Trevor Jensen

Syphilis in the United States: An Update for Clinicians With an Emphasis on HIV Coinfection

Diagnosis and treatment of syphilis are challenging because of its variable clinical presentation and course and the lack of definitive tests of cure after treatment. This review of the most recent literature on the epidemiology, clinical manifestations, current diagnosis, and treatment of syphilis is focused toward clinicians who treat patients with this disease. Syphilis coinfection with human immunodeficiency virus is emphasized because it is increasingly common in the United States and affects the initial presentation, disease course, diagnosis, and treatment of syphilis. Of particular consequence is the effect of human immunodeficiency virus on the clinical diagnosis, prevalence, and course of neurosyphilis, one of the most serious consequences of syphilis infection.

Surveillance for Malaria Elimination in Swaziland: A National Cross-Sectional Study Using Pooled PCR and Serology

Background To guide malaria elimination efforts in Swaziland and other countries, accurate assessments of transmission are critical. Pooled-PCR has potential to efficiently improve sensitivity to detect infections; serology may clarify temporal and spatial trends in exposure. Methodology/Principal Findings Using a stratified two-stage cluster, cross-sectional design, subjects were recruited from the malaria endemic region of Swaziland. Blood was collected for rapid diagnostic testing (RDT), pooled PCR, and ELISA detecting antibodies to Plasmodium falciparum surface antigens. Of 4330 participants tested, three were RDT-positive yet false positives by PCR. Pooled PCR led to the identification of one P. falciparum and one P. malariae infection among RDT-negative participants. The P. falciparum-infected participant reported recent travel to Mozambique. Compared to performing individual testing on thousands of samples, PCR pooling reduced labor and consumable costs by 95.5%. Seropositivity was associated with age ≥20 years (11·7% vs 1·9%, P<0.001), recent travel to Mozambique (OR 4.4 [95% CI 1.0–19.0]) and residence in southeast Swaziland (RR 3.78, P<0.001). Conclusions The prevalence of malaria infection and recent exposure in Swaziland are extremely low, suggesting elimination is feasible. Future efforts should address imported malaria and target remaining foci of transmission. Pooled PCR and ELISA are valuable surveillance tools for guiding elimination efforts.

Use of the slide positivity rate to estimate changes in malaria incidence in a cohort of Ugandan children

BackgroundAs malaria control efforts intensify, it is critical to monitor trends in disease burden and measure the impact of interventions. A key surveillance indicator is the incidence of malaria. Yet measurement of incidence is challenging. The slide positivity rate (SPR) has been used as a surrogate measure of malaria incidence, but limited data exist on the relationship between SPR and the incidence of malaria.MethodsA cohort of 690 children aged 1-10 years at enrollment were followed for all their health care needs over a four-year period in Kampala, Uganda. All children with fever underwent laboratory testing, allowing us to measure the incidence of malaria and non-malaria fevers. A formula was derived to estimate relative changes in the incidence of malaria (rΔIm) based on changes in the SPR and the assumption that the incidence of non-malaria fevers was consistent over time. Observed and estimated values of rΔIm were compared over two, six, and 12 month time intervals after restricting the analysis to children contributing observation time between the ages of 4-10 years to control for aging of the cohort.ResultsOver the four-year observation period the incidence of malaria declined significantly from 0.93 episodes per person-year in 2005 to 0.39 episodes per person-year in 2008 (p < 0.0001) and the incidence of non-malaria fevers declined significantly from 2.31 episodes per person-year in 2005 to 1.31 episodes per person-year in 2008 (p < 0.0001). Younger age was associated with a significantly greater incidence of malaria and the incidence of malaria was significantly higher during seasonal peaks occurring each January-February and May-June. Changes in SPR produced reasonably accurate estimates of rΔIm over all time intervals. The average absolute difference in observed and estimated values of rΔIm was lower for six-month intervals (0.13) than it was for two-month (0.21) or 12 month intervals (0.21).ConclusionChanges in SPR provided a useful estimate of changes in the incidence of malaria in a well defined cohort; however, a gradual decline in the incidence of non-malaria fevers introduced some bias in these estimates.

HIV infection is not associated with echocardiographic signs of cardiomyopathy or pulmonary hypertension among pregnant Ugandan women

Human Immunodeficiency Virus (HIV) infection is a well-recognized cause of cardiomyopathy and pulmonary hypertension. HIV causes both systolic and diastolic dysfunction(1, 2); more commonly in late stage AIDS, but also in patients with higher CD4 counts(3). However, little is known about the cardiac function of HIV-infected pregnant women. Peripartum cardiomyopathy (PPCM) is defined as the new onset of heart failure from left-ventricular systolic dysfunction during the last month of pregnancy or within five months after delivery in the absence of any identifiable cause or pre-existing cardiac disease(4). PPCM is more common in sub-Saharan Africa compared to the United States(5). Whether HIV-infection is a risk factor for PPCM which may partly explain this higher prevalence is not known.

Exploring Physician Perspectives of Residency Holdover Handoffs: A Qualitative Study to Understand an Increasingly Important Type of Handoff

BackgroundThe term “holdover admissions” refers to patients admitted by an overnight physician and whose care is then transferred to a new primary team the next morning. Descriptions of the holdover process in internal medicine are sparse.ObjectiveTo identify important factors affecting the quality of holdover handoffs at an internal medicine (IM) residency program and to compare them to previously identified factors for other handoffs.DesignWe undertook a qualitative study using structured focus groups and interviews. We analyzed data using qualitative content analysis.ParticipantsIM residents, IM program directors, and hospitalists at a large academic medical center.Main MeasuresA nine-question open-ended interview guide.Key ResultsWe identified 13 factors describing holdover handoffs. Five factors—physical space, standardization, task accountability, closed-loop verification, and resilience—were similar to those described in prior handoff literature in other specialties. Eight factors were new concepts that may uniquely affect the quality of the holdover handoff in IM. These included electronic health record access, redundancy, unwritten thoughts, different clinician needs, diagnostic uncertainty, anchoring, teaching, and feedback. These factors were organized into five overarching themes: physical environment, information transfer, responsibility, clinical reasoning, and education.ConclusionsThe holdover handoff in IM is complex and has unique considerations for achieving high quality. Further exploration of safe, efficient, and educational holdover handoff practices is necessary.

Hospital Privileging Practices for Bedside Procedures: A Survey of Hospitalist Experts

Many hospitalists are routinely granted hospital privileges to perform invasive bedside procedures, but criteria for privileging are not well described. We conducted a survey of 21 hospitalist procedure experts from the Society of Hospital Medicine Point‐of‐Care Ultrasound Task Force to better understand current privileging practices for bedside procedures and how those practices are perceived. Only half of all experts reported their hospitals require a minimum number of procedures performed to grant initial (48%) and ongoing (52%) privileges for bedside procedures. Regardless, most experts thought minimums should be higher than those in current practice and should exist alongside direct observation of manual skills. Experts reported that the use of ultrasound guidance was nearly universal for paracentesis, thoracentesis, and central venous catheter placement, but only 10% of hospitals required the use of ultrasound for initial privileging of these procedures.

An Industry/Academia Collaborative to Support Smoking-Cessation Grants

Department of Medicine, University of California, San Franornia; Duke University, Durham, North Carolina; Smoking Leadership Center, Department of Medicine, University of San Francisco, California; and Pfizer Independent Grants for d Change, New York, New York correspondence to: Steven A. Schroeder, MD, Department of niversity of California, San Francisco, 3333 California Street, an Francisco CA 94118. E-mail: steve.schroeder@ucsf.edu. 97/

Certification of Point-of-Care Ultrasound Competency

36.00 .doi.org/10.1016/j.amepre.2016.09.013 Many clinicians underperform in addressing smoking cessation. To address this gap between ideal and actual practice, Pfizer’s Independent Grants for Learning & Change (IGLC) partnered with the Smoking Cessation Leadership Center (SCLC) at University of California, San Francisco in a nationwide grants program.

An unusual manifestation of diabetic ketoacidosis and acute colonic pseudo-obstruction

1Division of General & Hospital Medicine, The University of Texas School of Medicine at San Antonio, San Antonio, Texas; 2Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas; 3Abbott Northwestern Hospital, Department of Medical Education, Minneapolis, Minnesota; 4Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California; 5Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont; 6Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire.

Can lessons from systems‐based mastery learning for thoracentesis be translated to hospitalists?

Lesson Patients presenting with diabetic ketoacidosis and acute colonic pseudo-obstruction should undergo a focused evaluation to identify underlying precipitants.