Depressive symptoms,physical symptoms,and health-related quality of life among older adults with HIV

Quality of Life Research - In the United States, approximately 45% of persons living with HIV (PLHIV) are ≥ 50 years of age. Many older PLHIV have multi-morbidities that...     

The chances that an emergency physician will demonstrate three abdominal aortic aneurysms by ultrasound in the emergency department for credentialing: A statistician's view

The Australasian College for Emergency Medicine requires 15 proctored examinations of the aorta for credentialing in ultrasonography for abdominal aortic aneurysm (AAA). Furthermore, at least three examinations need to be positive for an aneurysm. In the ED where AAA presentations are sporadic, what are the chances that an emergency physician (EP) will have the opportunity to demonstrate three AAAs in the next 12 months? The probability of an event occurring within a given time‐frame can be modelled by the Poisson distribution. Central to the Poisson distribution is the infrequency of the event such as encountering an AAA in the ED. An EP working 30 clinical hours/week in our tertiary‐referral hospital ED can be expected to encounter 15.6 (3.6 symptomatic + 12 asymptomatic) AAA in the next 12 months. The probability of seeing three or more cases during this time is 99.9%. Assuming a proctor can be found for half the cases, the probability of an EP performing proctored ultrasound examinations in at least three AAAs is 98%. This probability drops to 89% if a proctor can be found for only one‐third of cases. For an EP to be almost 100% certain of meeting the credentialing requirements, he/she would need almost 10 proctored ultrasound cases of AAA to be available within his/her shifts during the year. The Poisson distribution has enabled us to model the probability of encountering a given number of AAA in the ED. Analysis such as this may help rationalise the numbers needed for credentialing.     

Derivation and Multicenter Validation of the Drug Resistance in Pneumonia Clinical Prediction Score

The health care-associated pneumonia (HCAP) criteria have a limited ability to predict pneumonia caused by drug-resistant bacteria and favor the overutilization of broad-spectrum antibiotics. We aimed to derive and validate a clinical prediction score with an improved ability to predict the risk of pneumonia due to drug-resistant pathogens compared to that of HCAP criteria. A derivation cohort of 200 microbiologically confirmed pneumonia cases in 2011 and 2012 was identified retrospectively. Risk factors for pneumonia due to drug-resistant pathogens were evaluated by logistic regression, and a novel prediction score (the drug resistance in pneumonia [DRIP] score) was derived. The score was then validated in a prospective, observational cohort of 200 microbiologically confirmed cases of pneumonia at four U.S. centers in 2013 and 2014. The DRIP score (area under the receiver operator curve [AUROC], 0.88 [95% confidence interval {CI}, 0.82 to 0.93]) performed significantly better (P = 0.02) than the HCAP criteria (AUROC, 0.72 [95% CI, 0.64 to 0.79]). At a threshold of ≥4 points, the DRIP score demonstrated a sensitivity of 0.82 (95% CI, 0.67 to 0.88), a specificity of 0.81 (95% CI, 0.73 to 0.87), a positive predictive value (PPV) of 0.68 (95% CI, 0.56 to 0.78), and a negative predictive value (NPV) of 0.90 (95% CI, 0.81 to 0.93). By comparison, the performance of HCAP criteria was less favorable: sensitivity was 0.79 (95% CI, 0.67 to 0.88), specificity was 0.65 (95% CI, 0.56 to 0.73), PPV was 0.53 (95% CI, 0.42 to 0.63), and NPV was 0.86 (95% CI, 0.77 to 0.92). The overall accuracy of the HCAP criteria was 69.5% (95% CI, 62.5 to 75.7%), whereas that of the DRIP score was 81.5% (95% CI, 74.2 to 85.6%) (P = 0.005). Unnecessary extended-spectrum antibiotics were recommended 46% less frequently by applying the DRIP score (25/200, 12.5%) than by use of HCAP criteria (47/200, 23.5%) (P = 0.004), without increasing the rate at which inadequate treatment recommendations were made. The DRIP score was more predictive of the risk of pneumonia due to drug-resistant pathogens than HCAP criteria and may have the potential to decrease antibiotic overutilization in patients with pneumonia. Validation in larger cohorts of patients with pneumonia due to all causes is necessary.     

Nurse–physician collaboration in an academic medical centre: The influence of organisational and individual factors

Ineffective physician–nurse collaboration has been recognised to adversely impact patient and organisational outcomes, and some studies suggest an underlying factor may be that nurses and physicians have different perceptions of interprofessional collaboration (IPC). The objectives of this study were to evaluate for a difference in the perception of IPC between physicians and nurses and to explore potential contributing factors at the individual and organisational levels to any observed difference. Data including measures of perceptions of IPC were collected from a convenience sample of resident physicians (n = 47), attending physicians (n = 18), and nurses (n = 54) providing care for internal medicine patients in a large tertiary care academic medical centre. Regression analysis revealed significantly lower perceptions of IPC scores for nurses in comparison to the scores of both the resident and attending physician groups (p = .0001 for both). Although demographic and workload factors also differed by profession, only profession and workload remained significant in regression analysis. Given the known relationships between effective physician–nurse collaboration and superior patient and organisational outcomes, better defining the individual and organisational predictors of IPC scores may support development of more effective interventions targeting improvements in IPC.     

Slipped capital femoral epiphysis with severe vitamin D deficiency

Slipped capital femoral epiphysis is a relatively common disorder in late childhood and early adolescence, with an incidence in the United States of approximately 10 per 100,000. Although clinicians have theorized that contributing factors to the development of slipped capital femoral epiphysis include 25-hydroxyvitamin D deficiency and other nutritional deficiencies, the roles of these factors have not been fully analyzed. This article presents a case of a morbidly obese 13-year-old African-American boy who presented with sudden worsening of chronic hip pain and was diagnosed with stable, bilateral, grade-III slipped capital femoral epiphysis and severe vitamin D deficiency. He was initially treated with bilateral single-screw percutaneous fixation, however, after continued pain and nonunion, a right valgus subtrochanteric osteotomy was performed in association with correction of his severe vitamin D deficiency. This procedure led to improvement of his hip function and successful resolution of the pain. Approximately 3 months after the second operation and vitamin supplementation, the patient had signs of union, and his weight bearing progressed without discomfort. Although the osteotomy provided substantial biomechanical advantage by changing the forces across the physis from shear to compressive, correction of the vitamin D deficiency was critical in providing metabolic capacity for bone healing. Vitamin D plays an important role in bone formation and development, but the level of 25-hydroxyvitamin D is not routinely measured during assessment and treatment of slipped capital femoral epiphysis patients. The early detection and proper treatment of vitamin D may assist in the treatment of patients with slipped capital femoral epiphysis.     

Coccydynia: a review of pathoanatomy, aetiology, treatment and outcome

Coccydynia is a painful disorder characterised by coccygeal pain which is typically exaggerated by pressure. It remains an unsolved mystery because of the perceived unpredictability of the origin of the pain, some psychological traits that may be associated with the disorder, the presence of diverse treatment options, and varied outcomes. A more detailed classification based on the aetiology and pathoanatomy of coccydynia helps to identify patients who may benefit from conservative and surgical management. This review focuses on the pathoanatomy, aetiology, clinical features, radiology, treatment and outcome of coccydynia.