESULTSWe identified 2298 abstracts, three of which met the inclusion criteria. Of the included studies, one was cross-sectional and two were qualitative; one study involved transgender women (91 % minorities, 65 % of whom were African-Americans), and two involved African-American men who have sex with men (MSM). All of the studies focused on HIV infection. Sexual orientation and gender identity were patient-reported factors that negatively impacted patient/provider relationships and SDM. Engaging in SDM helped some patients overcome normative beliefs about clinical encounters. In this paper, we present a conceptual model for understanding SDM in African-American LGBT persons, wherein multiple systems of social stratification (e.g., race, gender, sexual orientation) influence patient and provider perceptions, behaviors, and shared decision making.DISCUSSIONFew studies exist that explore SDM among African-American LGBT persons, and no interventions were identified in our systematic review. Thus, we are unable to draw conclusions about the effect size of SDM among this population on health outcomes. Qualitative work suggests that race, sexual orientation and gender work collectively to enhance perceptions of discrimination and decrease SDM among African-American LGBT persons. More research is needed to obtain a comprehensive understanding of shared decision making and subsequent health outcomes among African-Americans along the entire spectrum of gender and sexual orientation.

Severe influenza in 33 US hospitals, 2013–2014: Complications and risk factors for death in 507 patients

BACKGROUND Influenza A (H1N1) pdm09 became the predominant circulating strain in the United States during the 2013-2014 influenza season. Little is known about the epidemiology of severe influenza during this season. METHODS A retrospective cohort study of severely ill patients with influenza infection in intensive care units in 33 US hospitals from September 1, 2013, through April 1, 2014, was conducted to determine risk factors for mortality present on intensive care unit admission and to describe patient characteristics, spectrum of disease, management, and outcomes. RESULTS A total of 444 adults and 63 children were admitted to an intensive care unit in a study hospital; 93 adults (20.9%) and 4 children (6.3%) died. By logistic regression analysis, the following factors were significantly associated with mortality among adult patients: older age (>65 years, odds ratio, 3.1 [95% CI, 1.4-6.9], P=.006 and 50-64 years, 2.5 [1.3-4.9], P=.007; reference age 18-49 years), male sex (1.9 [1.1-3.3], P=.031), history of malignant tumor with chemotherapy administered within the prior 6 months (12.1 [3.9-37.0], P<.001), and a higher Sequential Organ Failure Assessment score (for each increase by 1 in score, 1.3 [1.2-1.4], P<.001). CONCLUSION Risk factors for death among US patients with severe influenza during the 2013-2014 season, when influenza A (H1N1) pdm09 was the predominant circulating strain type, shifted in the first postpandemic season in which it predominated toward those of a more typical epidemic influenza season.

Bacterial and viral co-infections complicating severe influenza: Incidence and impact among 507 U.S. patients, 2013–14

Abstract Background Influenza acts synergistically with bacterial co-pathogens. Few studies have described co-infection in a large cohort with severe influenza infection. Objectives To describe the spectrum and clinical impact of co-infections. Study design Retrospective cohort study of patients with severe influenza infection from September 2013 through April 2014 in intensive care units at 33 U.S. hospitals comparing characteristics of cases with and without co-infection in bivariable and multivariable analysis. Results Of 507 adult and pediatric patients, 114 (22.5%) developed bacterial co-infection and 23 (4.5%) developed viral co-infection. Staphylococcus aureus was the most common cause of co-infection, isolated in 47 (9.3%) patients. Characteristics independently associated with the development of bacterial co-infection of adult patients in a logistic regression model included the absence of cardiovascular disease (OR 0.41 [0.23–0.73], p=0.003), leukocytosis (>11K/μl, OR 3.7 [2.2–6.2], p<0.001; reference: normal WBC 3.5–11K/μl) at ICU admission and a higher ICU admission SOFA score (for each increase by 1 in SOFA score, OR 1.1 [1.0–1.2], p=0.001). Bacterial co-infections (OR 2.2 [1.4–3.6], p=0.001) and viral co-infections (OR 3.1 [1.3–7.4], p=0.010) were both associated with death in bivariable analysis. Patients with a bacterial co-infection had a longer hospital stay, a longer ICU stay and were likely to have had a greater delay in the initiation of antiviral administration than patients without co-infection (p<0.05) in bivariable analysis. Conclusions Bacterial co-infections were common, resulted in delay of antiviral therapy and were associated with increased resource allocation and higher mortality.

Changing depot medroxyprogesterone acetate access at a faith-based institution

BACKGROUND Loyola University Medical Center is a Jesuit faith-based hospital that previously offered immediate postpartum depot medroxyprogesterone acetate (DMPA) for noncontraceptive indications. STUDY DESIGN We performed a historical cohort study comparing patients aged 25 years or less who received immediate postpartum DMPA versus women who did not. We used logistic regression to analyze associations between patient characteristics and repeat pregnancy within 1 year. RESULTS There was a total of 258 women in our cohort: 105 (40.70%) exposed to DMPA. Majorities were non-Caucasian, unmarried, Catholic and received public insurance. Multivariable analysis, after adjusting for race and religion, shows a statistically significant decrease in repeat pregnancy for patients given immediate postpartum DMPA (OR 0.27, 95% CI 0.10-0.72). CONCLUSION Limits on access to DMPA for noncontraceptive indications during the postpartum period resulted in significant increases in pregnancy rates for adolescents and young adult women at this faith-based institution.

PrEP guidelines have low sensitivity for identifying seroconverters in a sample of Young Black men who have sex with men in Chicago

Background: Identification of clients at greatest risk of acquiring HIV is critical for preexposure prophylaxi (PrEP) implementation. Young black MSM (YBMSM) have high incidence of HIV. We examined published guidelines in identifying eligible PrEP candidates, including seroconverters, in a representative cohort of YBMSM. Methods: The uConnect cohort included YBMSM aged 16–29 years during PrEP roll-out in Chicago from 2013 and 2016. YBMSM with indications for PrEP were determined using Center for Disease Control and Prevention (CDC) guidelines, the HIV incidence risk index for MSM (HIRI-MSM) scoring tool, and Gilead recommendations with calculation of sensitivities, specificities, and area under the curve (AUC) for HIV seroconversion over 18 months. Incidence rate ratios (IRRs) using Poisson regression were modeled to compare individual and network factors associated with seroconversion. Results: In the study cohort, 300 HIV uninfected YBMSM contributed 390.4 person-years of follow-up [mean age (SD), 22.3 years (3.07)]. HIV incidence was 8.5 cases per 100 person-years (95% confidence interval, 6.0–11.9). One network factor was associated with seroconversion: having partners more than 10 years older (IRR = 4.4, 95% confidence interval, 1.6–11.8). Overall, 49% of the cohort had an indication for PrEP using CDC guidelines; 72% using HIRI-MSM, and 86% using Gilead recommendations. HIV seroconverters (n = 33) were identified as PrEP eligible prior to seroconversion with sensitivities/AUCs for CDC (52%/0.51), HIRI-MSM (85%/0.57), and Gilead guidelines (94%/0.54). Conclusion: Low sensitivity of CDC guidelines and limited AUC of HIRI-MSM and Gilead screening tools are of concern for PrEP implementation among most at risk populations such as YBMSM. Consideration of demographics, local epidemiology, and network factors may better guide identification of clients who could benefit most from PrEP.

Elderly Man with Fever and Cough: TB or Not TB?

An 81-year-old man with a history of hypertension, type 2 diabetes mellitus, hyperlipidemia, and psoriasis presented for admission to the hospital with productive cough, subjective fevers, chills, and malaise for 5 days. He had been treated for a similar episode approximately 10 months prior. At that time he was diagnosed with pneumonia, and he was prescribed azithromycin. While his symptoms subsequently improved, he was noted to have wheezing during the previous several months. The patient reported that he had been diagnosed with tuberculosis in his teens, treated only with home remedies. He denied weight loss, night sweats, sore throat, abdominal pain, nausea, vomiting, or diarrhea. He had chronic, mild, bilateral lower extremity edema.

Student with Fever and Rash

A previously healthy 23-year-old man presented with 3 days of fever, chills, and headache. He was studying in the Midwestern United States, but he had recently traveled to a southern state for the winter holiday, where his family lived. He returned to school 1 week prior to presentation. He complained of a poor appetite and fatigue, reporting that he was sleeping most of the afternoons and evening. He noticed a new erythematous rash on his trunk and face 1 day prior to presentation.

An HIV Patient with Nausea, Vomiting, and Hiccups

A 38-year-old man with a history of human immunodeficiency virus infection presented with 1 month of nausea, vomiting, and hiccups that had worsened over the past day. He had a single episode of fever prior to admission and noted a dry cough. He had a 20-pound weight loss during the previous month. He had no recent sick contacts, and he did not recently travel out of the country. He had been admitted 10 days before to a different hospital with the same complaints. There, he was diagnosed with right lower lobe pneumonia and treated with levofloxacin.

Gender Differences in HIV Testing, Diagnosis, and Linkage to Care in Healthcare Settings: Identifying African American Women with HIV in Chicago

Women account for 25% of all people living with HIV and 19% of new diagnoses in the United States. African American (AA) women are disproportionately affected. Yet, differences in the care continuum entry are not well understood between patient populations and healthcare sites. We aim to examine gender differences in diagnosis and linkage to care (LTC) in the Expanded HIV Testing and Linkage to Care (X-TLC) program within healthcare settings. Data were collected from 14 sites on the South and West sides of Chicago. Multivariate logistic regression analysis was used to determine the differences in HIV diagnoses and LTC by gender and HIV status. From 2011 to 2016, X-TLC performed 281,017 HIV tests; 63.7% of those tested were women. Overall HIV seroprevalence was 0.57%, and nearly one third (29.4%) of HIV-positive patients identified were cisgender women. Of newly diagnosed HIV-positive women, 89% were AA. 58.5% of new diagnoses in women were made at acute care hospitals, with the remainder at community health centers. Women who were newly diagnosed had a higher baseline CD4 count at diagnosis compared with men. Overall, women had lower odds of LTC compared with men (adjusted odds ratio = 0.58, 95% confidence interval 0.44-0.78) when controlling for patient demographics and newly versus previously diagnosed HIV status. Thus, interventions that focus on optimizing entry into the care continuum for AA women need to be explored.

USA300 MRSA lineages persist on multiple body sites following infection

Abstract BACKGROUND USA300 methicillin-resistant Staphylococcus aureus (MRSA) is a community- and hospital- acquired pathogen that frequently causes infections but also can survive on the human body asymptomatically as a part of the normal flora. We devised a comparative genomic strategy to track colonizing USA300 at different body sites after S. aureus infection. METHODS We sampled ST8 S. aureus from subjects at the site of a first known MRSA infection. Within 60 days of this infection and again 12 months later, each subject was tested for asymptomatic colonization in the nose, throat and perirectal region. 93 S. aureus strains underwent whole genome shotgun sequencing. RESULTS Genome sequencing revealed that 23 patients carried USA300 intra-subject lineages (ISLs), defined as having an index infection isolate (III) and closely related strains. Pairwise distance between strains in different ISLs was 48 to 162 single nucleotide polymorphisms (SNPs), whereas within the same ISL it was 0 to 26 SNPs. At the initial sampling time among 23 subjects, we isolated S. aureus from the nose, throat and perirectal sites from 15, 11 and 15 of them, respectively. Twelve months later we isolated S. aureus within the same ISL from 9 subjects, with 6, 3 and 3 strains from the nose, throat and perirectal area, respectively. The median time from initial acquisition of the S. aureus USA300 strains to culture of the index infection was estimated at 18 weeks. Strains in ISLs from the same subject differed in plasmid and prophage content, and contained deletions that removed the mecA-containing SCCmec and ACME regions. Five strains contained frameshift mutations in agr toxin-regulating genes. Persistence of an ISL was not associated with clinical or demographic subject characteristics. CONCLUSION Clonal lineages of USA300 may continue to colonize people at one or more anatomic sites up to a year after an initial infection and experience loss of the SCCmec, loss and gain of other mobile genetic elements, and mutations in the agr operon.