An Online Learning Module to Increase Self-Efficacy and Involvement in Care for Patients With Advanced Lung Cancer: Research Protocol

Background

Improving patient care for individuals with lung cancer is a priority due to the increasing burden of the disease globally. One way this can be done is by improving patient self-management capabilities through increasing their self-efficacy. This can improve positive outcomes for patients with chronic conditions and increase their ability to manage the challenges of such illnesses. Unfortunately, patients with chronic conditions often struggle to travel far from home to engage with patient education events, a common means of improving self-efficacy. The development of more accessible tools for improving patient self-efficacy is required to increase quality of life for patients with chronic conditions.

Objective

To evaluate the feasibility of delivering symptom identification and management information to patients with advanced lung cancer using an online program.

Methods

This article describes a pre-post test study to evaluate a Qstream online learning platform to improve patient self-efficacy for managing advanced lung cancer symptoms. Undertaking this program should increase participant knowledge about the side-effects they may experience as a result of their treatment and in turn increase help-seeking behavior and self-efficacy for the participant cohort. Quantitative data collected by the Qstream platform on the completion rates of participants will be used as a tool to evaluate the intervention. Additionally, validated scales will be used to collect data on patient self-efficacy. Qualitative data will also be collected via an exit survey and thematic content analysis of semi-structured interviews.

Results

The research is in the preliminary stages but thus far a protocol has been approved in support of the project. Additionally, advisory committee members have been identified and initial meetings have been undertaken.

Conclusions

Development of new approaches for increasing patient understanding of their care is important to ensure high quality care continues to be delivered in the clinical setting.

Development and characterization of novel hydrogel containing antimicrobial drug for treatment of burns

INTRODUCTION

The aim of burn management and therapy is fast healing and epithelisation to prevent infection. The present study is concerned with the development and characterization of a novel nanaoparticulate system; cubosomes, loaded with silver sulfadiazine (SSD) and Aloe vera for topical treatment of infected burns.

METHODS

Cubosome dispersions were formulated by an emulsification technique using different concentrations of a lipid phase Glyceryl Monooleate (GMO) and Poloxamer 407. The optimum formulae were incorporated in an aloe vera gel containing carbopol 934, to form cubosomal hydrogels (cubogels). The cubogels were characterized by in vitro release of SSD, rheological properties, pH, bioadhesion, Transmission Electron Microscopy and in-vivo Wound Healing Study.

RESULTS

The results show that the different concentration of GMO had significant effect on particle size, % EE and in vitro drug release. From the in-vitro drug release pattern and similarity factor (f2), it was concluded that batch CG3 (15% GMO and 1% P407) exhibited complete and controlled drug release within 12 hour (i.e. 98.25%), better bio adhesion and superior burn healing as compared to the marketed product.

CONCLUSION

The in vivo burns healing study in rats revealed that the prepared optimized cubogel containing SSD and aloe vera has superior burns healing rate than cubogel with only SSD and marketed preparation so, it may be successfully used in the treatment of deep second degree burn.

A Randomized Single Blind Parallel Group Study Comparing Monoherbal Formulation Containing Holarrhena Antidysenterica Extract with Mesalamine in Chronic Ulcerative Colitis Patients

Background:

Incidences of side effects and relapses are very common in chronic ulcerative colitis patients after termination of the treatment.

Aims and Objectives:

This study aims to compare the treatment with monoherbal formulation of Holarrhena antidysenterica with Mesalamine in chronic ulcerative colitis patients with special emphasis to side effects and relapse.

Settings and Design:

Patients were enrolled from an Ayurveda Hospital and a private Hospital, Gujarat. The study was randomized, parallel group and single blind design.

Materials and Methods:

The protocol was approved by Institutional Human Research Ethics Committee of Anand Pharmacy College on 23^rd Jan 2013. Three groups (n = 10) were treated with drug Mesalamine (Group I), monoherbal tablet (Group II) and combination of both (Group III) respectively. Baseline characteristics, factors affecting quality of life, chronicity of disease, signs and symptoms, body weight and laboratory investigations were recorded. Side effects and complications developed, if any were recorded during and after the study.

Statistical Analysis Used:

Results were expressed as mean ± SEM. Data was statistically evaluated using t-test, Wilcoxon test, Mann Whitney U test, Kruskal Wallis test and ANOVA, wherever applicable, using GraphPad Prism 6.

Results:

All the groups responded positively to the treatments. All the patients were positive for occult blood in stool which reversed significantly after treatment along with rise in hemoglobin. Patients treated with herbal tablets alone showed maximal reduction in abdominal pain, diarrhea, and bowel frequency and stool consistency scores than Mesalamine treated patients. Treatment with herbal tablet alone and in combination with Mesalamine significantly reduced the stool infection. Patients treated with herbal drug alone and in combination did not report any side effects, relapse or complications while 50% patients treated with Mesalamine exhibited the relapse with diarrhea and flatulence after drug withdrawal.

Conclusion:

Thus, monoherbal formulation alone and with Mesalamine was efficacious than Mesalamine alone in UC.

Formulation and evaluation of clotrimazole transdermal spray

CONTEXT

Transdermal spray (TS) of clotrimazole (CTZ) was formulated to improve the drug transport through the skin up to 12 h to achieve the antifungal efficacy.

OBJECTIVE

The aim of present study was to formulate and evaluate antifungal transdermal spray to improve the permeation of clotrimazole across the skin and to decrease the dosing frequency in fungal infection.

MATERIALS AND METHODS

Different ratios of ethanol and acetone and various grades of eudragit and ethyl cellulose were evaluated according to six criteria: viscosity, drying time, stickiness, appearance and integrity on skin and water washability. Propylene glycol (PG) and polyethylene glycol 400 (PEG 400) were used in the study as plasticizer and solubilizer. The TS was evaluated for in vitro drug release, spray angle, spray pattern, average weight per dose, pH, drug content, evaporation time, leak test and antifungal efficacy study.

RESULTS AND DISCUSSION

Eudragit E100 and blend of ethanol and acetone (80:20) satisfied the desired criteria. The selection of optimized batch was based on the results of in vitro drug release, spray pattern and spray angle. The optimized batch showed the spray angle <85° and uniform spray pattern. The formulation containing PG showed higher drug release than PEG 400. The inclusion of eutectic mixture consisting of camphor and menthol (1:1) showed improved drug transport through the rat skin and larger mean zone of inhibition indicating the improved antifungal efficacy.

CONCLUSION

The TS of CTZ can be an innovative and promising approach for the topical administration in the fungal diseases.

Impact of an antimicrobial stewardship-led intervention for Staphylococcus aureus bacteraemia: a quasi-experimental study

BACKGROUND

Staphylococcus aureus bacteraemia (SAB) carries high rates of morbidity and mortality. Antimicrobial stewardship programmes (ASPs) are well situated to promote adherence to quality performance measures in order to optimize the management of SAB and associated clinical outcomes.

METHODS

This uncontrolled pre-post quasi-experimental study evaluated compliance with an ASP-driven comprehensive care bundle and associated clinical outcomes for patients with SAB. The ASP provided recommendations to prescribers to promote adherence with quality performance measures, which included: initiate effective antibiotics within 24 h of Gram's stain; achieve therapeutic vancomycin trough concentration; provide β-lactam therapy if MSSA; obtain repeat blood cultures every 48 h until clearance; complete appropriate treatment duration; eliminate or debride foci of infection; and obtain an echocardiogram for complicated bacteraemia.

RESULTS

One hundred and seventy patients with SAB were included: 82 patients in the pre-intervention group and 88 patients in the ASP-intervention group. Overall bundle adherence to quality performance measures improved from 56.1% (46/82) in the pre-intervention group to 84.1% (74/88) in the ASP-intervention group (P < 0.001), which was associated with a reduction in 30 day readmission with SAB [9 patients (11.0%) versus 1 patient (1.1%), P = 0.008]. The 30 day mortality was numerically lower in the ASP-intervention group, but the difference was not statistically significant [16 patients (19.5%) versus 10 patients (11.4%), P = 0.2].

CONCLUSIONS

Implementation of an ASP-driven comprehensive care bundle for SAB improved adherence with performance measures and was associated with a decrease in hospital readmission for SAB.

Importance of Urinary Tract Infection to Antibiotic Use Among Hospitalized Patients

Many patients with asymptomatic bacteriuria receive extended courses of broad-spectrum antibiotics. Antibiotic use was analyzed in patients admitted to the hospital with urinary tract infection. Strategies to optimize antibiotic use for such patients are discussed and include implementing a process whereby a urine culture is automatically performed if a urinalysis result suggests infection.

Liver X receptor: a cardinal target for atherosclerosis and beyond

The nuclear receptor liver X receptor [LXR] is activated by endogenous oxidized derivatives of cholesterol. It constitutes a critical receptor in the regulation of various physiological functions related to the development of metabolic and cardiovascular diseases, such as atherosclerosis and diabetes, as well as various other disorders. Both isoforms of LXR, LXRα [NR1H3] and LXRβ [NR1H2], form heterodimers with the isoforms of the retinoid X receptor [RXR], which then regulate the gene expression by binding to DNA sequences associated with target genes. LXR acts as a cholesterol sensor in response to an increased concentration of cholesterol in cells and induces the transcription of genes that protect cells from cholesterol overload. LXRs play numerous roles in controlling cholesterol homeostasis via their actions on bile acid synthesis and metabolism/excretion, reverse cholesterol transport and cholesterol absorption/excretion in the intestines. Therefore, these receptors show great potential as pharmacological targets for anti-atherosclerotic activities. Recent discoveries have also emphasized the important involvement of LXRs in the pathogenesis of diabetes, Alzheimer's disease, inflammation, adrenal steroid synthesis, skin aging and male fertility. However, LXR activation has also been shown to stimulate lipogenesis via sterol regulatory element binding protein-1c, leading to liver steatosis and hypertriglyceridemia. This review summarizes recent scientific discoveries and the biological actions of LXR with a special focus on the involvement of this type of receptor in important diseases and conditions.

Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial

BACKGROUND AND OBJECTIVE

Physician awareness of the results of tests pending at discharge (TPADs) is poor. We developed an automated system that notifies responsible physicians of TPAD results via secure, network email. We sought to evaluate the impact of this system on self-reported awareness of TPAD results by responsible physicians, a necessary intermediary step to improve management of TPAD results.

METHODS

We conducted a cluster-randomized controlled trial at a major hospital affiliated with an integrated healthcare delivery network in Boston, Massachusetts. Adult patients with TPADs who were discharged from inpatient general medicine and cardiology services were assigned to the intervention or usual care arm if their inpatient attending physician and primary care physician (PCP) were both randomized to the same study arm. Patients of physicians randomized to discordant study arms were excluded. We surveyed these physicians 72 h after all TPAD results were finalized. The primary outcome was awareness of TPAD results by attending physicians. Secondary outcomes included awareness of TPAD results by PCPs, awareness of actionable TPAD results, and provider satisfaction.

RESULTS

We analyzed data on 441 patients. We sent 441 surveys to attending physicians and 353 surveys to PCPs and received 275 and 152 responses from 83 different attending physicians and 112 different PCPs, respectively (attending physician survey response rate of 63%). Intervention attending physicians and PCPs were significantly more aware of TPAD results (76% vs 38%, adjusted/clustered OR 6.30 (95% CI 3.02 to 13.16), p<0.001; 57% vs 33%, adjusted/clustered OR 3.08 (95% CI 1.43 to 6.66), p=0.004, respectively). Intervention attending physicians tended to be more aware of actionable TPAD results (59% vs 29%, adjusted/clustered OR 4.25 (0.65, 27.85), p=0.13). One hundred and eighteen (85%) and 43 (63%) intervention attending physician and PCP survey respondents, respectively, were satisfied with this intervention.

CONCLUSIONS

Automated email notification represents a promising strategy for managing TPAD results, potentially mitigating an unresolved patient safety concern.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT01153451).

Inappropriate testing for urinary tract infection in hospitalized patients: an opportunity for improvement

Urine cultures are frequently obtained for hospitalized patients. We reviewed documented indications for culture and compared these with professional society guidelines. Lack of documentation and important clinical scenarios (before orthopedic procedures and when the patient has altered mental status without a urinary catheter) are highlighted as areas of use outside of current guidelines.

Omeprazole improves the anti-obesity and antidiabetic effects of exendin-4 in db/db mice (-4 db/db)*

BACKGROUND

In addition to its glucoregulatory actions, exendin-4, a stable glucagon-like peptide-1 receptor agonist, exhibits protective effects in the pancreas and anti-obesity effects. Suitable combination treatment with other anti-obesity or pancreas protective agents would be an effective approach to optimize these additional effects. In the present study, we investigated the effects of the addition of omeprazole, a proton pump inhibitor, to exendin-4 in db/db mice, an experimental model of obesity and type 2 diabetes.

METHODS

The effects repeated dose treatment for 14 days with exendin-4 (8 μg/kg, s.c.) and omeprazole (30 mg/kg, s.c.) on glycemic control, food intake, and body weight were determined in obese and hyperglycemic db/db mice. The effects of these treatments on plasma gastrin, ghrelin, and leptin levels were determined, along with effects on nausea-like symptoms. The pancreatic effects of the repeated dose treatment were assessed by measuring %HbA1c in the circulation as well as pancreatic insulin and glucagon content and glucokinase activity.

RESULTS

Combination treatment resulted in significant decreases in plasma leptin and ghrelin levels after repeated dosing. Omeprazole improved the anorectic and body weight-lowering effects and reversed the inhibitory effect of exendin-4 on gastrin levels after repeated dose treatment. The 14-day combination treatment significantly reduced glucose excursion and improved insulin levels, with a concomitant decrease in %HbA1c levels. It also improved glucokinase activity and pancreatic insulin content, with a significant decrease in glucagon content.

CONCLUSIONS

Combined treatment with omeprazole with exendin-4 reduces food intake and body weight gain, most likely through changes in plasma ghrelin and leptin levels, and improves pancreatic insulin and glucagon content by improving glucokinase activity.

Impact of an antimicrobial stewardship program comprehensive care bundle on management of candidemia

STUDY OBJECTIVE

To analyze the impact of a comprehensive care bundle directed by an antimicrobial stewardship team (AST) on the management of candidemia.

DESIGN

Single-center, quasi-experimental study.

SETTING

A 930-bed academic hospital.

PATIENTS

Seventy-eight patients with candidemia were evaluated; 41 patients received the candidemia care bundle (AST group), and 37 did not (historical control group).

MEASUREMENTS AND MAIN RESULTS

A candidemia care bundle was developed by an interdisciplinary AST, incorporating key elements from the Infectious Diseases Society of America's Clinical Practice Guidelines for the Management of Candidemia. The AST made prospective recommendations in accordance with the care bundle. Bundle elements were utilization of appropriate antifungal agents with appropriate duration of use, removal of intravenous catheters, repeat blood cultures, monitoring of time until clearance of candidemia, and performance of ophthalmologic examinations. Compliance with all candidemia care bundle elements was significantly higher in the AST group versus the control group (78.0% vs 40.5%, p=0.0016). Implementation of the care bundle significantly improved rates of ophthalmologic examination (97.6% vs 75.7%, p=0.0108), selection of appropriate antifungal therapy (100% vs 86.5%, p=0.0488), and compliance with an appropriate duration of therapy (97.6% vs 67.7%, p=0.0012). In addition, the AST group had fewer excess total days of therapy beyond the recommended duration than the control group (5 vs 83 total antifungal days). Length of hospitalization (20 vs 21 days, p=0.9184), time until clearance of candidemia (3 vs 3 days p=0.610), rate of persistent candidemia (22% vs 40.5%, p=0.126), and rate of recurrent candidemia (4.9% vs 5.4%, p=0.916) were similar in the AST group versus the control group.

CONCLUSION

A comprehensive candidemia care bundle directed by our institution's AST improved the management of patients with candidemia. We encourage further exploration into the use of care bundles by ASTs as part of their multifaceted approach to promoting appropriate antimicrobial utilization and optimizing the management of patients with infectious diseases.

Effects of spray drying conditions on the physicochemical properties of the Tramadol-Hcl microparticles containing Eudragit(®) RS and RL

The preparation of Tramadol-HCL spray-dried microspheres can be affected by the long drug recrystallization time. Polymer type and drug–polymer ratio as well as manufacturing parameters affect the preparation. The purpose of this work was to evaluate the possibility to obtain tramadol spray-dried microspheres using the Eudragit^® RS and RL; the influence of the spray-drying parameters on morphology, dimension, and physical stability of microspheres was studied. The effects of matrix composition on microparticle properties were characterized by Laser Light scattering, differential scanning calorimetry (DSC), X-ray diffraction study, FT-infrared and UV-visible spectroscopy. The spray-dried microparticles were evaluated in terms of shape (SEM), size distribution (Laser light scattering method), production yield, drug content, initial drug loding and encapsulation efficiency. The results of X-ray diffraction and thermal analysis reveals the conversion of crystalline drug to amorphous. FTIR analysis confirmed the absence of any drug polymer interaction. The results indicated that the entrapment efficiency (EE), and product yield were depended on polymeric composition and polymeric ratios of the microspheres prepared. Tramadol microspheres based on Eudragit^® blend can be prepared by spray-drying and the nebulization parameters do not influence significantly on particle properties.

Development and characterisation of thermo reversible mucoadhesive moxifloxacin hydrochloride in situ ophthalmic gel

A sustain release thermo reversible in situ gel of Moxifloxacin Hydrochloride using mucoadhesive polymer was prepared. Mucoadhesive polymer was used to obtain an ophthalmic delivery system with improved mechanical and mucoadhesive properties that will provide prolong retention time for treatment of ocular diseases. Developed formulations were evaluated for drug-excipient compatibility study, pH, Clarity, Gelation temperature study, Mucoadhesion properties and in-vitro release studies. Drug-excipient compatibility study was performed by FTIR technique. The individual IR spectra of the pure drug and polymers as well as the combination spectra of the drug and polymer were taken, which indicate no interaction between Moxifloxacin and polymers when compared with infrared spectrum of pure drug as all functional group frequencies were present. The values of other parameters obtained were in acceptable range. In vitro release tests revealed that 98% drug was released from the in situ gel containing 0.5% and 1.00% HPMC in 12 hr. provides prolonged release.

Impact of online education on intern behaviour around joint commission national patient safety goals: a randomised trial

PURPOSE

To compare the effectiveness of two types of online learning methodologies for improving the patient-safety behaviours mandated in the Joint Commission National Patient Safety Goals (NPSG).

METHODS

This randomised controlled trial was conducted in 2010 at Massachusetts General Hospital and Brigham and Women's Hospital (BWH) in Boston USA. Incoming interns were randomised to either receive an online Spaced Education (SE) programme consisting of cases and questions that reinforce over time, or a programme consisting of an online slide show followed by a quiz (SQ). The outcome measures included NPSG-knowledge improvement, NPSG-compliant behaviours in a simulation scenario, self-reported confidence in safety and quality, programme acceptability and programme relevance.

RESULTS

Both online learning programmes improved knowledge retention. On four out of seven survey items measuring satisfaction and self-reported confidence, the proportion of SE interns responding positively was significantly higher (p<0.05) than the fraction of SQ interns. SE interns demonstrated a mean 4.79 (36.6%) NPSG-compliant behaviours (out of 13 total), while SQ interns completed a mean 4.17 (32.0%) (p=0.09). Among those in surgical fields, SE interns demonstrated a mean 5.67 (43.6%) NPSG-compliant behaviours, while SQ interns completed a mean 2.33 (17.9%) (p=0.015). Focus group data indicates that SE was more contextually relevant than SQ, and significantly more engaging.

CONCLUSION

While both online methodologies improved knowledge surrounding the NPSG, SE was more contextually relevant to trainees and was engaging. SE impacted more significantly on both self-reported confidence and the behaviour of surgical residents in a simulated scenario.

Bartonella henselae infections in solid organ transplant recipients: report of 5 cases and review of the literature

Bartonella henselae is the causative agent of cat scratch disease and bacillary angiomatosis-peliosis. The spectrum of disease, diagnosis, and management of B. henselae infection in solid organ transplant recipients has not been well characterized. We identified 29 cases of solid organ transplant recipients who had Bartonella infection, 24 by a review of the English-language literature and 5 from our institution. Localized cat scratch disease was found in 8 patients (28%), and disseminated infection was found in 21 patients (72%). The mean time after transplantation to development of Bartonella infection among those with cat scratch disease was 5.6 ± 5.3 years, and among those with disseminated infection was 2.7 ± 2.4 years. Prominent clinical features included cat exposure in 26 patients (90%), fever in 27 patients (93%), lymphadenopathy in 12 patients (41%), and skin lesions in 7 patients (24%). Methods used in establishing the diagnosis of Bartonella infection included culture, polymerase chain reaction (PCR) assay, serologic assays, and histopathologic examination. Culture was positive in 2 of only 4 patients in whom this was performed, and PCR was positive in 12 of 14 patients (86%) in whom this test was performed. Serologic assays were positive in all 23 patients who were tested. Histopathologic examination of tissues in all 8 patients who had cat scratch disease revealed granulomatous inflammation in 4 (50%) and bacillary angiomatosis-peliosis in 2 (25%). Among the 15 patients who had disseminated infection and who had tissue examined, 8 (53%) had only granulomatous inflammation, 4 had only bacillary angiomatosis-peliosis (27%), and 2 had both granulomas and bacillary angiomatosis-peliosis (13%). A positive Warthin-Starry or Steiner stain was noted in 12 of 19 patients (63%) who had 1 of these stains performed. All 8 patients with cat scratch disease and 19 of 21 patients with disseminated bartonellosis were cured with antimicrobial therapy. Two patients, both of whom had endocarditis, died. Among solid organ transplant recipients, infection with B. henselae is uncommon and has diverse disease manifestations including disseminated disease. Persistent fevers or lymphadenopathy in a transplant recipient who has been exposed to cats should prompt clinicians to maintain a high index of suspicion for B. henselae infection. Identifying B. henselae as the causative organism often requires multiple diagnostic studies. Once the diagnosis is established, most solid organ transplant recipients respond appropriately to antimicrobial treatment.

Effect of Aqueous Extract of Embelica officinalis on Selenite Induced Cataract in Rats

Cataract is clouding of the eye lens that reduces the amount of incoming light and results in deteriorating vision. Blindness is thought to reach 75 million by 2020. Of these, unoperated cataract may be expected to account for at least 35 million. Thus, the burden of cataract is increasing remorselessly. Embelica officinalis is reported to have a very good antioxidant property and thus we hypothesized that it could be a good candidate in treatment of cataract. Hence, the aim of this study was to investigate the effect of aqueous extract of Embelica officinalis on selenite induced cataract in rats. For the purpose of this study, cataract was induced in young suckling (on the 10(th) day of life) albino wistar rats using sodium selenite (a single dose of sodium selenite; 20μM/kg; subcutaneously). After induction of cataract, the test drug (Embelica Officinalis) and the reference standard (ascorbic acid) were administered orally for 18 days. The progression or disappearance of cataract was observed with the help of an ophthalmoscope (OM-18, Takagi resolution 1.6). At the end of this study the alterations in the levels of total protein, soluble protein, reduced glutathione and malondialdehyde were estimated in the lens homogenate. Results showed that treatment with Embelica officinalis, as well as ascorbic acid, produced a significant decrease (p < 0.05) in malondialdehyde and a simultaneous increase in lens glutathione levels (p < 0.05). The malondialdehyde content was decreased by 48% in animals treated with Embelica officinalis. Similarly, lens glutathione was increased by 82.5% in animals treated with Embelica officinalis. There was also a significant (p < 0.05) increase in protein content (total protein = 59.36% and soluble protein = 105.78%) in animals treated with Embelica officinalis, indicating improvement in cataractogenic condition in the selenite induced cataract model. At the end of the treatment, disappearance of cataract was observed in test and standard treated animals. In conclusion, it could be said that aqueous extract of Embelica officinalis delayed the progression of cataract in sodium selenite induced cataractogenic rats.

Trends in clinician perceptions of a new electronic health record

Clinician perceptions of a newly implemented electronic health record (EHR) play an important role in its success or failure. Limited data exist describing how these attitudes change over time. We measured attitudes of primary care clinicians toward a new EHR during the first year following implementation. We found that perceptions of the new system became significantly more favorable over time with variable rates of change for different aspects of the EHR.

Non-AIDS-defining cancers: should antiretroviral therapy be initiated earlier?

Non-AIDS-defining cancers have recently gained more attention, and it appears that several of these cancers may be more common the the HAART era. By most accounts in the literature, the overall risk of non-AIDS-defining cancer in HIV-infected persons is 2 to 3 times that in the general population. In this article, we review the literature on 5 of the most common non-AIDS-defining cancers (Hodgkin disease, anal cancer, hepatocellular carcinoma, oral cancer, and lung cancer) in the pre- and post-HAART periods. It remains unclear whether earlier initiation (CD4+ cell count above 350/microL) of antiretroviral therapy may be beneficial in preventing non-AIDS-defining cancer. Further large-scale, randomized, prospective studies on this question are warranted.

Long-Term Immunologic and Virologic Responses in Patients with Highly Resistant HIV Infection Who Are Treated with an Incompletely Suppressive Antiretroviral Regimen

BACKGROUND

Some treatment-experienced patients with highly drug-resistant human immunodeficiency virus (HIV) infection have no option but to continue to receive an incompletely suppressive regimen (ISR). We performed a study to determine their long-term immunologic and virologic responses to ISR, to investigate risks for immunologic or virologic failure, and to examine for the occurrence of new drug-resistance mutations.

METHODS

Antiretroviral treatment-experienced HIV-infected patients with a genotype sensitivity score < or = 1, an HIV load > 1000 copies/mL, and no available optimized regimen were included in the study. The proportion of patients treated with ISR who developed immunologic failure (defined as a 25% reduction in the CD4 cell count from the baseline level) and virologic failure (defined as a > or = 0.5-log10 increase in the HIV load from the baseline level) was determined. Cox proportional hazards analysis was used to investigate variables associated with immunologic or virologic failure. New drug-resistant mutations were calculated in 27 patients with sequential genotypes available.

RESULTS

Forty-seven patients (median duration of prior antiretroviral therapy, 89 months; median CD4 cell count, 277 cells/mm3; and median HIV load, 19,728 copies/mL) had multiple HIV mutations (a median of 5 nucleoside reverse-transcriptase inhibitor mutations, 1 nonnucleoside reverse-transcriptase inhibitor mutation, and 6 protease inhibitor mutations; median genotype sensitivity score, 0) at baseline. By 48 months after ISR use, 43% had developed immunologic failure, and 22% had developed virologic failure. None of the studied variables (i.e., age, < 50 years; baseline HIV load, > 100,000 copies/mL; baseline CD4 cell count, < 200 cells/mm3; or inclusion of lamivudine in the treatment regimen) were associated with immunologic or virologic failure. New nucleoside reverse-transcriptase inhibitor mutations occurred in 63% of patients, and new primary protease inhibitor mutations occurred in 52.6% of protease inhibitor recipients. No deaths occurred. A total of 8.5% of patients experienced a new AIDS-defining event.

CONCLUSIONS

Most patients with highly drug-resistant HIV infection who were treated with an ISR maintain durable immunologic and virologic responses. New drug-resistant mutations occur frequently.

Physicians value patient review of their electronic health record data as a means to improve accuracy of medication list documentation

Providers place great value on their patients as sources of clinical information. Patient access to and review of their medication list from their electronic health record prior to a visit may improve the accuracy of medication documentation.

Patient review of selected electronic health record data improves visit experience

Patients are increasingly empowered, informed and active participants in their healthcare. Patients at Partners Healthcare in Boston, MA utilized a web- based portal, Patient Gateway, to submit pre-visit health status information through a journal to their provider. Results of a patient survey indicate that such tools have the potential to improve communication and patient satisfaction, and that the content of information influences the patients visit experience.

Patient care experience enhanced by use of online journals

Patient involvement in their healthcare has increased with the use of electronic patient portals. The ability to submit updates to select sections of their medical record prior to a visit is shown to be effective in enhancing patients care experience. Those patients who discussed the updates with their physician at the visit reported an even more positive response.

Effect of Maintaining Highly Active Antiretroviral Therapy on AIDS Events among Patients with Late-Stage HIV Infection and Inadequate Response to Therapy

BACKGROUND

We evaluated the effect of maintaining highly active antiretroviral therapy (HAART) on the development of new acquired immunodeficiency syndrome (AIDS)-related events in patients with late-stage human immunodeficiency virus (HIV) infection who had suboptimal CD4+ cell count and viral load responses to HIV therapy.

METHODS

In patients with pretreatment CD4+ cell counts of <200 cells/mm3, incidence rates of new AIDS-related events occurring during HIV treatment were calculated during period 1 (pre-HAART era, 1990-1995; 88 patients) and period 2 (HAART era, 1996-2004; 214 patients) according to CD4+ cell count responses while receiving treatment. Cox multivariate model was used to compare rates of AIDS-related events from period 2 with those from period 1 according to specific CD4+ cell count response categories and rates of AIDS-related events for various viral load ranges within CD4+ cell count categories during period 2.

RESULTS

For period 2 patients with CD4+ cell counts <50 cells/mm3 and viral loads >100,000 copies/mL, the rate of AIDS-related events (39.3 events per 100 person-years) was significantly lower than that for period 1 patients with CD4+ cell counts <50 cells/mm3 (76.4 events per 100 person-years; P=.02). This held true for patients with CD4+ cell counts <100 cells/mm3; there were also significantly fewer AIDS-related events in period 2 (18 events per 100 person-years) than in period 1 (65.2 events per 100 person-years; P=.001), including those events occurring among period 2 patients with viral loads >100,000 copies/mL (29.5 events per 100 person-years; P=.01). Similarly, for patients with CD4+ cell counts of 100-200 cells/mm3, there were fewer AIDS-related events in period 2 (7.8 events per 100 person-years) than in period 1 (34.5 events per 100 person-years; P=.001); even for patients in period 2 with viral loads >100,000 copies/mL (15.4 events per 100 person-years; P=.04).

CONCLUSIONS

Our data suggest that, even among patients with late-stage HIV infection and inadequate CD4+ cell count and viral load responses to HIV therapy, maintaining HAART may reduce the incidence of AIDS-related events.

Clinicians recognize value of patient review of their electronic health record data

Increasing patient demands for convenient access to their own health care information has led to the development of "patient portals" that allow limited patient access to ambulatory electronic health records (EHR). Little is known about clinicians attitudes towards this new model of health care. In our study, we collected baseline information about primary care providers (PCP) usage of a secure, web-based patient portal linked to the ambulatory EHR. We also assessed providers initial perceptions of these technologies as facilitators of patient-provider communications and the potential for these tools to improve quality of outpatient care.

Viral load responses to HAART is an independent predictor of a new AIDS event in late stage HIV infected patients: prospective cohort study

BACKGROUND

A sizeable number of HIV-infected patients receiving HAART do not maintain prolonged virologic suppression. We evaluated long-term HIV viral load (VL) responses to HAART as a risk factor for AIDS events (AE) that is independent of CD4 responses.

METHODS

A cohort of patients with pre-therapy CD4 < 200/mm3 who had CD4 and VL measurements for > one year after receiving HAART at a university clinic were prospectively enrolled. Cox proportional multivariate regression model was used to determine whether CD4 and VL responses were independently associated with new AE.

RESULTS

The patient (N = 214) mean baseline CD4 = 92/mm3, VL = 219,000 c/mL and follow-up duration 42.3 months (range 13-72 months). A new AE occurred in 56 patients; CD4 cell count response to HAART that remained < 200/mm3 throughout the study period was a significant risk factor for new AE (RR = 9.7-12.5; p < 0.001). Similarly, VL responses that remained > 5,000 c/mL during this period was also a significant risk factor (RR = 6.7-12.8; p = 0.001) that was independent of CD4 response adjusted for <> 200/mm3.

CONCLUSION

Maintaining adequate long-term virologic responses to HAART provides a clinical benefit independent of CD4 responses.

Designing an electronic medication reconciliation system

Unintended medication discrepancies at hospital admission and discharge potentially harm patients. Explicit medication reconciliation (MR) can prevent unintended discrepancies among care settings and is mandated by JCAHO for 2005. Enterprise-wide, we are linking pre-admission and discharge medication lists in our outpatient electronic health records (EHR) with our inpatient order entry applications (OE) - currently not interoperable - to support MR and inform the development of comprehensive MR among hospitalized patients.

Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality

While evidence-based medicine has increasingly broad-based support in health care, it remains difficult to get physicians to actually practice it. Across most domains in medicine, practice has lagged behind knowledge by at least several years. The authors believe that the key tools for closing this gap will be information systems that provide decision support to users at the time they make decisions, which should result in improved quality of care. Furthermore, providers make many errors, and clinical decision support can be useful for finding and preventing such errors. Over the last eight years the authors have implemented and studied the impact of decision support across a broad array of domains and have found a number of common elements important to success. The goal of this report is to discuss these lessons learned in the interest of informing the efforts of others working to make the practice of evidence-based medicine a reality.

Dual infection with Ehrlichia chaffeensis and a spotted fever group rickettsia: a case report

Well-documented cases of simultaneous human infection with more than one tick-borne pathogen are rare. To our knowledge only two dual infections have been reported: simultaneous human infection with the agent of human granulocytic ehrlichiosis and Borrelia burgdorferi and simultaneous human infection with B. burgdorferi and Babesia microti (1-2). Rocky Mountain spotted fever has long been known to be endemic in North Carolina; cases of human ehrlichial infection were recognized there soon after Ehrlichia chaffeensis was recognized as an important cause of tick-borne disease in the southeastern United States. Because both Rocky Mountain spotted fever and ehrlichiosis are prevalent in North Carolina, occasional cases of simultaneous human infection by rickettsial and ehrlichial agents would not be surprising; however, no such cases seem to have been reported.