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Ford JS, Kayandabila J, Morrison JC, Seth S, Lyimo B, Mukhtar A, Schick M, May L, Debes JD. Combined Hepatitis B Virus and Hepatocellular Carcinoma Screening Using Point-of-Care Testing and Ultrasound in a Tanzanian Emergency Department. Am J Trop Med Hyg 2024; 110:399-403. [PMID: 38190742 PMCID: PMC10859790 DOI: 10.4269/ajtmh.23-0365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/20/2023] [Indexed: 01/10/2024] Open
Abstract
The WHO aims to detect 90% of global cases of hepatitis B virus (HBV) by 2030. Sub-Saharan Africa carries a disproportionate burden of HBV and hepatocellular carcinoma (HCC). In this study, we sought to assess the utility of a combined HBV and HCC screening program in Tanzania. We conducted a prospective, serial cross-sectional study of patients who participated in a combined HBV and HCC screening program at a regional referral hospital emergency department (ED) in Arusha, Tanzania, between April 19, 2022 and June 3, 2022. All patients completed a study questionnaire and were tested for HBV surface antigen. Patients who were HBV positive were screened for HCC via point-of-care ultrasound (POCUS). The primary outcome was the number of new HBV diagnoses. Data were analyzed with descriptive statistics. A total of 846 patients were tested for HBV (primary ED: 761, clinic referral: 85). The median age of patients was 44 ± 15 years, and 66% were female. Only 15% of patients reported having a primary care doctor. Thirteen percent of patients had been previously vaccinated for HBV. There were 17 new HBV diagnoses (primary ED: 16, clinic referral: 1), which corresponds to a seroprevalence of 2.0% (95% CI: 1.2%, 3.2%). No patients had liver masses detected on POCUS. An ED-based, combined HBV and HCC screening protocol can be feasibly implemented. This study could serve as a model for HBV/HCC screening in regions with high HBV endemicity and low rates of community screening.
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Affiliation(s)
- James S. Ford
- Department of Emergency Medicine, University of California, San Francisco, California
| | | | | | - Samwel Seth
- Department of Medicine, Arusha Lutheran Medical Center, Arusha, Tanzania
| | - Benson Lyimo
- Department of Surgery, Arusha Lutheran Medical Center, Arusha, Tanzania
| | - Aliasghar Mukhtar
- Department of Emergency Medicine, Arusha Lutheran Medical Center, Arusha, Tanzania
| | - Michael Schick
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California
| | - Larissa May
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California
| | - Jose D. Debes
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Vuillier L, Greville-Harris M, Talbot CV, May L, Moseley RL. Early evaluation of a DBT-informed online intervention for people with eating disorders. J Eat Disord 2024; 12:9. [PMID: 38243262 PMCID: PMC10799469 DOI: 10.1186/s40337-024-00974-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/16/2024] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVES Eating disorders (EDs) have a worldwide prevalence of 7.8%, with towering mortality rates and high healthcare costs. The current recommended treatment for EDs principally works by directly targeting ED thoughts and behaviours, but recovery rates are low. A multifaceted link between difficulties with emotions and EDs is now widely established, and newer third-wave therapies that aim to address these underlying emotion difficulties are promising. The current study piloted an online emotion self-help intervention which was co-developed with clinicians and people with lived experienced of EDs. The intervention aimed to specifically address difficulties with emotion identification and regulation, as well as unhelpful beliefs about emotions, which are believed to give rise to and maintain ED thoughts and behaviours. METHOD We recruited 39 people with self-reported EDs to test this intervention over a one-week period. Our participants were asked to complete a series of questionnaires measuring emotion processes and psychopathology on Day 1 (T1) before being given access to the intervention. Participants were then asked to practice the newly acquired skills for seven days, before taking the same questionnaires on Day 9 (T2). We also asked participants to qualitatively report on their experience of the intervention. RESULTS We found significant improvements in ED psychopathology (ED-15), depression (PHQ-9), and anxiety (GAD-7) pre- to post-intervention, with medium to large effect sizes. All our emotion variables namely alexithymia (TAS-20), difficulties regulating emotions (DERS-SF), and unhelpful beliefs about emotions (EBQ) also showed significant changes post-intervention with medium to large effect sizes. Most importantly, changes in emotion regulation processes were linked to improved eating psychopathology. The qualitative analysis corroborated this finding, highlighting how the intervention helped them form new beliefs about emotions, which helped them reduce ED behaviours. DISCUSSION Significant improvements in emotion processing and regulations, as well as psychopathology, along with positive qualitative feedback, suggest that the intervention effectively met its aims of increasing awareness of the link between emotions and eating psychopathology, providing help to identify and regulate emotions, and normalising emotional experiences. While our results are promising, further research is required to assess its effectiveness longer term and in clinical settings.
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Affiliation(s)
- Laura Vuillier
- Department of Psychology, Bournemouth University, Poole, UK.
| | | | - C V Talbot
- Department of Psychology, Bournemouth University, Poole, UK
| | - L May
- Southern Health University NHS Foundation Trust, Southampton, UK
| | - R L Moseley
- Department of Psychology, Bournemouth University, Poole, UK
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Morgan Bustamante BL, Fejerman L, May L, Martínez-López B. Community-acquired Staphylococcus aureus skin and soft tissue infection risk assessment using hotspot analysis and risk maps: the case of California emergency departments. BMC Public Health 2024; 24:123. [PMID: 38195461 PMCID: PMC10775506 DOI: 10.1186/s12889-023-17336-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/25/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Community-acquired Staphylococcus aureus (CA-Sa) skin and soft tissue infections (SSTIs) are historically associated with densely populated urban areas experiencing high poverty rates, intravenous drug use, and homelessness. However, the epidemiology of CA-Sa SSTIs in the United States has been poorly understood since the plateau of the Community-acquired Methicillin-resistant Staphylococcus aureus epidemic in 2010. This study examines the spatial variation of CA-Sa SSTIs in a large, geographically heterogeneous population and identifies neighborhood characteristics associated with increased infection risk. METHODS Using a unique neighborhood boundary, California Medical Service Study Areas, a hotspot analysis, and estimates of neighborhood infection risk ratios were conducted for all CA-Sa SSTIs presented in non-Federal California emergency departments between 2016 and 2019. A Bayesian Poisson regression model evaluated the association between neighborhood-level infection risk and population structure, neighborhood poverty rates, and being a healthcare shortage area. RESULTS Emergency departments in more rural and mountainous parts of California experienced a higher burden of CA-Sa SSTIs between 2016 and 2019. Neighborhoods with high infection rates were more likely to have a high percentage of adults living below the federal poverty level and be a designated healthcare shortage area. Measures of population structure were not associated with infection risk in California neighborhoods. CONCLUSIONS Our results highlight a potential change in the epidemiology of CA-Sa SSTIs in California emergency departments. Future studies should investigate the CA-Sa burden in other geographies to identify whether this shift in epidemiology holds across other states and populations. Further, a more thorough evaluation of potential mechanisms for the clustering of infections seen across California neighborhoods is needed.
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Affiliation(s)
- Brittany L Morgan Bustamante
- Public Health Sciences, School of Medicine, University of California, Davis, Davis, CA, USA.
- Center for Animal Disease Modeling and Surveillance, Department of Veterinary Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, USA.
| | - Laura Fejerman
- Public Health Sciences, School of Medicine, University of California, Davis, Davis, CA, USA
| | - Larissa May
- Emergency Medicine, School of Medicine, University of California, Davis, Davis, CA, USA
| | - Beatriz Martínez-López
- Center for Animal Disease Modeling and Surveillance, Department of Veterinary Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, USA
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May L, Robbins EM, Canchola JA, Chugh K, Tran NK. A study to assess the impact of the cobas point-of-care RT-PCR assay (SARS-CoV-2 and Influenza A/B) on patient clinical management in the emergency department of the University of California at Davis Medical Center. J Clin Virol 2023; 168:105597. [PMID: 37742483 DOI: 10.1016/j.jcv.2023.105597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/08/2023] [Accepted: 09/17/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Rapid detection of SARS-CoV-2 is crucial for reduction of transmission and clinical decision-making. Several rapid (<30 min) molecular point-of-care (POC) tests based on nucleic acid amplification exist for diagnosis of SARS-CoV-2 & Influenza A/B infections. METHODS This unblinded, pre-post study enrolled consecutive patients with symptoms/signs consistent with SARS-CoV-2 infection presenting to the University of California, Davis emergency department (ED). Outcomes following implementation of the cobas® SARS-CoV-2 & Influenza A/B test for use on the cobas Liat System (intervention: December 2020-May 2021) were compared with previous standard-of-care using centralized laboratory reverse transcriptase polymerase chain reaction (RT-PCR) methods (control: April 2020-October 2020). RESULTS Electronic health records of 8879 symptomatic patient visits were analyzed, comprising 4339 and 4540 visits and 538 and 638 positive SARS-CoV-2 PCR test results in the control and intervention periods, respectively. Compared with the control period, turnaround time (TAT) was shorter in the intervention period (median 0.98 vs 12.30 h; p < 0.0001). ED length of stay (LOS) was generally longer in the intervention period compared with the control period, but for those SARS-CoV-2-negative who were admitted, ED LOS was shorter (median 12.53 vs 17.93 h; p < 0.0001). The rate of antibiotic prescribing was lower in the intervention than in the control period (42.86% vs 49.16%; p < 0.0001) and antiviral prescribing was higher (7.64% vs 5.49%; p < 0.0001). CONCLUSION This real-world study confirms faster TAT with a POC RT-PCR method in an emergency care setting and highlights the importance of rapid SARS-CoV-2 detection to aid patient management and inform treatment decisions.
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Affiliation(s)
- Larissa May
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, California, USA
| | | | | | - Kamal Chugh
- Roche Molecular Systems, Pleasanton, California, USA
| | - Nam K Tran
- Department of Emergency Medicine, University of California, Davis, Sacramento, California, USA.
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Morgan Bustamante BL, May L, Fejerman L, Martínez-López B. A Bayesian multilevel analysis exploring population-level effects mediating the relationship between area-level poverty and community-acquired Methicillin-resistant Staphylococcus aureus (CA-MRSA) infection across California communities. Health Place 2023; 83:103094. [PMID: 37515963 DOI: 10.1016/j.healthplace.2023.103094] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/06/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
Poverty is an often-cited driver of health disparities, and associations between poverty and community-acquired Methicillin-resistant Staphylococcus aureus (CA-MRSA) infection are well documented. However, the pathways through which poverty influences infection have not been thoroughly examined. This project aims to identify mediating variables, or mechanisms, explaining why area-level poverty is associated with CA-MRSA infection in Californians. Bayesian multilevel models accounting for spatial confounding were developed to test whether the association between area-level poverty and CA-MRSA infection is mediated by living in a primary care shortage area (HCSA), living near an adult correctional facility, and residential environmental degradation. The association between area-level poverty and CA-MRSA infection can be partially explained by spatial autocorrelation, living in an HCSA, and environmental degradation in the neighborhood. Combined, the mediators explain approximately 6% of the odds of CA-MRSA infection for individuals living in neighborhoods with high poverty rates and 50% of the statistical association between area-level poverty and CA-MRSA infection. The statistical association between area-level poverty and infection was completely explained by the mediators for individuals living in neighborhoods with low poverty rates.
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Affiliation(s)
- Brittany L Morgan Bustamante
- Public Health Sciences, School of Medicine, University of California, Davis, CA, United States; Center for Animal Disease Modeling and Surveillance, Department of Veterinary Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, CA, United States.
| | - Larissa May
- Department, School of Medicine, University of California, Davis, CA, United States
| | - Laura Fejerman
- Public Health Sciences, School of Medicine, University of California, Davis, CA, United States
| | - Beatriz Martínez-López
- Center for Animal Disease Modeling and Surveillance, Department of Veterinary Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, CA, United States
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Ford JS, Mousa MA, Voong S, Matsumoto CG, Chechi T, Tran N, May L. Risk factors for HIV infection at a large urban emergency department: a cross-sectional study. Sex Transm Infect 2023; 99:404-408. [PMID: 37015802 DOI: 10.1136/sextrans-2022-055513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 03/20/2023] [Indexed: 04/06/2023] Open
Abstract
OBJECTIVES In 2019, the US Preventative Services Task Force released updated guidelines recommending HIV screening in all individuals aged 15-64 years and all pregnant females. In the current study, we aimed to identify risk factors for HIV infection in an emergency department (ED) population. METHODS We performed a cross-sectional study that employed a post hoc risk factor analysis of ED patients ≥18 years who were screened for HIV between 27 November 2018 and 26 November 2019, at a single urban, quaternary referral academic hospital. Patients were screened using HIV antigen/antibody testing and diagnoses were confirmed using HIV-1/HIV-2 antibody testing. The outcome of interest was the number of positive HIV tests. Multiple logistic regression models were used to identify risk factors associated with HIV positivity. RESULTS 14 335 adult patients were screened for HIV (mean age: 43±14 years; 52% female). HIV seroprevalence was 0.7%. Independent risk factors for HIV positivity included male sex (adjusted OR (aOR) 3.1 (95% CI 1.7 to 5.6)), unhoused status (aOR 2.9 (95% CI 1.7 to 4.9)), history of illicit drug use (aOR 1.8 (95% CI 1.04 to 3.13)) and Medicare insurance status (aOR 2.2 (95% CI 1.1 to 4.4)). CONCLUSIONS The study ED services a high-risk population with regard to HIV infection. These data support universal screening of ED patients for HIV. Risk factor profiles could improve targeted screening at institutions without universal HIV testing protocols.
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Affiliation(s)
- James S Ford
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mohammad A Mousa
- Department of Emergency Medicine, University of California Davis Health, Sacramento, CA, USA
| | - Stephanie Voong
- Department of Emergency Medicine, University of California Davis Health, Sacramento, CA, USA
| | - Cynthia G Matsumoto
- Department of Population Health and Accountable Care, University of California Davis Health, Sacramento, CA, USA
| | - Tasleem Chechi
- Department of Emergency Medicine, University of California Davis Health, Sacramento, CA, USA
| | - Nam Tran
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, CA, USA
| | - Larissa May
- Department of Emergency Medicine, University of California Davis Health, Sacramento, CA, USA
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Sennhauser S, May L, Mallikarjunappa SS, Bhatt K, Van Beuningen A. Mimicry. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Andrade A, Bang H, Reddick K, Villaseñor B, Tran NK, May L. Evaluation of pharmacist guided intervention using procalcitonin and respiratory virus testing. Am J Emerg Med 2023; 66:146-151. [PMID: 36773457 PMCID: PMC10038929 DOI: 10.1016/j.ajem.2023.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/23/2023] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Acute respiratory infections make up a sizable percentage of emergency department (ED) visits and many result in antibiotics being prescribed. Procalcitonin (PCT) has been found to reduce antibiotic use in both outpatient and critical care settings, yet remains underused in the ED. This study aimed to evaluate whether point of care molecular influenza and Respiratory Syncytial Virus (RSV) testing, PCT, and a pharmacist driven educational intervention in aggregate optimizes antibiotic and antiviral prescribing in the ED setting. METHODS A randomized trial of the Cobas Liat Flu/RSV Assay, procalcitonin, and the use of pharmacist-led education in patients 0-50 years of age being seen in the ED for Influenza Like Illness (ILI) or acute respiratory illness. The study enrolled 200 ED patients between March 2018 and April 2022. RESULTS There was little difference in antibiotic or antiviral prescribing between the intervention and control groups in this study (39%-32% = 7.0%, 95% CI: -6.2, 20.2, P = 0.30). However, a post-hoc analysis of the use of procalcitonin showed results were used as indicated in the ED (P = 0.001). CONCLUSION PCT can be used in both adult and pediatric populations to help guide the decision of whether to treat with antibiotics in the ED setting. Pharmacist guided education may not be a driving factor.
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Affiliation(s)
- Amia Andrade
- Department of Emergency Medicine, UC Davis Medical Center, 2315 Stockton Blvd, PSSB 2100, Sacramento, CA 95817, United States of America.
| | - Heejung Bang
- Department of Public Health Sciences, School of Medicine, One Shields Ave., Med-Sci 1C, Davis, CA 95616, United States of America.
| | - Katie Reddick
- Department of Emergency Medicine, UC Davis Medical Center, 2315 Stockton Blvd, PSSB 2100, Sacramento, CA 95817, United States of America.
| | - Bryan Villaseñor
- Department of Emergency Medicine, UC Davis Medical Center, 2315 Stockton Blvd, PSSB 2100, Sacramento, CA 95817, United States of America.
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California, Davis, 3435 Tupper Hall, Davis, CA 95616, United States of America.
| | - Larissa May
- Department of Emergency Medicine, UC Davis Medical Center, 2315 Stockton Blvd, PSSB 2100, Sacramento, CA 95817, United States of America.
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Fleming S, Sennhauser S, May L, Simone N, Beuningen A, Bhatt K. A Case of Acute Mitoxantrone Mediated Myocarditis in Refractory Acute Myeloid Leukemia (AML). J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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Moseley RL, Atkinson C, Surman R, Greville-Harris M, May L, Vuillier L. Sex-specific mechanisms for eating disorder risk in men and women with autistic traits: the role of alexithymia. J Eat Disord 2023; 11:18. [PMID: 36765413 PMCID: PMC9912205 DOI: 10.1186/s40337-023-00746-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 02/02/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND A poorly understood relationship exists between eating disorders (ED) and autism spectrum conditions (ASC: henceforth 'autism'). ED are more prevalent in autistic people and people with high autistic traits, and autistic features are prognostic of longer illness. Aiming to understand what increases the risk of ED in relation to autism and autistic traits, previous research has implicated alexithymia as a causal mechanism in this relationship. These studies could not, however, disentangle whether alexithymia explains the relationship between ED pathology and autistic traits directly or through its impact on anxious/depressive symptoms, which in turn result in higher ED symptomatology. Moreover, despite evidence for sex differences in the aetiology of ED, little research has examined the impact of sex on these relationships. METHODS Focusing on the association between autistic traits and ED psychopathology, we examined independent mediating effects of alexithymia and anxious/depressive symptoms, as well as sequential mediation effects where alexithymia affects ED psychopathology via its impact on anxious/depressive symptoms. Participants were 198 men and 265 women with formally diagnosed and suspected ED, who completed an online survey of standardised scales. RESULTS In men, higher autistic traits were associated with ED psychopathology sequentially via greater alexithymia and through that, greater depressive/anxious symptoms. In women, alexithymia mediated the relationship between autistic traits and ED psychopathology both directly and sequentially through its impact on anxious/depressive symptoms. Interestingly, depressive/anxious symptoms also mediated that relationship independently from alexithymia. CONCLUSIONS While cross-sectional, these findings suggest that the relationship between autistic traits and ED symptomatology is mediated by other variables. In support of its proposed role in the aetiology of ED, alexithymia was directly associated with ED symptoms in women. It also affected ED symptoms indirectly, in all participants, via its effect on depressive/anxious symptoms. Interventions focusing on alexithymia may facilitate recovery not only via their effect on ED, but via their effect on other forms of state psychopathology which contribute to the maintenance and development of ED. Sex differences, however, reflect that alternative therapeutic targets for men and women may be beneficial.
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Affiliation(s)
- R L Moseley
- Department of Psychology, Bournemouth University, Poole, UK.
| | - C Atkinson
- Department of Psychology, Bournemouth University, Poole, UK
| | - R Surman
- Department of Psychology, Bournemouth University, Poole, UK
| | | | - L May
- Dorset Healthcare University NHS Foundation Trust, Poole, UK
| | - L Vuillier
- Department of Psychology, Bournemouth University, Poole, UK
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Ford JS, Morgan Bustamante BL, Virk MK, Ramirez N, Matsumoto CG, Lee DJ, MacDonald S, May L. Use of clinical decision support for antibiotic stewardship in the emergency department and outpatient clinics: An interrupted time-series analysis. Antimicrob Steward Healthc Epidemiol 2023; 3:e80. [PMID: 37205319 PMCID: PMC10186615 DOI: 10.1017/ash.2023.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 05/21/2023]
Abstract
Objective To evaluate the impact of implementing clinical decision support (CDS) tools for outpatient antibiotic prescribing in the emergency department (ED) and clinic settings. Design We performed a before-and-after, quasi-experimental study that employed an interrupted time-series analysis. Setting The study institution was a quaternary, academic referral center in Northern California. Participants We included prescriptions for patients in the ED and 21 primary-care clinics within the same health system. Intervention We implemented a CDS tool for azithromycin on March 1, 2020, and a CDS tool for fluoroquinolones (FQs; ie, ciprofloxacin, levofloxacin, and moxifloxacin) on November 1, 2020. The CDS added friction to inappropriate ordering workflows while adding health information technology (HIT) features to easily perform recommended actions. The primary outcome was the number of monthly prescriptions for each antibiotic type, by implementation period (before vs after). Results Immediately after azithromycin-CDS implementation, monthly rates of azithromycin prescribing decreased significantly in both the ED (-24%; 95% CI, -37% to -10%; P < .001) and outpatient clinics (-47%; 95% CI, -56% to -37%; P < .001). In the first month after FQ-CDS implementation in the clinics, there was no significant drop in ciprofloxacin prescriptions; however, there was a significant decrease in ciprofloxacin prescriptions over time (-5% per month; 95% CI, -6% to -3%; P < .001), suggesting a delayed effect of the CDS. Conclusion Implementing CDS tools was associated with an immediate decrease in azithromycin prescriptions, in both the ED and clinics. CDS may serve as a valuable adjunct to existing antimicrobial stewardship programs.
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Affiliation(s)
- James S. Ford
- Department of Emergency Medicine, University of California–San Francisco, San Francisco, California
| | | | - Mehr Kaur Virk
- Department of Emergency Medicine, University of California Davis, School of Medicine. Sacramento, California
| | - Nancy Ramirez
- Department of Emergency Medicine, University of California Davis, School of Medicine. Sacramento, California
| | - Cynthia G. Matsumoto
- Office of Population Health and Accountable Care, University of California Davis, Sacramento, California
| | - Daniel Jin Lee
- Department of Emergency Medicine, University of California Davis, School of Medicine. Sacramento, California
| | - Scott MacDonald
- Department of Clinical Informatics, University of California Davis Health, Sacramento, California
| | - Larissa May
- Department of Emergency Medicine, University of California Davis, School of Medicine. Sacramento, California
- Author for correspondence: Larissa May, University of California–Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA95817. E-mail:
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Vuillier L, Joseph J, Greville-Harris M, May L, Somerville MP, Harrison A, Moseley RL. What about males? Exploring sex differences in the relationship between emotion difficulties and eating disorders. J Eat Disord 2022; 10:193. [PMID: 36514166 PMCID: PMC9749243 DOI: 10.1186/s40337-022-00715-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE While eating disorders (EDs) are more commonly diagnosed in females, there is growing awareness that men also experience EDs and may do so in a different way. Difficulties with emotion processing and emotion regulation are believed to be important in EDs, but as studies have involved predominantly female samples, it is unclear whether this is also true for males. METHODS In a sample of 1604 participants (n = 631 males), we assessed emotion processing and emotion regulation in males with EDs (n = 109) and compared results to both females with EDs (n = 220) and males from the general population (n = 522). We also looked at whether emotion processing and emotion regulation difficulties predicted various aspects of eating psychopathology and whether this was moderated by sex. We assessed emotion processing with the Toronto Alexithymia Scale, emotion regulation with the Difficulties in Emotion Regulation Scale and the Emotion Regulation Questionnaire, and eating psychopathology with the Eating Disorder Examination Questionnaire. RESULTS We found that males with ED, like their female counterparts, suffered from emotion processing and emotion regulation deficits. We did find some sex differences, in that males with EDs tended to report more difficulties with their emotions as well as a more externally oriented thinking style compared to females with EDs. Difficulties with emotion processing and emotion regulation were strongly predictive of various aspects of eating psychopathology in both sexes. Importantly, we found that sex moderated the relationship between cognitive reappraisal and eating restraint. As such, low use of reappraisal was found to be associated with higher levels of restraint in females but not in males. DISCUSSION Difficulties with emotion processing and emotion regulation are associated with eating psychopathology in both males and females. Reappraisal was not found to be associated with reduced eating psychopathology in males, suggesting a cautious approach to interventions targeting this strategy. Research around explanatory mechanisms and interventions must adopt a broader viewpoint including those that are traditionally overlooked in EDs.
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Affiliation(s)
- L Vuillier
- Department of Psychology, Bournemouth University, Poole, UK.
| | - J Joseph
- Department of Psychology, Bournemouth University, Poole, UK
| | | | - L May
- Dorset Healthcare University NHS Foundation Trust, Poole, UK
| | - M P Somerville
- UCL Institute of Education, University College London, London, UK
| | - A Harrison
- UCL Institute of Education, University College London, London, UK
| | - R L Moseley
- Department of Psychology, Bournemouth University, Poole, UK
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Ford J, Mousa M, Voong S, Matsumoto C, Chechi T, Tram N, May L. 153 Risk Factors for Human Immunodeficiency Virus Infection at a Large Urban Emergency Department. Ann Emerg Med 2022. [DOI: 10.1016/j.annemergmed.2022.08.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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14
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Ford JS, Hollywood E, Steuble B, Meng Z, Voong S, Chechi T, Tran N, May L. Risk factors for hepatitis C virus infection at a large urban emergency department. J Viral Hepat 2022; 29:930-937. [PMID: 35789152 DOI: 10.1111/jvh.13730] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/23/2022] [Accepted: 06/17/2022] [Indexed: 12/09/2022]
Abstract
In 2020, Centers for Disease Control and Prevention (CDC) released guidelines recommending HCV screening in all adults 18 years and older. In the current study, we aimed to identify risk factors for HCV infection in an ED population. We performed a retrospective analysis of ED patients ≥ 18 years who were screened for HCV between 28 November 2018, and 27 November 2019, at a single urban, quaternary referral academic hospital. An HCV-antibody immunoassay (HCV-Ab) was used for screening; positive results were confirmed by measuring HCV ribonucleic acid (RNA). The outcome of interest was the number of new HCV diagnoses (presence of viremia by HCV RNA testing). Multiple logistic regression models were used to identify risk factors associated with a new HCV diagnosis. 16,722 adult patients were screened for HCV (mean age: 46 ± 15 years; 51% female). HCV seroprevalence was 5%. Independent risk factors for HCV included increasing age [10-year aOR 1.26 (95% CI 1.23, 1.30)], male sex [aOR 1.25 (95% CI 1.03, 1.51)], undomiciled housing status [aOR 2.8 (95% CI 2.3, 3.5)], history of tobacco use [aOR 3.0 (95% CI 2.3, 3.9)], history of illicit drug use [aOR 3.6 (95% CI 2.9, 4.5)], Medicaid insurance status [aOR 4.0 (95% CI 2.9, 5.5)] and Medicare insurance status [aOR 1.6 (95% CI 1.1, 2.2)].The ED services a high-risk population with regards to HCV infection. These data support universal screening of ED patients for HCV. Risk factor profiles could improve targeted screening at institutions without universal testing protocols.
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Affiliation(s)
- James S Ford
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Erika Hollywood
- A.T. Still University School of Osteopathic Medicine in Arizona, Mesa, Arizona, USA
| | - Bradley Steuble
- Touro University of California, College of Osteopathic Medicine, Vallejo, California, USA
| | - Zichun Meng
- Department of Statistics, Graduate Group of Biostatistics, University of California Davis Health, Sacramento, California, USA
| | - Stephanie Voong
- Department of Emergency Medicine, University of California, Davis, California, USA
| | - Tasleem Chechi
- Department of Emergency Medicine, University of California, Davis, California, USA
| | - Nam Tran
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, California, USA
| | - Larissa May
- Department of Emergency Medicine, University of California, Davis, California, USA
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15
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May L, Morgan B, Matsumoto C. 229 Clinical Decision Support for Antibiotic Stewardship in the Emergency Department. Ann Emerg Med 2022. [DOI: 10.1016/j.annemergmed.2022.08.252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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16
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Bauer W, Gläser S, Thiemig D, Wanner K, Peric A, Behrens S, Bialas J, Behrens A, Galtung N, Liesenfeld O, Sun L, May L, Mace S, Ott S, Vesenbeckh S. Detection of Viral Infection and Bacterial Coinfection and Superinfection in Coronavirus Disease 2019 Patients Presenting to the Emergency Department Using the 29-mRNA Host Response Classifier IMX-BVN-3: A Multicenter Study. Open Forum Infect Dis 2022; 9:ofac437. [PMID: 36111173 PMCID: PMC9452140 DOI: 10.1093/ofid/ofac437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/24/2022] [Indexed: 11/24/2022] Open
Abstract
Background Identification of bacterial coinfection in patients with coronavirus disease 2019 (COVID-19) facilitates appropriate initiation or withholding of antibiotics. The Inflammatix Bacterial Viral Noninfected (IMX-BVN) classifier determines the likelihood of bacterial and viral infections. In a multicenter study, we investigated whether IMX-BVN version 3 (IMX-BVN-3) identifies patients with COVID-19 and bacterial coinfections or superinfections. Methods Patients with polymerase chain reaction-confirmed COVID-19 were enrolled in Berlin, Germany; Basel, Switzerland; and Cleveland, Ohio upon emergency department or hospital admission. PAXgene Blood RNA was extracted and 29 host mRNAs were quantified. IMX-BVN-3 categorized patients into very unlikely, unlikely, possible, and very likely bacterial and viral interpretation bands. IMX-BVN-3 results were compared with clinically adjudicated infection status. Results IMX-BVN-3 categorized 102 of 111 (91.9%) COVID-19 patients into very likely or possible, 7 (6.3%) into unlikely, and 2 (1.8%) into very unlikely viral bands. Approximately 94% of patients had IMX-BVN-3 unlikely or very unlikely bacterial results. Among 7 (6.3%) patients with possible (n = 4) or very likely (n = 3) bacterial results, 6 (85.7%) had clinically adjudicated bacterial coinfection or superinfection. Overall, 19 of 111 subjects for whom adjudication was performed had a bacterial infection; 7 of these showed a very likely or likely bacterial result in IMX-BVN-3. Conclusions IMX-BVN-3 identified COVID-19 patients as virally infected and identified bacterial coinfections and superinfections. Future studies will determine whether a point-of-care version of the classifier may improve the management of COVID-19 patients, including appropriate antibiotic use.
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Affiliation(s)
- Wolfgang Bauer
- Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Emergency Medicine, Berlin, Germany
| | - Sven Gläser
- Klinik für Innere Medizin–Pneumologie, Vivantes Klinikum Spandau und Klinik für Innere Medizin–Pneumologie und Infektiologie, Vivantes Klinikum Neukölln, Berlin, Germany
- Klinik für Innere Medizin–Pneumologie und Infektiologie, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Dorina Thiemig
- Klinik für Innere Medizin–Pneumologie und Infektiologie, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Katrin Wanner
- Klinik für Innere Medizin–Pneumologie, Vivantes Klinikum Spandau und Klinik für Innere Medizin–Pneumologie und Infektiologie, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Alexander Peric
- Klinik für Innere Medizin–Pneumologie und Infektiologie, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Steffen Behrens
- Klinik für Innere Medizin–Kardiologie, Vivantes–Netzwerk für Gesundheit/Vivantes Humboldt-Klinikum and Klinik für Innere Medizin–Kardiologie und konservative Intensivmedizin, Vivantes–Netzwerk für Gesundheit/Vivantes Klinikum Spandau, Berlin, Germany
| | - Johanna Bialas
- Labor Berlin–Charité Vivantes Services GmbH, Berlin, Germany
| | - Angelika Behrens
- Klinik für Innere Medizin, Gastroenterologie und Pneumologie, Evangelische Elisabeth Klinik Krankenhausbetriebs gGmbH, Berlin, Germany
| | - Noa Galtung
- Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Emergency Medicine, Berlin, Germany
| | | | - Lisa Sun
- Inflammatix Inc, Burlingame, California, USA
| | - Larissa May
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Sharron Mace
- Department of Emergency Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sebastian Ott
- Department of Pulmonary Medicine, St Claraspital AG, Basel, Switzerland
- University of Bern, Bern, Switzerland
| | - Silvan Vesenbeckh
- Department of Pulmonary Medicine, St Claraspital AG, Basel, Switzerland
- Department of Pulmonology, University Hospital Zürich, Zürich, Switzerland
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17
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Kassamali Escobar Z, Thomasson S, Bouchard T, Kvak S, Lee KM, Lansang JM, Lynch JB, May L, D’Angeli M, Bryson-Cahn C. Experience with two antimicrobial prescribing tools in ambulatory care settings. Antimicrob Steward Healthc Epidemiol 2022; 2:e141. [PMID: 36483410 PMCID: PMC9726541 DOI: 10.1017/ash.2022.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 06/17/2023]
Abstract
We compared experiences with The Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adult and Children in Emergency Department and Urgent Care Settings versus Choosing Wisely to evaluate inappropriate antimicrobial prescribing in ambulatory care. Both identified the same clinics, diagnoses, and antibiotics for high-yield antibiotic stewardship interventions.
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Affiliation(s)
- Zahra Kassamali Escobar
- University of Washington Medicine, Valley Medical Center Renton, Washington
- University of Washington School of Pharmacy, Seattle, Washington
| | - Scott Thomasson
- University of Washington Medicine, Valley Medical Center Renton, Washington
| | - Todd Bouchard
- University of Washington Medicine, Valley Medical Center Renton, Washington
| | - Staci Kvak
- University of Washington Medical Center, Seattle, Washington
| | - Kyung Min Lee
- University of Washington Medicine, Valley Medical Center Renton, Washington
| | - Jose Mari Lansang
- University of Washington Medicine, Valley Medical Center Renton, Washington
| | - John B. Lynch
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
| | - Larissa May
- Department of Emergency Medicine, University of California–Davis Health, Sacramento, California
| | - Marisa D’Angeli
- Healthcare Associated Infections Program, Washington State Department of Health, Shoreline, Washington
| | - Chloe Bryson-Cahn
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington
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18
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Tran NK, May L, Cohen SH, Rodrigo J, Gong R, Liu Y, Conner P. Comparative performance of COVID-19 serology testing. Pract Lab Med 2022; 31:e00289. [PMID: 35818626 PMCID: PMC9259022 DOI: 10.1016/j.plabm.2022.e00289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/07/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022] Open
Abstract
Background The 2019 novel coronavirus infectious disease (COVID-19) pandemic resulted in a surge of assays aimed at detecting severe acute respiratory syndrome (SARS) – coronavirus (CoV) – 2 infection and prior exposure. Although both molecular and antigen testing have clearly defined uses, the utility of serology remains uncertain and is presently not recommended for assessing immunity. Methods We conducted a pragmatic, observational study evaluating four commercially available emergency use authorized laboratory-based COVID-19 serology assays (Assays A–D). Remnant samples from hospitalized, and non-hospitalized SARS-CoV-2 PCR positive patients, as well as vaccinated and unvaccinated individuals were collected and tested. Positive percent agreement (PPA) and negative percent agreement (NPA) were calculated. Antibody concentrations were compared across the platforms and populations. Results A total of 588 remnant samples derived from 500 patients were tested. PPA at 5–12 weeks post-PCR positive results for Assays A-D was 98.3, 97.4, 99.2, and 95.8% respectively. NPA was 100% across all platforms. Mean antibody concentrations at 2–4 weeks post-PCR positive result were significantly higher in hospitalized versus non-hospitalized patients, respectively, for Assay A (131.8 [101.7] vs. 95.6 [100.3] AU/mL, P < 0.001), B (61.7 [62.4] vs. 38.1 [40.5] AU/mL, P < 0.001), and C (157.6 [105.3] vs. 133.3 [100.7] AU/mL, P < 0.001). For individuals receiving two vaccine doses mean antibody concentrations were respectively 169.6 (104.4), 27.3 (50.8), 189.6 (120.9), 21.19 (13.1) AU/mL for Assays A-D. Conclusions Overall, PPA and NPA differed across the four assays. Assays A and C produced higher PPA and NPA and detected larger concentrations of antibodies following vaccination.
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Affiliation(s)
- Nam K Tran
- Dept. of Pathology and Laboratory Medicine, UC Davis, United States
| | - Larissa May
- Department of Emergency Medicine, UC Davis, United States
| | - Stuart H Cohen
- Department of Internal Medicine, Division of Infectious Diseases, United States
| | - John Rodrigo
- Dept. of Pathology and Laboratory Medicine, UC Davis, United States
| | - Raymond Gong
- Dept. of Pathology and Laboratory Medicine, UC Davis, United States
| | - Ying Liu
- Dept. of Pathology and Laboratory Medicine, UC Davis, United States
| | - Peter Conner
- Dept. of Pathology and Laboratory Medicine, UC Davis, United States
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19
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Rashidi HH, Pepper J, Howard T, Klein K, May L, Albahra S, Phinney B, Salemi MR, Tran NK. Comparative performance of two automated machine learning platforms for COVID-19 detection by MALDI-TOF-MS. PLoS One 2022; 17:e0263954. [PMID: 35905092 PMCID: PMC9337631 DOI: 10.1371/journal.pone.0263954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/25/2022] [Indexed: 11/19/2022] Open
Abstract
The 2019 novel coronavirus infectious disease (COVID-19) pandemic has resulted in an unsustainable need for diagnostic tests. Currently, molecular tests are the accepted standard for the detection of SARS-CoV-2. Mass spectrometry (MS) enhanced by machine learning (ML) has recently been postulated to serve as a rapid, high-throughput, and low-cost alternative to molecular methods. Automated ML is a novel approach that could move mass spectrometry techniques beyond the confines of traditional laboratory settings. However, it remains unknown how different automated ML platforms perform for COVID-19 MS analysis. To this end, the goal of our study is to compare algorithms produced by two commercial automated ML platforms (Platforms A and B). Our study consisted of MS data derived from 361 subjects with molecular confirmation of COVID-19 status including SARS-CoV-2 variants. The top optimized ML model with respect to positive percent agreement (PPA) within Platforms A and B exhibited an accuracy of 94.9%, PPA of 100%, negative percent agreement (NPA) of 93%, and an accuracy of 91.8%, PPA of 100%, and NPA of 89%, respectively. These results illustrate the MS method's robustness against SARS-CoV-2 variants and highlight similarities and differences in automated ML platforms in producing optimal predictive algorithms for a given dataset.
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Affiliation(s)
- Hooman H. Rashidi
- Robert. J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - John Pepper
- Spectra Pass LLC & Allegiant Airlines, Las Vegas, Nevada, United States of America
| | - Taylor Howard
- Dept. of Pathology and Laboratory Medicine, UC Davis, Davis, California, United States of America
| | - Karina Klein
- Dept. of Emergency Medicine, UC Davis, Davis, California, United States of America
| | - Larissa May
- Dept. of Emergency Medicine, UC Davis, Davis, California, United States of America
| | - Samer Albahra
- Robert. J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Brett Phinney
- Proteomics Core, UC Davis, Davis, California, United States of America
| | | | - Nam K. Tran
- Dept. of Pathology and Laboratory Medicine, UC Davis, Davis, California, United States of America
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20
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Ko ER, Henao R, Frankey K, Petzold EA, Isner PD, Jaehne AK, Allen N, Gardner-Gray J, Hurst G, Pflaum-Carlson J, Jayaprakash N, Rivers EP, Wang H, Ugalde I, Amanullah S, Mercurio L, Chun TH, May L, Hickey RW, Lazarus JE, Gunaratne SH, Pallin DJ, Jambaulikar G, Huckins DS, Ampofo K, Jhaveri R, Jiang Y, Komarow L, Evans SR, Ginsburg GS, Tillekeratne LG, McClain MT, Burke TW, Woods CW, Tsalik EL. Prospective Validation of a Rapid Host Gene Expression Test to Discriminate Bacterial From Viral Respiratory Infection. JAMA Netw Open 2022; 5:e227299. [PMID: 35420659 PMCID: PMC9011121 DOI: 10.1001/jamanetworkopen.2022.7299] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/24/2022] [Indexed: 12/24/2022] Open
Abstract
Importance Bacterial and viral causes of acute respiratory illness (ARI) are difficult to clinically distinguish, resulting in the inappropriate use of antibacterial therapy. The use of a host gene expression-based test that is able to discriminate bacterial from viral infection in less than 1 hour may improve care and antimicrobial stewardship. Objective To validate the host response bacterial/viral (HR-B/V) test and assess its ability to accurately differentiate bacterial from viral infection among patients with ARI. Design, Setting, and Participants This prospective multicenter diagnostic study enrolled 755 children and adults with febrile ARI of 7 or fewer days' duration from 10 US emergency departments. Participants were enrolled from October 3, 2014, to September 1, 2019, followed by additional enrollment of patients with COVID-19 from March 20 to December 3, 2020. Clinical adjudication of enrolled participants identified 616 individuals as having bacterial or viral infection. The primary analysis cohort included 334 participants with high-confidence reference adjudications (based on adjudicator concordance and the presence of an identified pathogen confirmed by microbiological testing). A secondary analysis of the entire cohort of 616 participants included cases with low-confidence reference adjudications (based on adjudicator discordance or the absence of an identified pathogen in microbiological testing). Thirty-three participants with COVID-19 were included post hoc. Interventions The HR-B/V test quantified the expression of 45 host messenger RNAs in approximately 45 minutes to derive a probability of bacterial infection. Main Outcomes and Measures Performance characteristics for the HR-B/V test compared with clinical adjudication were reported as either bacterial or viral infection or categorized into 4 likelihood groups (viral very likely [probability score <0.19], viral likely [probability score of 0.19-0.40], bacterial likely [probability score of 0.41-0.73], and bacterial very likely [probability score >0.73]) and compared with procalcitonin measurement. Results Among 755 enrolled participants, the median age was 26 years (IQR, 16-52 years); 360 participants (47.7%) were female, and 395 (52.3%) were male. A total of 13 participants (1.7%) were American Indian, 13 (1.7%) were Asian, 368 (48.7%) were Black, 131 (17.4%) were Hispanic, 3 (0.4%) were Native Hawaiian or Pacific Islander, 297 (39.3%) were White, and 60 (7.9%) were of unspecified race and/or ethnicity. In the primary analysis involving 334 participants, the HR-B/V test had sensitivity of 89.8% (95% CI, 77.8%-96.2%), specificity of 82.1% (95% CI, 77.4%-86.6%), and a negative predictive value (NPV) of 97.9% (95% CI, 95.3%-99.1%) for bacterial infection. In comparison, the sensitivity of procalcitonin measurement was 28.6% (95% CI, 16.2%-40.9%; P < .001), the specificity was 87.0% (95% CI, 82.7%-90.7%; P = .006), and the NPV was 87.6% (95% CI, 85.5%-89.5%; P < .001). When stratified into likelihood groups, the HR-B/V test had an NPV of 98.9% (95% CI, 96.1%-100%) for bacterial infection in the viral very likely group and a positive predictive value of 63.4% (95% CI, 47.2%-77.9%) for bacterial infection in the bacterial very likely group. The HR-B/V test correctly identified 30 of 33 participants (90.9%) with acute COVID-19 as having a viral infection. Conclusions and Relevance In this study, the HR-B/V test accurately discriminated bacterial from viral infection among patients with febrile ARI and was superior to procalcitonin measurement. The findings suggest that an accurate point-of-need host response test with high NPV may offer an opportunity to improve antibiotic stewardship and patient outcomes.
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Affiliation(s)
- Emily R. Ko
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
- Hospital Medicine, Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ricardo Henao
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Informatics, Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Katherine Frankey
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Elizabeth A. Petzold
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Pamela D. Isner
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Anja K. Jaehne
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, Michigan
| | - Nakia Allen
- Department of Pediatrics, Henry Ford Hospital System, Detroit, Michigan
| | - Jayna Gardner-Gray
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, Michigan
- Department of Medicine, Henry Ford Hospital System, Detroit, Michigan
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital System, Detroit, Michigan
| | - Gina Hurst
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, Michigan
- Department of Medicine, Henry Ford Hospital System, Detroit, Michigan
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital System, Detroit, Michigan
| | - Jacqueline Pflaum-Carlson
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, Michigan
- Department of Medicine, Henry Ford Hospital System, Detroit, Michigan
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital System, Detroit, Michigan
| | - Namita Jayaprakash
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, Michigan
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital System, Detroit, Michigan
| | - Emanuel P. Rivers
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, Michigan
- Department of Surgery, Henry Ford Hospital System, Detroit, Michigan
| | - Henry Wang
- McGovern Medical University of Texas Health, Houston
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Irma Ugalde
- McGovern Medical University of Texas Health, Houston
| | - Siraj Amanullah
- Department of Emergency Medicine, Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island
- Department of Pediatrics, Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island
| | - Laura Mercurio
- Department of Emergency Medicine, Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island
- Department of Pediatrics, Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island
| | - Thomas H. Chun
- Department of Emergency Medicine, Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island
- Department of Pediatrics, Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island
| | - Larissa May
- Department of Emergency Medicine, University of California, Davis
| | - Robert W. Hickey
- Division of Pediatric Emergency Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob E. Lazarus
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Shauna H. Gunaratne
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Daniel J. Pallin
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - David S. Huckins
- Department of Emergency Medicine, Newton-Wellesley Hospital, Boston, Massachusetts
| | - Krow Ampofo
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Ravi Jhaveri
- Department of Pediatrics, University of North Carolina at Chapel Hill
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yunyun Jiang
- The Biostatistics Center, George Washington University, Rockville, Maryland
| | - Lauren Komarow
- The Biostatistics Center, George Washington University, Rockville, Maryland
| | - Scott R. Evans
- The Biostatistics Center, George Washington University, Rockville, Maryland
| | - Geoffrey S. Ginsburg
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
| | - L. Gayani Tillekeratne
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medical Service, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Micah T. McClain
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medical Service, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Thomas W. Burke
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Christopher W. Woods
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medical Service, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Ephraim L. Tsalik
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Emergency Medicine Service, Durham Veterans Affairs Health Care System, Durham, North Carolina
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21
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May L, Sickler J, Robbins EM, Tang S, Chugh K, Tran N. The impact of point-of-care polymerase chain reaction testing on prescribing practices in primary care for management of Strep A: a retrospective before –after study. Open Forum Infect Dis 2022; 9:ofac147. [PMID: 35531385 PMCID: PMC9070329 DOI: 10.1093/ofid/ofac147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/23/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Rapid antigen detection tests (RADTs) are the standard of care (SOC) for testing in patients with suspected Group A β-hemolytic Streptococcus (Strep A) infection. Due to lower sensitivity, guidelines recommend confirmatory microbiological culture following negative RADT results. This process is time-consuming, and adherence is often poor, resulting in high rates of inappropriate antibiotic prescribing. We sought to evaluate the impact of switching from RADTs to point-of-care (POC) PCR testing on use of antibiotics in primary care, when used as part of an antibiotic stewardship initiative.
Methods
In this retrospective before–after study, electronic medical records of any patients presenting with suspected acute pharyngitis (June 2018–May 2019) across 15 outpatient primary care clinics were evaluated. Strep A was detected using the cobas ® Strep A assay (cobas ® Liat ® system).
Results
Analysis of 10,081 eligible patient records showed that POC PCR testing resulted in a 44.1% reduction in antibiotic prescribing for patients with a negative POC PCR test result (10.1% PCR vs 18.0% RADT; p<0.0001). Rates of antibiotic prescription varied across clinical sites, ranging between 10.7–33.8% and 12.4–34.4% during the use of PCR tests and RADTs, respectively. POC PCR had no impact on prescription rates in patients with positive POC test results compared to RADTs (76.2% vs 76.5%, respectively). Over 99% of antibiotics were prescribed during the initial primary care encounter.
Conclusion
As part of a broader antibiotic stewardship initiative, implementation of POC PCR as SOC in outpatients with acute pharyngitis symptoms reduced the volume of inappropriate antibiotic prescriptions.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California Davis, CA, USA
| | | | | | - Shaowu Tang
- Roche Molecular Systems, Pleasanton, CA, USA
| | - Kamal Chugh
- Roche Molecular Systems, Pleasanton, CA, USA
| | - Nam Tran
- Department of Pathology and Laboratory Medicine, University of California Davis, CA, USA
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Hluhanich R, Ford J, Bruce D, Chechi T, Voong S, Sarkar S, Poole P, Tran N, May L. Comparing Hepatitis C Virus Screening in Clinics Versus the
Emergency Department. West J Emerg Med 2022; 23:312-317. [PMID: 35679493 PMCID: PMC9183782 DOI: 10.5811/westjem.2021.11.53870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 11/15/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction: New evidence suggests that emergency department (ED)-based infectious diseases screening programs have utility. We aimed to compare clinic-based and ED-based hepatitis C virus (HCV) screening programs within a single health system, to identify key differences in HCV antibody (Ab) positivity and chronic HCV, as well as population demographics.
Methods: In the clinic-based program, adults in the birth cohort (born 1945-1965) were screened for HCV. In the ED-based program, non-targeted HCV screening of all adults was conducted. We included patients screened between June 2019–June 2020. Patients were screened for anti-HCV Ab, and positive results were followed by HCV viral load (VL) testing. Our primary outcomes were seroprevalence of HCV Ab and HCV VL.
Results: There were 1,296 and 12,778 patients screened for HCV in the clinics and the ED, respectively. In the clinic setting, 13 patients (1%) screened positive for HCV Ab and nine (69%) completed VL testing, which was positive in one patient (11%). In the ED, 1,053 patients (8%) screened positive for HCV Ab and 847 (80%) underwent reflex VL testing, which was positive in 381 patients (45%). In an ED birth cohort sub-analysis, Hepatitis C virus Ab seroprevalence was 15% (675/4521).
Conclusion: In this study of patients in a single healthcare system, ED-based HCV screening was higher yield than clinic-based screening.
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Affiliation(s)
- Rebecca Hluhanich
- UC Davis Health, Hepatology and Infectious Diseases Clinical Pharmacy, Sacramento, California; Rebecca Hluhanich and James Ford contributed equally to the production of this manuscript and share first-authorship
| | - James Ford
- UC Davis Health, Department of Emergency Medicine, Sacramento, California; Rebecca Hluhanich and James Ford contributed equally to the production of this manuscript and share first-authorship
| | - Devin Bruce
- UC Davis Health, Department of Emergency Medicine, Sacramento, California
| | - Tasleem Chechi
- UC Davis Health, Department of Emergency Medicine, Sacramento, California
| | - Stephanie Voong
- UC Davis Health, Department of Emergency Medicine, Sacramento, California
| | - Souvik Sarkar
- UC Davis Health, Department of Internal Medicine, Division of Gastroenterology, Sacramento, California
| | - Patricia Poole
- UC Davis Health, Department of Pharmacy, Sacramento, California
| | - Nam Tran
- UC Davis Health, Department of Pathology and Laboratory Medicine, Sacramento, California
| | - Larissa May
- UC Davis Health, Department of Emergency Medicine, Sacramento, California
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Abstract
BACKGROUND The prevalence of syphilis is increasing in the United States. The emergency department (ED) is an important setting to screen and treat underserved populations. To tailor testing protocols to the local population, we aimed to identify risk factors for syphilis positivity in ED patients. METHODS We performed a retrospective analysis of ED patients who were screened for syphilis between November 2018 and August 2020. Patients were screened for Treponema pallidum antibody using a multiplex flow immunoassay, and positive results were confirmed by rapid plasma reagin or T. pallidum particle agglutination. Risk factors for new syphilis diagnoses were identified using multiple logistic regression. RESULTS We screened 1974 patients for syphilis (mean age, 37 ± 16 years; 56% female). We identified 201 patients with new infections without previous treatment. Independent risk factors for a new diagnosis of syphilis included housing status (undomiciled, 23% [60 of 256]; domiciled, 9% [133 of 1559]; adjusted odds ratio [aOR], 1.9 [95% confidence interval {CI}, 1.2-3.0]), history of HIV (positive, 44% [28 of 63]; negative, 9% [173 of 1893]; aOR, 5.8 [95% CI, 3.0-11.2]), tobacco use (positive, 15% [117 of 797]; negative, 4% [29 of 665]; aOR, 2.4 [95% CI, 1.5-3.9]), and illicit drug use (positive, 14% [112 of 812]; negative, 8% [52 of 678]; aOR, 2.2 [95% CI, 1.0-2.5]). CONCLUSIONS Undomiciled housing status, history of HIV, history of tobacco use, and history of illicit drug use were independently associated with a new diagnosis of syphilis in the ED. Broadening targeted syphilis screening algorithms beyond sexually transmitted disease-related complaints could help identify new syphilis cases for treatment.
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Affiliation(s)
| | | | | | | | | | - Nam Tran
- Pathology and Laboratory Medicine, UC Davis Health, Sacramento, CA
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Tran NK, Albahra S, Rashidi H, May L. Innovations in infectious disease testing: Leveraging COVID-19 pandemic technologies for the future. Clin Biochem 2022; 117:10-15. [PMID: 34998789 PMCID: PMC8735816 DOI: 10.1016/j.clinbiochem.2021.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/13/2021] [Accepted: 12/30/2021] [Indexed: 12/26/2022]
Abstract
Innovations in infectious disease testing have improved our abilities to detect and understand the microbial world. The 2019 novel coronavirus infectious disease (COVID-19) pandemic introduced new innovations including non-prescription “over the counter” infectious disease tests, mass spectrometry-based detection of COVID-19 host response, and the implementation of artificial intelligence (AI) and machine learning (ML) to identify individuals infected by the severe acute respiratory syndrome - coronavirus – 2 (SARS-CoV-2). As the world recovers from the COVID-19 pandemic; these innovative solutions will give rise to a new era of infectious disease tests extending beyond the detection of SARS-CoV-2. To this end, the purpose of this review is to summarize current trends in infectious disease testing and discuss innovative applications specifically in the areas of POC testing, MS, molecular diagnostics, sample types, and AI/ML.
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Affiliation(s)
- Nam K Tran
- Dept. of Pathology and Laboratory Medicine, UC Davis School of Medicine, United States.
| | - Samer Albahra
- Dept. of Pathology and Laboratory Medicine, UC Davis School of Medicine, United States
| | - Hooman Rashidi
- Dept. of Pathology and Laboratory Medicine, UC Davis School of Medicine, United States
| | - Larissa May
- Department of Emergency Medicine, UC Davis School of Medicine, United States
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Thai B, Chia L, Nguyen A, Hutchinson D, Kompa A, White P, May L. Adenosine Receptor-Mediated Cardioprotection Post-Myocardial Infarction Associated With Advanced Age. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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Tran NK, Albahra S, May L, Waldman S, Crabtree S, Bainbridge S, Rashidi H. Evolving Applications of Artificial Intelligence and Machine Learning in Infectious Diseases Testing. Clin Chem 2021; 68:125-133. [PMID: 34969102 PMCID: PMC9383167 DOI: 10.1093/clinchem/hvab239] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/15/2021] [Indexed: 12/31/2022]
Abstract
Background Artificial intelligence (AI) and machine learning (ML) are poised to transform infectious disease testing. Uniquely, infectious disease testing is technologically diverse spaces in laboratory medicine, where multiple platforms and approaches may be required to support clinical decision-making. Despite advances in laboratory informatics, the vast array of infectious disease data is constrained by human analytical limitations. Machine learning can exploit multiple data streams, including but not limited to laboratory information and overcome human limitations to provide physicians with predictive and actionable results. As a quickly evolving area of computer science, laboratory professionals should become aware of AI/ML applications for infectious disease testing as more platforms are become commercially available. Content In this review we: (a) define both AI/ML, (b) provide an overview of common ML approaches used in laboratory medicine, (c) describe the current AI/ML landscape as it relates infectious disease testing, and (d) discuss the future evolution AI/ML for infectious disease testing in both laboratory and point-of-care applications. Summary The review provides an important educational overview of AI/ML technique in the context of infectious disease testing. This includes supervised ML approaches, which are frequently used in laboratory medicine applications including infectious diseases, such as COVID-19, sepsis, hepatitis, malaria, meningitis, Lyme disease, and tuberculosis. We also apply the concept of “data fusion” describing the future of laboratory testing where multiple data streams are integrated by AI/ML to provide actionable clinical knowledge.
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Affiliation(s)
- Nam K Tran
- Department of Pathology and Laboratory Medicine, UC Davis School of Medicine, CA
| | - Samer Albahra
- Department of Pathology and Laboratory Medicine, UC Davis School of Medicine, CA
| | - Larissa May
- Department of Emergency Medicine, UC Davis School of Medicine, CA
| | - Sarah Waldman
- Department of Internal Medicine, Division of Infectious Diseases, UC Davis School of Medicine, CA
| | - Scott Crabtree
- Department of Internal Medicine, Division of Infectious Diseases, UC Davis School of Medicine, CA
| | - Scott Bainbridge
- Department of Pathology and Laboratory Medicine, UC Davis School of Medicine, CA
| | - Hooman Rashidi
- Department of Pathology and Laboratory Medicine, UC Davis School of Medicine, CA
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Tran NK, May L. Evolution of COVID-19 Testing and the Role of Rapid Antigen Testing in Molecular-Focused World. Arch Pathol Lab Med 2021; 146:404-406. [DOI: 10.5858/arpa.2021-0610-ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Nam K. Tran
- From the Department of Pathology and Laboratory Medicine (Tran), University of California, Davis
| | - Larissa May
- Department of Emergency Medicine (May), University of California, Davis
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28
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May L, Tran N, Ledeboer NA. Point-of-care COVID-19 testing in the emergency department: current status and future prospects. Expert Rev Mol Diagn 2021; 21:1333-1340. [PMID: 34758686 PMCID: PMC8631689 DOI: 10.1080/14737159.2021.2005582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 11/09/2021] [Indexed: 01/08/2023]
Abstract
INTRODUCTION This expert review outlines current and future point-of-care technologies for the diagnosis of the SARS-CoV-2 virus, which is responsible for causing coronavirus disease COVID-19 in the emergency department. COVID-19 first emerged in late 2019 and is responsible for a range of presentations from minor upper respiratory tract symptoms to severe pneumonia and multisystem organ failure. Among the technologies available include the gold standard of molecular point-of-care tests as well as antigen detection tests. AREAS COVERED We discuss point-of-care molecular tests including multiplex, targeted, and single plex panels as well as various antigen testing methodologies in terms of availability and performance characteristics. In addition, we focus on current testing best practices and considerations for point-of-care testing in the emergency department based on a search of the literature available in PubMed to date and a review of FDA and CDC guidance. EXPERT OPINION While there have been many advances in SARS-CoV-2 point-of-care testing, there remain challenges to implementation in the emergency department setting. A paradigm shift is needed to improve diagnosis and clinical outcomes.
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Affiliation(s)
- Larissa May
- Davis Department of Emergency Medicine, University of California, Sacramento, CA, USA
| | - Nam Tran
- Davis Department of Pathology and Laboratory Medicine, University of California, USA
| | - Nathan A. Ledeboer
- Department of Pathology and Laboratory Medicine, Medical College of Wisconsin, USA
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Elder JW, Gu Z, Kim J, Moulin A, Bang H, Parikh A, May L. Assessing local California trends in emergency physician opioid prescriptions from 2012 to 2020: Experiences in a large academic health system. Am J Emerg Med 2021; 51:192-196. [PMID: 34763238 DOI: 10.1016/j.ajem.2021.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES There has been increased focus nationally on limiting opioid prescriptions. National data demonstrates a decrease in annual opioid prescriptions among emergency medicine physicians. We analyzed data from 2012 to 2020 from a large academic health system in California to understand trends in opioid prescribing patterns for emergency department (ED) discharged patients and assessed the potential impact of two initiatives at limiting local opioid prescriptions. METHODS In 2012-2020, monthly ED visit data was used to evaluate the total number of outpatient opioid prescriptions and percent of ED visits with opioid prescriptions (as primary outcomes). Descriptive statistics, graphic representation, and segmented regression with interrupted times series were used based on two prespecified time points associated with intensive local initiatives directed at limiting opioid prescribing1) comprehensive emergency medicine resident education and 2) electronic health record (EHR)-based intervention. RESULTS Between March 2012 and July 2020, a total of 41,491 ED discharged patients received an opioid prescription. The three most commonly prescribed drugs were hydrocodone (84.1%), oxycodone (10.8%), and codeine (2.8%). After implementing comprehensive emergency medicine resident education, the total number of opioid prescriptions, the percentage of opioid prescriptions over total ED visit numbers and the total tablet number showed decreasing trends (p's ≤ 0.01), in addition to the natural (pre-intervention) decreasing trends. In contrast, later interventions in the EHR tended to show attenuated decreasing trends. CONCLUSIONS From 2012 to 2020, we found that total opioid prescriptions decreased significantly for discharged ED patients. This trend is seen nationally. However, our specific interventions further heightened this downward trend. Evidence-based legislation, policy changes, and educational initiatives that impact prescribing practices should guide future efforts.
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Affiliation(s)
- Joshua W Elder
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA, United States of America.
| | - Zheng Gu
- Department of Research & Evaluation, Southern California Permanente Medical Group, Kaiser Permanente Research, Pasadena, CA, United States of America
| | - Jeehyoung Kim
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Republic of Korea
| | - Aimee Moulin
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA, United States of America
| | - Heejung Bang
- Department of Research & Evaluation, Southern California Permanente Medical Group, Kaiser Permanente Research, Pasadena, CA, United States of America.; Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, CA, United States of America
| | - Aman Parikh
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA, United States of America
| | - Larissa May
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA, United States of America
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Ford JS, Chechi T, Otmar M, Baker M, Waldman S, Morgan B, Tan D, Tran NK, May L. ED syphilis and gonorrhea/chlamydia cotesting practices before and after the implementation of an electronic health record-based alert. Emerg Med J 2021; 39:emermed-2020-210331. [PMID: 34548414 DOI: 10.1136/emermed-2020-210331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/08/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The prevalence of syphilis is increasing in many countries, including the USA. The ED is often used by underserved populations, making it an important setting to test and treat patients who are not evaluated in outpatient clinical settings. We aimed to assess the utility of an ED-based syphilis and gonorrhoea/chlamydia cotesting protocol by comparing testing practices before and after its implementation. METHODS We implemented an electronic health record (EHR) alert that prompted clinicians to order syphilis testing in patients undergoing gonorrhoea/chlamydia testing. We performed a retrospective cohort analysis that compared outcomes between the preimplementation period (January-November 2018) and the postimplementation period (January-November 2019). Patients were tested for Treponema pallidum antibody (TPA) using a multiplex flow immunoassay (MFI), and positive results were confirmed by rapid plasma reagin (RPR). The primary implementation outcome was the number of syphilis tests/month, and the primary clinical outcome was the number of syphilis diagnoses/month (defined as positive TPA MFI and RPR). We performed an interrupted time-series analysis to evaluate the effect of implementing the alert over time. RESULTS Four-hundred and ninety-four and 1106 unique patients were tested for syphilis in the preimplementation and postimplementation periods, respectively. Syphilis testing increased by 55.6 tests/month (95% CI 45.9 to 65.3, p<0.001) following alert implementation. Patients tested in the postimplementation period who were tested using the alert were much younger (difference: 14 years (95% CI 12 to 15)) and were more likely to be female (difference: 15% (95% CI 8 to 21)) and African-American (difference: 11% (95% CI 5 to 17)) than patients tested by clinician-initiated testing. Presumptive syphilis diagnoses increased from 3.4 diagnoses/month to 7.9 diagnoses/month (difference, 4.5 (95% CI 2.2 to 6.9), p<0.001). CONCLUSIONS Our study demonstrates that use of a targeted EHR alert testing protocol can increase syphilis testing and diagnosis and may reduce clinician bias in testing.
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Affiliation(s)
- James S Ford
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
| | - Tasleem Chechi
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
| | - Michella Otmar
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
| | - Melissa Baker
- Georgetown University School of Medicine, Washington, DC, USA
| | - Sarah Waldman
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
| | - Brittany Morgan
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
| | - David Tan
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, California, USA
| | - Larissa May
- Department of Emergency Medicine, University of California Davis Health, Sacramento, California, USA
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31
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Patel R, Polage CR, Bard JD, May L, Lee FM, Fabre V, Hayden MK, Doernberg SDB, Haake DA, Trautner BW, Grigoryan L, Tsalik EL, Hanson KE. Envisioning Future UTI Diagnostics. Clin Infect Dis 2021; 74:1284-1292. [PMID: 34463708 DOI: 10.1093/cid/ciab749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Indexed: 11/13/2022] Open
Abstract
Urinary tract infections (UTIs) are among the most common bacterial infections in the United States and are a major driver of antibiotic use - both appropriate and inappropriate - across healthcare settings. UTI treatment has become complex due to antibacterial resistance; one quarter of urinary tract isolates of Escherichia coli in the United States in 2017 were resistant to fluoroquinolones and one third to trimethoprimsulfamethoxazole (1), agents with historically predictable activity against E. coli. As a result, more broad-spectrum antibiotics are being used to treat UTIs, contributing to selection of further antibiotic resistance.
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Affiliation(s)
- Robin Patel
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA. Division of Clinical Microbiology, Mayo Clinic, Rochester, MN, USA
| | | | - Jennifer Dien Bard
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA; Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Larissa May
- Department of Emergency Medicine, University of California-Davis Health, Sacramento, CA, USA
| | - Francesca M Lee
- Division of Infectious Diseases, Department of Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Valeria Fabre
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mary K Hayden
- Division of Infectious Diseases, Rush Medical College, Chicago, IL, USA
| | - Sarah D B Doernberg
- Division of Infectious Disease, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - David A Haake
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, and the Division of Infectious Diseases, Department of Medicine, the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Larissa Grigoryan
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Ephraim L Tsalik
- Duke University Center for Applied Genomics and Precision Medicine, Durham, NC, USA; Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Kimberly E Hanson
- Department of Internal Medicine and Department of Pathology, University of Utah, Salt Lake City, UT, USA
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32
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Solnick RE, May L, Fleegler M, Kocher KE. Are Case Counts Necessary When Facing a Public Health Crisis? Sexually Transmitted Infections Deserve Data. Ann Emerg Med 2021; 78:460-461. [PMID: 34420564 DOI: 10.1016/j.annemergmed.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Rachel E Solnick
- University of Michigan National Clinical Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Emergency Medicine, School of Medicine, University of Michigan, Ann Arbor, MI
| | - Larissa May
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA
| | - Melissa Fleegler
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Keith E Kocher
- Department of Emergency Medicine, School of Medicine, University of Michigan, Ann Arbor, MI; Department of Learning Health Sciences, School of Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
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Colliard A, Pincet L, Simon C, May L, Lambercy K. Free flap for soft palate reconstruction: long-term functional evaluation of a new technique. Eur Arch Otorhinolaryngol 2021; 279:1445-1452. [PMID: 34076726 PMCID: PMC8897334 DOI: 10.1007/s00405-021-06897-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 05/19/2021] [Indexed: 11/30/2022]
Abstract
Purpose The soft palate (SP) has a complex anatomy and physiology. Reconstruction after tumour resection is a challenge, and procedures that only restore bulk don’t give good results. We aim to present a new technique for the in-setting and the functional outcomes. Methods We retrospectively included in a monocentric retrospective cohort study every patient with a first diagnosis of a soft palate squamous cell carcinoma (SPSCC), who underwent a tumoral resection with a free flap reconstruction, from February 2013 to July 2017. For the in-setting, a special care is given for the flap in-setting: we suture the flap more caudally than usual under the tongue base, creating a neo-posterior pilar. The primary outcome was the deglutition function, assessed by the M. D Anderson Dysphagia Inventory (MDADI). We also analyzed the patient’s quality of life with the FOSS score and the occurrence of nasal regurgitation or larynx aspiration. Results We included twenty patients, with a median follow-up of 26.5 months. The median MDADI score was 89, and the mode was 93. A Fisher test shows a significant improvement of MDADI scores for unilateral vs bilateral reconstructions (p = 0.03). The median FOSS score was 2, and the mode was 2. Seven (35%) patients complained of nasal regurgitation, three (15%) reported episodic laryngeal aspiration. Supplementary Information The online version contains supplementary material available at 10.1007/s00405-021-06897-0.
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Affiliation(s)
- A Colliard
- Department of Otorhinolaryngology and Head and Neck Surgery, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon, Service d'ORL, BH 10 CHUV, Avenue du Bugnon, 46-1011, Lausanne, Switzerland
| | - L Pincet
- Department of Otorhinolaryngology and Head and Neck Surgery, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon, Service d'ORL, BH 10 CHUV, Avenue du Bugnon, 46-1011, Lausanne, Switzerland.
| | - C Simon
- Department of Otorhinolaryngology and Head and Neck Surgery, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon, Service d'ORL, BH 10 CHUV, Avenue du Bugnon, 46-1011, Lausanne, Switzerland
| | - L May
- Department of Maxillofacial Surgery, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon, 46-1011, Lausanne, Switzerland
| | - K Lambercy
- Department of Otorhinolaryngology and Head and Neck Surgery, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon, Service d'ORL, BH 10 CHUV, Avenue du Bugnon, 46-1011, Lausanne, Switzerland
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34
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Ford JS, Chechi T, Toosi K, Mahmood B, Meehleis D, Otmar M, Tran N, May L. Universal Screening for Hepatitis C Virus in the ED Using a Best Practice Advisory. West J Emerg Med 2021; 22:719-725. [PMID: 34125052 PMCID: PMC8203013 DOI: 10.5811/westjem.2021.1.49667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/23/2021] [Indexed: 12/26/2022] Open
Abstract
Introduction In 2019 the United States Preventive Services Task Force (USPSTF) released draft guidelines recommending universal hepatitis C virus (HCV) screening for individuals aged 18–79. We aimed to assess the efficacy of an emergency department-based HCV screening program, by comparing screening practices before and after its implementation. Methods We performed a retrospective cohort analysis of two temporally matched, 11-month study periods, corresponding to before and after the implementation of a best practice advisory (BPA). Patients were screened for anti-HCV antibody (Ab), and positive results were followed by HCV viral load (VL) testing. The primary implementation outcome was ED testing volume (number of tests performed/month). The primary screening outcomes were the seroprevalence of anti-HCV Ab and HCV VL. We describe data with simple descriptive statistics. Results The median age of patients was similar between periods (pre: 50 years [interquartile range [IQR] 34–62], post: 47 years [IQR 33–59]). Patients screened were more likely to be males in the pre-BPA period (Male, pre: 60%, post: 49%). During the pre-BPA study period, a total of 69,604 patients were seen in the ED, and 218 unique patients were screened for HCV (mean 19.8 tests/month). During the post-BPA study period, a total of 68,225 patients were seen in the ED, and 14,981 unique patients were screened for HCV (mean 1361.9 tests/month). Anti-HCV Ab seroprevalence was 23% (51/218) and 9% (1340/14,981) in the pre-BPA and post-BPA periods, respectively. In the pre-BPA period, six patients with a positive anti-HCV Ab level had follow-up VL testing (detectable in three). In the post-BPA period, reflex VL testing was performed in most patients (91%, 1225/1,340), and there were 563 patients with detectable VLs, indicating active infection. Conclusion Our study shows that using a universal BPA-driven screening protocol can dramatically increase the number of patients screened for HCV and increase the number of new HCV diagnoses.
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Affiliation(s)
- James S Ford
- UC Davis Health, Department of Emergency Medicine, Sacramento, California
| | - Tasleem Chechi
- UC Davis Health, Department of Emergency Medicine, Sacramento, California
| | - Kavian Toosi
- UC Davis Health, Department of Emergency Medicine, Sacramento, California
| | - Bilawal Mahmood
- UC Davis Health, Department of Emergency Medicine, Sacramento, California
| | - Dillon Meehleis
- UC Davis Health, Department of Emergency Medicine, Sacramento, California
| | - Michella Otmar
- UC Davis Health, Department of Emergency Medicine, Sacramento, California
| | - Nam Tran
- UC Davis Health, Department of Pathology and Laboratory Medicine, Sacramento, California
| | - Larissa May
- UC Davis Health, Department of Emergency Medicine, Sacramento, California
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Blanchard J, Solaipandian M, John EB, Pandith M, Jeo B, Saji S, Kumar A, May L, Davey K, Douglass K, Smith J. Self-prescribing of antibiotics by patients seeking care in Indian emergency departments. J Am Coll Emerg Physicians Open 2021; 2:e12432. [PMID: 33969344 PMCID: PMC8082699 DOI: 10.1002/emp2.12432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/13/2021] [Accepted: 03/23/2021] [Indexed: 11/09/2022] Open
Abstract
STUDY OBJECTIVE Antibiotic resistance is a global health threat. India has one of the highest rates of antibiotic use in the world. The objective of this study was to evaluate the prevalence of self-prescribed antibiotic use of patients presenting with febrile and infectious disease-related complaints to Indian emergency departments. METHODS This was a prospective observational study conducted at 6 Indian emergency departments (EDs) between January 1, 2019 and December 31, 2019. Adult patients who presented with a chief complaint of febrile illness or infectious disease complaints were included. Our principal outcomes of interest were self-prescribed use of antibiotics within the prior 6 months or for the presenting complaint. We queried respondents about source of antibiotics as well as about demographic characteristics that influenced use. RESULTS A total of 1421 patients were enrolled. Sixty percent (n = 856) of respondents reported using antibiotics in the prior 6 months or for their current complaint. Those who reported self-prescribing antibiotics either in the past or currently had at least some college education (P < 0.001), tended to use the pharmacy (P < 0.001) or the ED (P = 0.001) for their care when sick, and were more likely to have some comorbid conditions (P = 0.014) as compared to the group that did not self-prescribe antibiotics. The most common reason respondents reported self-prescribing antibiotics was because they did not want to wait to see their doctor (n = 278, 33%). Thirty-five percent of patients who were self-prescribed antibiotics before presentation did not receive and were not prescribed antibiotics in the ED, at discharge, or both. CONCLUSIONS Self-prescribing of antibiotics occurs commonly in India. This use increases the risk for resistance due to inappropriate or unnecessary use. Promotion of antibiotic stewardship is needed to curtail such use.
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Affiliation(s)
- Janice Blanchard
- Department of Emergency MedicineGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | | | | | - Moin Pandith
- Max Super Specialty HospitalPatparganj, MaxDelhiIndia
| | - Binu Jeo
- Baby Memorial HospitalCalicutKeralaIndia
| | - Sherin Saji
- MGM Muthood Medical Centre HospitalKozhencherryPathanamthittaIndia
| | | | - Larissa May
- Department of Emergency MedicineUniversity of California DavisSacramentoCaliforniaUSA
| | - Kevin Davey
- Department of Emergency MedicineGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Katherine Douglass
- Department of Emergency MedicineGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Jeffrey Smith
- Department of Emergency MedicineGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
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Nandi D, Auerbach S, Bansal N, Kaufman B, Lal A, Law S, Lorts A, May L, Mehegan M, Mokshagundam D, O'connor M, Rosenthal D, Shezad M, Simpson K, Sutcliffe D, VanderPluym C, Wittlieb-Weber C, Zafar F, Cripe L, Villa C. Ventricular Assist Device Outcomes in Children and Young Adults with Muscular Dystrophy: An ACTION Analysis. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Vuillier L, May L, Greville-Harris M, Surman R, Moseley RL. The impact of the COVID-19 pandemic on individuals with eating disorders: the role of emotion regulation and exploration of online treatment experiences. J Eat Disord 2021; 9:10. [PMID: 33436064 PMCID: PMC7802411 DOI: 10.1186/s40337-020-00362-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/17/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The Covid-19 pandemic has wrought disruption to everyday life and services, and emerging evidence suggests that those with eating disorders (EDs) are likely to experience marked distress and exacerbation of their symptoms. However, little is known around the most relevant factors to symptom change; whether certain emotion regulation and coping strategies are linked to better outcomes; and how people with EDs are adjusting to psychological interventions moving online. METHOD In a mixed-method design, we collected qualitative and quantitative data from 207 (76 males) self-selected UK residents with self-reported ED, who described and ranked impacts of the pandemic on their symptoms. Regression analysis examined whether emotion regulation strategies were associated with self-reported symptom change, ED symptomatology, and negative emotional states. Thematic analysis explored participants' experiences of the pandemic, particularly factors affecting their ED, coping strategies used, and experiences of psychological intervention. RESULTS Most participants (83.1%) reported worsening of ED symptomatology, though factors affecting symptom change differed between specific EDs. Emotion regulation, such as having fewer strategies, poorer emotional clarity, and non-acceptance of emotions, explained nearly half of the variance in emotional distress during the pandemic. Qualitative findings indicated that difficult emotions (such as fear and uncertainty), changes to routine, and unhelpful social messages were triggering for participants during the pandemic. While some participants described employing positive coping strategies (such as limiting social media exposure), many reported using ED behaviours (among other maladaptive strategies, like alcohol use) to cope with the pandemic. Finally, loss of treatment support, feeling underserving of support and experiencing a 'detached connection' online were further exacerbating factors for these participants. DISCUSSION While our sample was self-selected and may not represent all people with EDs, our results suggest that people with EDs have been strongly affected by the pandemic. Some aspects of online treatment were found to be beneficial but our findings suggest it also needs some improvement. Our paper discusses implications for online treatment such as taking into account personal circumstances and, in a time where people have limited control over the antecedents of negative emotion, the need to develop skills to manage emotions when they arise.
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Affiliation(s)
- L Vuillier
- Department of Psychology, Bournemouth University, Poole, UK.
| | - L May
- Department of Psychology, Bournemouth University, Poole, UK
- Dorset Healthcare University NHS Foundation Trust, Poole, UK
| | | | - R Surman
- Department of Psychology, Bournemouth University, Poole, UK
| | - R L Moseley
- Department of Psychology, Bournemouth University, Poole, UK
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Huang J, Escobar ZK, Jain R, Chan JD, Lynch JB, D’Angeli MA, May L, Bryson-Cahn C. 136. Don’t Sweat the Small Stuff: Solutions for Large-Scale Stewardship Obstacles. Open Forum Infect Dis 2020. [PMCID: PMC7776268 DOI: 10.1093/ofid/ofaa439.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background In an effort to support stewardship endeavors, the MITIGATE (a Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adult and Children in Emergency Department and Urgent Care Settings) Toolkit was published in 2018, aiming to reduce unnecessary antibiotics for viral respiratory tract infections (RTIs). At the University of Washington, we have incorporated strategies from this toolkit at our urgent care clinics. This study aims to address solutions to some of the challenges we experienced. Challenges and Solutions ![]()
Methods This was a retrospective observational study conducted at Valley Medical Center (Sept 2019-Mar 2020) and the University of Washington (Jan 2019-Feb 2020) urgent care clinics. Patients were identified through ICD-10 diagnosis codes included in the MITIGATE toolkit. The primary outcome was identifying challenges and solutions developed during this process. Results We encountered five challenges during our roll-out of MITIGATE. First, using both ICD-9 and ICD-10 codes can lead to inaccurate data collection. Second, technical support for coding a complex data set is essential and should be accounted for prior to beginning stewardship interventions of this scale. Third, unintentional incorrect diagnosis selection was common and may require reeducation of prescribers on proper selection. Fourth, focusing on singular issues rather than multiple outcomes is more feasible and can offer several opportunities for stewardship interventions. Lastly, changing prescribing behavior can cause unintended tension during implementation. Modifying benchmarks measured, allowing for bi-directional feedback, and identifying provider champions can help maintain open communication. Conclusion Resources such as the MITIGATE toolkit are helpful to implement standardized data driven stewardship interventions. We have experienced some challenges including a complex data build, errors with diagnostic coding, providing constructive feedback while maintaining positive stewardship relationships, and choosing feasible outcomes to measure. We present solutions to these challenges with the aim to provide guidance to those who are considering using this toolkit for outpatient stewardship interventions. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | - Rupali Jain
- University of Washington School of Medicine, Seattle, WA
| | | | | | | | - Larissa May
- University of California Davis, Sacramento, CA
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Escobar ZK, Bouchard T, Lansang JM, Thomassen S, Huang J, Lynch JB, May L, Kvak S, D’Angeli MA, Bryson-Cahn C. 143. Initial Impact of COVID-19 on Ambulatory Antibiotic Prescribing for Respiratory Viral Infections. Open Forum Infect Dis 2020. [PMCID: PMC7777875 DOI: 10.1093/ofid/ofaa439.188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one third of this usage is considered unnecessary. In 2019, our institution implemented the MITIGATE Toolkit, endorsed by the Centers for Disease Control and Prevention to reduce inappropriate antibiotic prescribing for viral respiratory infections in emergency and urgent care settings. In February 2020 we identified our first hospitalized patient with SARS-CoV(2). In March, efforts to limit person-to-person contact led to shelter in place orders and substantial reorganization of our healthcare system. During this time we continued to track rates of unnecessary antibiotic prescribing. Methods This was a single center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. We provided monthly individual feedback to urgent care prescribers, (Sep 2019-Mar 2020), primary care, and ED providers (Jan 2020 – Mar 2020) notifying them of their specific rate of unnecessary antibiotic prescribing and labeling them as a top performer or not a top performer compared to their peers. The primary outcome was rate of inappropriate antibiotic prescribing. Results Pre toolkit intervention, 14,398 patient visits met MITIGATE inclusion criteria and 12% received an antibiotic unnecessarily in Jan-April 2019. Post-toolkit intervention, 12,328 patient visits met inclusion criteria and 7% received an antibiotic unnecessarily in Jan-April 2020. In April 2020, patient visits dropped to 10–50% of what they were in March 2020 and April 2019. During this time the unnecessary antibiotic prescribing rate doubled in urgent care to 7.8% from 3.6% the previous month and stayed stable in primary care and the ED at 3.2% and 11.8% respectively in April compared to 4.6% and 10.4% in the previous month. Conclusion Rates of inappropriate antibiotic prescribing were reduced nearly in half from 2019 to 2020 across 3 ambulatory care settings. The increase in prescribing in April seen in urgent care and after providers stopped receiving their monthly feedback is concerning. Many factors may have contributed to this increase, but it raises concerns for increased inappropriate antibacterial usage as a side effect of the SARS-CoV(2) pandemic. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | | | | | | | | | - Larissa May
- University of California Davis, Sacramento, CA
| | - Staci Kvak
- Washington State Department of Health, Shoreline, WA
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May L, Martín Quirós A, Ten Oever J, Hoogerwerf J, Schoffelen T, Schouten J. Antimicrobial stewardship in the emergency department: characteristics and evidence for effectiveness of interventions. Clin Microbiol Infect 2020; 27:204-209. [PMID: 33144202 DOI: 10.1016/j.cmi.2020.10.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Emergency departments (EDs) are the entrance gates for patients presenting with infectious diseases into the hospital, yet most antimicrobial stewardship programmes are primarily focused on inpatient management. With equally high rates of inappropriate antibiotic use, the ED is a frequently overlooked yet important unit for targeted antimicrobial stewardship (AMS) interventions. OBJECTIVES We aimed to (a) describe the specific aspects of antimicrobial stewardship in the ED and (b) summarize the findings from improvement studies that have investigated the effectiveness of antimicrobial stewardship interventions in the ED setting. SOURCES (a) a PubMed search for 'antimicrobial stewardship' and 'emergency department', and (b) published reviews on effectiveness combined with publications from the first source. CONTENT (a) An in depth analysis of selected publications provided four key antimicrobial use processes typically performed by front-line healthcare professionals in the ED: making a (tentative) clinical diagnosis, starting empirical therapy based on that diagnosis, performing microbiological tests before starting that therapy and following up patients who are discharged from the ED. (b) Further, we discuss the literature on improvement strategies in the ED focusing on guidelines and clinical pathways and multifaceted improvement strategies. We also summarize the evidence of microbiologic culture review. IMPLICATIONS Based on our review of the literature, we describe four essential elements of antimicrobial use in the ED. Studying the various interventions targeting these care processes, we have found them to be of a variable degree of success. Nonetheless, while there is a paucity of AS studies specifically targeting the ED, there is a growing body of evidence that AS programmes in the ED are effective with modifications to the ED setting. We present key questions for future research.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California Davis, Sacramento, CA, USA
| | | | - Jaap Ten Oever
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jacobien Hoogerwerf
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Teske Schoffelen
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.
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May L, Nguyen MH, Trajano R, Tancredi D, Aliyev ER, Mooso B, Anderson C, Ondak S, Yang N, Cohen S, Wiedeman J, Miller LG. A multifaceted intervention improves antibiotic stewardship for skin and soft tissues infections. Am J Emerg Med 2020; 46:374-381. [PMID: 33139143 DOI: 10.1016/j.ajem.2020.10.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 10/08/2020] [Accepted: 10/10/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Assess the effectiveness of a multifaceted stewardship intervention to reduce frequency and duration of inappropriate antibiotic use for emergency department (ED) patients with skin and soft tissue infections (SSTI). We hypothesized the antibiotic stewardship program would reduce antibiotic duration and improve guideline adherence in discharged SSTI patients. DESIGN Nonrandomized controlled trial. SETTING Academic EDs (intervention site and control site). PATIENTS OR PARTICIPANTS Attending physicians and nurse practitioners at participating EDs. INTERVENTION(S) Education regarding guideline-based treatment of SSTI, tests of antimicrobial treatment of SSTI, implementation of a clinical treatment algorithm and order set in the electronic health record, and ED clinicians' audit and feedback. RESULTS We examined 583 SSTIs. At the intervention site, clinician adherence to guidelines improved from 41% to 51% (aOR = 2.13 [95% CI: 1.20-3.79]). At the control site, there were no changes in adherence during the "intervention" period (aOR = 1.17 [0.65-2.12]). The between-site comparison of these during vs. pre-intervention odds ratios was not different (aOR = 1.82 [0.79-4.21]). Antibiotic duration decreased by 26% at the intervention site during the intervention compared to pre-intervention (Adjusted Geometric Mean Ratio [95% CI] = 0.74 [0.66-0.84]). Adherence was inversely associated with SSTI severity (severe vs mild; adjusted OR 0.42 [0.20-0.89]) and purulence (0.32 [0.21-0.47]). Mean antibiotic prescription duration was 1.95 days shorter (95% CI: 1.54-2.33) in the time period following the intervention than pre-intervention period. CONCLUSIONS A multifaceted intervention resulted in modest improvement in adherence to guidelines compared to a control site, driven by treatment duration reductions.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California, Davis, 2315 Stockton Blvd., Sacramento, CA 96817, USA.
| | - Megan H Nguyen
- Western University of Health Sciences, Pomona, CA, United States of America; Division of Infectious Diseases, Harbor-UCLA Medical Center, 1124 West Carson Street, Torrance, CA 90502, United States of America.
| | - Renee Trajano
- Department of Emergency Medicine, University of California, Davis, 2315 Stockton Blvd., Sacramento, CA 96817, USA
| | - Daniel Tancredi
- Department of Pediatrics, University of California, Davis, 2516 Stockton Blvd., Sacramento, CA 95817, USA.
| | - Elmar R Aliyev
- Health Economics Department, School of Pharmacy, University of Southern California, 1985 Zonal Avenue, Los Angeles, CA 90089, USA.
| | - Benjamin Mooso
- Department of Emergency Medicine, University of California, Davis, 2315 Stockton Blvd., Sacramento, CA 96817, USA.
| | - Chance Anderson
- Department of Emergency Medicine, University of California, Davis, 2315 Stockton Blvd., Sacramento, CA 96817, USA.
| | - Susan Ondak
- Department of Emergency Medicine, University of California, Davis, 2315 Stockton Blvd., Sacramento, CA 96817, USA
| | - Nuen Yang
- Division of Biostatistics, University of California, Davis, One Shields Avenue, Davis, CA 95616, USA.
| | - Stuart Cohen
- Division of Infectious Diseases, University of California, Davis, 4150 V Street, Sacramento, CA 95817, USA.
| | - Jean Wiedeman
- Department of Pediatrics, University of California, Davis, 2516 Stockton Blvd., Sacramento, CA 95817, USA.
| | - Loren G Miller
- Division of Infectious Diseases, UCLA Medical Center, 1000 W. Carson St. Box 466, Torrance, CA 90509, USA.
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Ford JS, Parikh A, Sandhu R, Turnipseed S, Morris B, May L, Holmes JF. Testing Asymptomatic Emergency Department Patients for Coronavirus Disease 2019 (COVID-19) in a Low-prevalence Region. Acad Emerg Med 2020; 27:771-774. [PMID: 32516467 PMCID: PMC7300628 DOI: 10.1111/acem.14044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 12/16/2022]
Affiliation(s)
- James S. Ford
- From the University of California Davis Health Sacramento CA USA
| | - Aman Parikh
- From the University of California Davis Health Sacramento CA USA
| | - Rupinder Sandhu
- From the University of California Davis Health Sacramento CA USA
| | | | - Beth Morris
- From the University of California Davis Health Sacramento CA USA
| | - Larissa May
- From the University of California Davis Health Sacramento CA USA
| | - James F. Holmes
- From the University of California Davis Health Sacramento CA USA
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Bouzid D, Zanella MC, Kerneis S, Visseaux B, May L, Schrenzel J, Cattoir V. Rapid diagnostic tests for infectious diseases in the emergency department. Clin Microbiol Infect 2020; 27:182-191. [PMID: 32120036 PMCID: PMC7129254 DOI: 10.1016/j.cmi.2020.02.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 02/12/2020] [Accepted: 02/17/2020] [Indexed: 12/23/2022]
Abstract
Background Rapid diagnostic tests (RDTs) for infectious diseases, with a turnaround time of less than 2 hours, are promising tools that could improve patient care, antimicrobial stewardship and infection prevention in the emergency department (ED) setting. Numerous RDTs have been developed, although not necessarily for the ED environment. Their successful implementation in the ED relies on their performance and impact on patient management. Objectives The aim of this narrative review was to provide an overview of currently available RDTs for infectious diseases in the ED. Sources PubMed was searched through August 2019 for available studies on RDTs for infectious diseases. Inclusion criteria included: commercial tests approved by the US Food and Drug Administration (FDA) or Conformité Européenne (CE) in vitro diagnostic devices with data on clinical samples, ability to run on fully automated systems and result delivery within 2 hours. Content A nonexhaustive list of representative commercially available FDA- or CE-approved assays was categorized by clinical syndrome: pharyngitis and upper respiratory tract infection, lower respiratory tract infection, gastrointestinal infection, meningitis and encephalitis, fever in returning travellers and sexually transmitted infection, including HIV. The performance of tests was described on the basis of clinical validation studies. Further, their impact on clinical outcomes and anti-infective use was discussed with a focus on ED-based studies. Implications Clinicians should be familiar with the distinctive features of each RDT and individual performance characteristics for each target. Their integration into ED work flow should be preplanned considering local constraints of given settings. Additional clinical studies are needed to further evaluate their clinical effectiveness and cost-effectiveness.
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Affiliation(s)
- D Bouzid
- Emergency Department, AP-HP, Bichat Claude Bernard Hospital, Paris, France; University of Paris, IAME, INSERM, Paris, France
| | - M-C Zanella
- Laboratory of Bacteriology, Division of Laboratory Medicine and Division of Infectious Diseases, University of Geneva Hospitals, Geneva, Switzerland; University of Geneva Medical School, Geneva, Switzerland
| | - S Kerneis
- University of Paris, IAME, INSERM, Paris, France; AP-HP, Antimicrobial Stewardship Team, Hôpitaux Universitaires Paris Centre-Cochin, Paris, France; Pharmacoepidémiology and Infectious Diseases (Phemi), Pasteur Institute, Paris, France
| | - B Visseaux
- University of Paris, IAME, INSERM, Paris, France; AP-HP, Bichat Claude Bernard Hospital, Virology, Paris, France
| | - L May
- Department of Emergency Medicine, University of California-Davis, Sacramento, CA, USA
| | - J Schrenzel
- Laboratory of Bacteriology, Division of Laboratory Medicine and Division of Infectious Diseases, University of Geneva Hospitals, Geneva, Switzerland; University of Geneva Medical School, Geneva, Switzerland; Genomic Research Laboratory, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - V Cattoir
- Service de Bactériologie-Hygiène Hospitalière, CHU de Rennes, Rennes, France; CNR de `la Résistance aux Antibiotiques (laboratoire associé'Entérocoques), Rennes, France; Unité Inserm U1230, Université de Rennes 1, Rennes, France.
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Yadav K, Stahmer A, Mistry RD, May L. An Implementation Science Approach to Antibiotic Stewardship in Emergency Departments and Urgent Care Centers. Acad Emerg Med 2020; 27:31-42. [PMID: 31625653 DOI: 10.1111/acem.13873] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/08/2019] [Accepted: 10/13/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antibiotic stewardship efforts have expanded focus from inpatient to include outpatient settings. However, stewardship is urgently needed in acute care ambulatory settings: emergency departments (EDs) and urgent care centers (UCCs). Implementation of antibiotic stewardship in acute ambulatory care settings has been limited. Two major barriers to effective implementation exist: 1) lack of adaptation of successful outpatient stewardship interventions to the acute care ambulatory setting and 2) absence of rigorous measurement of implementation processes in EDs and UCCs in a manner that informs future scale and spread. OBJECTIVES Our objective was to apply an implementation science approach to address antibiotic overuse and inappropriate use in EDs and UCCs. METHODS This study was a redesign of an evidence-based outpatient antibiotic stewardship intervention at participating EDs and UCCs using an innovative implementation science framework (dynamic adaptation process), adaptable for local clinical workflow and local champion provision. We evaluated multiple implementation outcome metrics throughout a cluster-randomized comparative effectiveness clinical trial of two approaches to the adapted antibiotic stewardship interventions. RESULTS Our preimplementation phase included 21 in-depth interviews and online provider surveys (52% response rate). For the postimplementation survey, we had a 39% response rate. We identified common themes including patient expectations, lack of knowledge of existing guidelines, and maintenance of education over time. Additional themes indicated differences in modifications needed by type of clinical setting. Adoption of public commitment was high, with 79% of providers signing a commitment log, and 84% received public commitment flair. Signing of public commitment posters rate was 62%, as several sites chose not to use this component. Acceptability, fidelity, and appropriateness were also measured. CONCLUSIONS We demonstrate that implementation science approaches can help address the problem of unnecessary antibiotic use in EDs and UCCs with high acceptability and adoption. Similar approaches could be used to tailor quality improvement interventions in these settings.
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Affiliation(s)
- Kabir Yadav
- Department of Emergency Medicine Harbor‐UCLA Medical Center TorranceCA
- Lundquist Institute Torrance CA
| | - Aubyn Stahmer
- Department of Psychiatry and Behavioral Sciences University of California‐Davis Sacramento CA
| | - Rakesh D. Mistry
- Department of Pediatrics Section of Emergency Medicine Children’s Hospital of Colorado Aurora CO
| | - Larissa May
- Department of Emergency Medicine University of California‐Davis Sacramento CA
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May L, Tatro G, Poltavskiy E, Mooso B, Hon S, Bang H, Polage C. Rapid Multiplex Testing for Upper Respiratory Pathogens in the Emergency Department: A Randomized Controlled Trial. Open Forum Infect Dis 2019; 6:ofz481. [PMID: 32128326 PMCID: PMC7043218 DOI: 10.1093/ofid/ofz481] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/04/2019] [Indexed: 01/10/2023] Open
Abstract
Background Acute upper respiratory tract infections are a common cause of emergency department (ED) visits and often result in unnecessary antibiotic treatment. Methods We conducted a randomized clinical trial to evaluate the impact of a rapid, multipathogen respiratory panel (RP) test vs usual care (control). Patients were eligible if they were ≥12 months old, had symptoms of upper respiratory infection or influenza-like illness, and were not on antibiotics. The primary outcome was antibiotic prescription; secondary outcomes included antiviral prescription, disposition, and length of stay (ClinicalTrials.gov# NCT02957136). Results Of 191 patients enrolled, 93 (49%) received RP testing; 98 (51%) received usual care. Fifty-three (57%) RP and 7 (7%) control patients had a virus detected and reported during the ED visit (P = .0001). Twenty (22%) RP patients and 33 (34%) usual care patients received antibiotics during the ED visit (–12%; 95% confidence interval, –25% to 0.4%; P = .06/0.08); 9 RP patients received antibiotics despite having a virus detected. The magnitude of antibiotic reduction was greater in children (–19%) vs adults (–9%, post hoc analysis). There was no difference in antiviral use, length of stay, or disposition. Conclusions Rapid RP testing was associated with a trend toward decreased antibiotic use, suggesting a potential benefit from more rapid viral tests in the ED. Future studies should determine if specific groups are more likely to benefit from testing and evaluate the relative cost and effectiveness of broad testing, focused testing, and a combined diagnostic and antimicrobial stewardship approach.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Grant Tatro
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Eduard Poltavskiy
- Graduate Group in Epidemiology, University of California Davis, Davis, California, USA
| | - Benjamin Mooso
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Simson Hon
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Heejung Bang
- Graduate Group in Epidemiology, University of California Davis, Davis, California, USA.,Department of Public Health Sciences, University of California Davis, Davis, California, USA
| | - Christopher Polage
- Department of Pathology, University of California Davis, Sacramento, California, USA.,Department of Pathology, Duke University, Durham, North Carolina, USA
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Kassamali Z, Bryson-Cahn C, Bouchard T, Min Lee K, G. Lansang JM, Thomassen S, Lynch JB, Lynch JB, May L, Kvak S, D’Angeli MA. 2073. Apples and Oranges: Comparing Toolkits to Track Antimicrobial Prescribing in Ambulatory Care Settings. Open Forum Infect Dis 2019. [PMCID: PMC6809970 DOI: 10.1093/ofid/ofz360.1753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one-third of this usage is considered unnecessary. Multiple tools have emerged to evaluate antibiotic prescribing in ambulatory settings. The toolkits, MITIGATE and Choosing Wisely, have been funded by the Centers for Disease Control and Prevention and promoted by the American Board of Internal Medicine, respectively, but use different reporting criteria. Notably, the target rate of antibiotic prescribing in the MITIGATE framework is zero, whereas the target rate for Choosing Wisely is not zero because it includes diagnoses for which an antibiotic may be appropriate. We compared both to evaluate prescribing in primary care and specialty clinics, urgent care, and the emergency department. Methods This was a single-center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. The primary outcome was rate of inappropriate antibiotic prescribing overall and in each of the individual settings. Results Between March 2018 and April 2019, 42,650 patient visits met MITIGATE inclusion criteria and 11% received an antibiotic unnecessarily. In the same time-period, 23,366 patient visits met Choosing Wisely inclusion criteria and 17% received an antibiotic unnecessarily. Within the MITIGATE framework, inappropriate prescribing was highest in the ED (17%), followed by primary care (12%), urgent care (10%), and specialty care (5%). Choosing Wisely, inappropriate prescribing was highest in primary care (23%), followed by urgent care (15%), and specialty care (8%). The ED was not included in the Choosing Wisely technical specifications. The top coded diagnosis in both frameworks was acute respiratory infection, unspecified. Conclusion Rates of inappropriate antibiotic prescribing varied widely depending upon the toolkit used. Inappropriate antibiotic prescribing in primary care by Choosing Wisely framework was double that of MITIGATE. Careful consideration of the differences and goals of using these toolkits is needed both on the local level for individual provider feedback and more broadly, when comparing prescribing rates between institutions. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Zahra Kassamali
- University of Washington Medicine, Valley Medical Center, University of Washington, Seattle, Washington
| | | | - Todd Bouchard
- University of Washington Medicine, Valley Medical Center, Renton, Washington
| | - Kyung Min Lee
- University of Washington Medicine, Valley Medical Center, Renton, Washington
| | | | - Scott Thomassen
- University of Washington Medicine, Valley Medical Center, Renton, Washington
| | - John B Lynch
- University of Washington School of Medicine, Seattle, Washington
| | - John B Lynch
- University of Washington School of Medicine, Seattle, Washington
| | - Larissa May
- University of California - Davis, Sacramento, California
| | - Staci Kvak
- Washington State Department of Health, Shoreline, Washington
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Affiliation(s)
| | | | - Larissa May
- Department of Emergency Medicine, Davis School of Medicine, University of California Davis Health , Sacramento , CA , USA
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Yadav K, Meeker D, Mistry RD, Doctor JN, Fleming‐Dutra KE, Fleischman RJ, Gaona SD, Stahmer A, May L. A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings. Acad Emerg Med 2019; 26:719-731. [PMID: 31215721 DOI: 10.1111/acem.13690] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 10/29/2018] [Accepted: 12/22/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antibiotics are commonly prescribed during emergency department (ED) and urgent care center (UCC) visits for viral acute respiratory infection (ARI). We evaluate the comparative effectiveness of an antibiotic stewardship intervention adapted for acute care ambulatory settings (adapted intervention) to a stewardship intervention that additionally incorporates behavioral nudges (enhanced intervention) in reducing inappropriate prescriptions. METHODS This study was a pragmatic, cluster-randomized clinical trial conducted in three academic health systems comprising five adult and pediatric EDs and four UCCs. Randomization of the nine sites was stratified by health system; all providers at each site received either the adapted or the enhanced intervention. The main outcome was the proportion of antibiotic-inappropriate ARI diagnosis visits that received an outpatient antibiotic prescription by individual providers. We estimated a hierarchical mixed-effects logistic regression model comparing visits during the influenza season for 2016 to 2017 (baseline) and 2017 to 2018 (intervention). RESULTS There were 44,820 ARI visits among 292 providers across all nine cluster sites. Antibiotic prescribing for ARI visits dropped from 6.2% (95% confidence interval [CI] = 4.5% to 7.9%) to 2.4% (95% CI = 1.3% to 3.4%) during the study period. We found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.2% (95% CI = 1.0% to 3.4%) to 1.5% (95% CI = 0.7% to 2.3%) with an odds ratio of 0.67 (95% CI = 0.54 to 0.82). Difference-in-differences between the two interventions was not significantly different. CONCLUSION Implementation of antibiotic stewardship for ARI is feasible and effective in the ED and UCC settings. More intensive behavioral nudging methods were not more effective in high-performance settings.
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Affiliation(s)
- Kabir Yadav
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
- Los Angeles Biomedical Research Institute Torrance CA
| | - Daniella Meeker
- Schaeffer Center for Health Policy and Economics University of Southern California Los Angeles CA
| | - Rakesh D. Mistry
- Department of Pediatrics Section of Emergency Medicine Children's Hospital of Colorado Aurora CO
| | - Jason N. Doctor
- Schaeffer Center for Health Policy and Economics University of Southern California Los Angeles CA
| | | | | | - Samuel D. Gaona
- Department of Emergency Medicine University of California–Davis SacramentoCA
| | - Aubyn Stahmer
- Department of Psychiatry and Behavioral Sciences University of California–Davis SacramentoCA
| | - Larissa May
- Department of Emergency Medicine University of California–Davis SacramentoCA
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Lammer F, May L, Martus P, Schroers R, Schlegel U, Hofer S, Bairey O, Schmitz N, Griesinger F, Schmidt-Hieber M, Weißinger F, Reimer P, le Coutre P, Fix P, Hopfer O, Junghanß C, Höffkes H, Heilmeier B, Möhle R, Lange E, Korfel A, Keller U. PROSPECTIVE MULTICENTER REGISTRY FOR SECONDARY CNS INVOLVEMENT IN MALIGNANT LYMPHOMA: AN UPDATE WITH DATA FROM 181 PATIENTS. Hematol Oncol 2019. [DOI: 10.1002/hon.64_2630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- F. Lammer
- Haematology; Oncology, Charité University Medicine; Berlin Germany
| | - L. May
- Haematology; Oncology, Charité University Medicine; Berlin Germany
| | - P. Martus
- Institute of Clinical Epidemiology and Applied Biostatistics; University Hospital Tübingen; Tübingen Germany
| | - R. Schroers
- Haematology; Oncology, Knappschaftskrankenhaus, Ruhr-Universität Bochum; Bochum Germany
| | - U. Schlegel
- Neurology; Knappschaftskrankenhaus, Ruhr-Universität Bochum; Bochum Germany
| | - S. Hofer
- Oncology; Luzerner Kantonsspital; Luzern Switzerland
| | - O. Bairey
- Haematology; Tel Aviv University; Tel Aviv Israel
| | - N. Schmitz
- Haematology; Oncology, Universitätsklinikum Münster; Münster Germany
| | - F. Griesinger
- Haematology; Oncology, Pius Hospital Oldenburg; Oldenburg Germany
| | | | - F. Weißinger
- Haematology; Oncology, Evangelisches Klinikum Bethel; Bielefeld Germany
| | - P. Reimer
- Haematology; Oncology, St. Josef Krankenhaus Essen-Werden; Essen Germany
| | - P. le Coutre
- Haematology; Oncology, Charité University Medicine; Berlin Germany
| | - P. Fix
- Haematology; Oncology, Klinikum Weimar; Weimar Germany
| | - O. Hopfer
- Haematology; Oncology, Klinikum Frankfurt (Oder); Frankfurt (Oder) Germany
| | - C. Junghanß
- Haematology; Oncology, University Rostock; Rostock Germany
| | - H. Höffkes
- Haematology; Oncology, Klinikum Fulda; Fulda Germany
| | - B. Heilmeier
- Oncology; Krankenhaus Barmherzige Brüder; Regensburg Germany
| | - R. Möhle
- Haematology; Oncology, University Hospital Tübingen; Tübingen Germany
| | - E. Lange
- Haematology; Oncology, Evangelisches Krankenhaus Hamm; Hamm Germany
| | - A. Korfel
- Haematology; Oncology, Charité University Medicine; Berlin Germany
| | - U. Keller
- Haematology; Oncology, Charité University Medicine; Berlin Germany
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Broniatowski DA, Klein EY, May L, Martinez EM, Ware C, Reyna VF. Patients' and Clinicians' Perceptions of Antibiotic Prescribing for Upper Respiratory Infections in the Acute Care Setting. Med Decis Making 2019; 38:547-561. [PMID: 29847253 DOI: 10.1177/0272989x18770664] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Reducing inappropriate prescribing is key to mitigating antibiotic resistance, particularly in acute care settings. Clinicians' prescribing decisions are influenced by their judgments and actual or perceived patient expectations. Fuzzy trace theory predicts that patients and clinicians base such decisions on categorical gist representations that reflect the bottom-line understanding of information about antibiotics. However, due to clinicians' specialized training, the categorical gists driving clinicians' and patients' decisions might differ, which could result in mismatched expectations and inefficiencies in targeting interventions. We surveyed clinicians and patients from 2 large urban academic hospital emergency departments (EDs) and a sample of nonpatient subjects regarding their gist representations of antibiotic decisions, as well as relevant knowledge and expectations. Results were analyzed using exploratory factor analysis (EFA) and multifactor regression. In total, 149 clinicians (47% female; 74% white), 519 online subjects (45% female; 78% white), and 225 ED patients (61% female; 56% black) completed the survey. While clinicians demonstrated greater knowledge of antibiotics and concern about side effects than patients, the predominant categorical gist for both patients and clinicians was "why not take a risk," which compares the status quo of remaining sick to the possibility of benefit from antibiotics. This gist also predicted expectations and prior prescribing in the nonpatient sample. Other representations reflected the gist that "germs are germs" conflating bacteria and viruses, as well as perceptions of side effects and efficacy. Although individually rational, reliance on the "why not take a risk" representation can lead to socially suboptimal results, including antibiotic resistance and individual patient harm due to adverse events. Changing this representation could alter clinicians' and patients' expectations, suggesting opportunities to reduce overprescribing.
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Affiliation(s)
- David A Broniatowski
- Department of Engineering Management and Systems Engineering, The George Washington University, Washington, DC, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA.,Center for Disease Dynamics, Economics, & Policy, Washington, DC, USA
| | - Larissa May
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA
| | - Elena M Martinez
- Center for Disease Dynamics, Economics, & Policy, Washington, DC, USA
| | - Chelsea Ware
- Department of Medicine, The GW Medical Faculty Associates, Washington, DC, USA
| | - Valerie F Reyna
- Departments of Human Development and Psychology, Center for Behavioral Economics and Decision Research and Human Neuroscience Institute, Cornell University, Ithaca, NY, USA
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