Increased Clinical and Economic Burden Associated With Peripheral Intravenous Catheter-Related Complications: Analysis of a US Hospital Discharge Database.

The burden of complications associated with peripheral intravenous use is underevaluated, in part, due to the broad use, inconsistent coding, and lack of mandatory reporting of these devices. This study aimed to analyze the clinical and economic impact of peripheral intravenous-related complications on hospitalized patients. This analysis of Premier Perspective® Database US hospital discharge records included admissions occurring between July 1, 2013 and June 30, 2015 for pneumonia, chronic obstructive pulmonary disease, myocardial infarction, congestive heart failure, chronic kidney disease, diabetes with complications, and major trauma (hip, spinal, cranial fractures). Admissions were assumed to include a peripheral intravenous. Admissions involving surgery, dialysis, or central venous lines were excluded. Multivariable analyses compared inpatient length of stay, cost, admission to intensive care unit, and discharge status of patients with versus without peripheral intravenous-related complications (bloodstream infection, cellulitis, thrombophlebitis, other infection, or extravasation). Models were conducted separately for congestive heart failure, chronic obstructive pulmonary disease, diabetes with complications, and overall (all 7 diagnoses) and adjusted for demographics, comorbidities, and hospital characteristics. We identified 588 375 qualifying admissions: mean (SD), age 66.1 (20.6) years; 52.4% female; and 95.2% urgent/emergent admissions. Overall, 1.76% of patients (n = 10 354) had peripheral intravenous-related complications. In adjusted analyses between patients with versus without peripheral intravenous complications, the mean (95% confidence interval) inpatient length of stay was 5.9 (5.8-6.0) days versus 3.9 (3.9-3.9) days; mean hospitalization cost was $10 895 ($10 738-$11 052) versus $7009 ($6988-$7031). Patients with complications were less likely to be discharged home versus those without (62.4% [58.6%-66.1%] vs 77.6% [74.6%-80.5%]) and were more likely to have died (3.6% [2.9%-4.2%] vs 0.7% [0.6%-0.9%]). Models restricted to single admitting diagnosis were consistent with overall results. Patients with peripheral intravenous-related complications have longer length of stay, higher costs, and greater risk of death than patients without such complications; this is true across diagnosis groups of interest. Future research should focus on reducing these complications to improve clinical and economic outcomes.

The Impact of Hurricane Sandy on HIV Testing Rates: An Interrupted Time Series Analysis, January 1, 2011‒December 31, 2013.

BACKGROUND: Hurricane Sandy made landfall on the eastern coast of the United States on October 29, 2012 resulting in 117 deaths and 71.4 billion dollars in damage. Persons with undiagnosed HIV infection might experience delays in diagnosis testing, status confirmation, or access to care due to service disruption in storm-affected areas. The objective of this study is to describe the impact of Hurricane Sandy on HIV testing rates in affected areas and estimate the magnitude and duration of disruption in HIV testing associated with storm damage intensity. METHODS: Using MarketScan data from January 2011‒December 2013, this study examined weekly time series of HIV testing rates among privately insured enrollees not previously diagnosed with HIV; 95 weeks pre- and 58 weeks post-storm. Interrupted time series (ITS) analyses were estimated by storm impact rank (using FEMA's Final Impact Rank mapped to Core Based Statistical Areas) to determine the extent that Hurricane Sandy affected weekly rates of HIV testing immediately and the duration of that effect after the storm. RESULTS: HIV testing rates declined significantly across storm impact rank areas. The mean decline in rates detected ranged between -5% (95% CI: -9.3, -1.5) in low impact areas and -24% (95% CI: -28.5, -18.9) in very high impact areas. We estimated at least 9,736 (95% CI: 7,540, 11,925) testing opportunities were missed among privately insured persons following Hurricane Sandy. Testing rates returned to baseline in low impact areas by 6 weeks post event (December 9, 2012); by 15 weeks post event (February 10, 2013) in moderate impact areas; and by 17 weeks after the event (February 24, 2013) in high and very high impact areas. CONCLUSIONS: Hurricane Sandy resulted in a detectable and immediate decline in HIV testing rates across storm-affected areas. Greater storm damage was associated with greater magnitude and duration of testing disruption. Disruption of basic health services, like HIV testing and treatment, following large natural and man-made disasters is a public health concern.  Disruption in testing services availability for any length of time is detrimental to the efforts of the current HIV prevention model, where status confirmation is essential to control disease spread.

Vulnerabilities Associated with Post-disaster Declines in HIV-testing: Decomposing the Impact of Hurricane Sandy.

INTRODUCTION: Using Interrupted Time Series Analysis and generalized estimating equations, this study identifies factors that influence the size and significance of Hurricane Sandy's estimated impact on HIV testing in 90 core-based statistical areas from January 1, 2011 to December 31, 2013. METHODS: Generalized estimating equations were used to examine the effects of sociodemographic and storm-related variables on relative change in HIV testing resulting from Interrupted Time Series analyses. RESULTS: There is a significant negative relationship between HIV prevalence and the relative change in testing at all time periods. A one unit increase in HIV prevalence corresponds to a 35% decrease in relative testing the week of the storm and a 14% decrease in relative testing at week twelve. Building loss was also negatively associated with relative change for all time points. For example, a one unit increase in building loss at week 0 corresponds with an 8% decrease in the relative change in testing (p=0.0001) and a 2% at week twelve (p=0.001). DISCUSSION: Our results demonstrate that HIV testing can be negatively affected during public health emergencies. Communities with high percentages of building loss and significant HIV disease burden should prioritize resumption of testing to support HIV prevention.

Primary Care Physicians' Views about Prescribing Methadone to Treat Opioid Use Disorder.

BACKGROUND: Methadone maintenance treatment is an effective way to reduce harms associated with opioid use disorder and, in several countries, is delivered in community-based primary care settings. Expanding methadone into primary care depends, in part, on physicians' willingness and readiness to integrate it into their practices. OBJECTIVES: This qualitative study explores factors that primary care physicians consider important when contemplating prescribing methadone to treat opioid use disorder. METHODS: In-depth interviews were conducted during 2015 with 20 primary care physicians in various sized communities throughout Nova Scotia, Canada. Participants shared their views and experiences related to prescribing methadone to treat opioid use disorder. Data were analyzed inductively using thematic analysis to identify predominant themes. RESULTS: Participants discussed an interplay of factors as they contemplated prescribing methadone to treat opioid use disorder in primary care. Physician-related factors included access to methadone expertise, support from allied professionals, suitability of skills, and personal experiences. Patient-related factors involved perceptions about methadone users as a difficult patient group with highly complex needs. Practice-related factors encompassed concerns about threats to physicians' careers, surveillance duties, unfair remuneration, safety risks, and practice disruptions. Contextual factors included knowledge deficits about substance use disorders, the generalist nature of primary care, methadone's socio-political context, and opioid prescribing patterns in primary care. CONCLUSIONS: Understanding the perspectives of physicians is vital to expanding methadone into primary care. This study identifies factors that should be addressed to attract, support, and retain primary care physicians in prescribing methadone to treat opioid use disorder.

Snacking and Diet Quality Are Associated With the Coping Strategies Used By a Socioeconomically Diverse Urban Cohort of African-American and White Adults.

BACKGROUND: Stress affects health-related quality of life through several pathways, including physiological processes and health behaviors. There is always a relationship between stress (the stimulus) and coping (the response). The relationship between snacking and snackers' diet quality and stress coping is a topic overlooked in research. OBJECTIVE: The study was primarily designed to determine whether energy provided by snacks and diet quality were associated with coping behaviors to manage stress. DESIGN: We analyzed a baseline cohort of the Healthy Aging in Neighborhoods of Diversity across the Life Span study (2004 to 2009). PARTICIPANTS: The sample was composed of 2,177 socioeconomically diverse African-American and white adults who resided in Baltimore, MD. MAIN OUTCOME MEASURES: Energy from snacks was calculated from 2 days of 24-hour dietary recalls collected using the US Department of Agriculture's Automated Multiple Pass Method. Snack occasions were self-reported as distinct eating occasions. Diet quality was evaluated by the Healthy Eating Index-2010. STATISTICAL ANALYSES PERFORMED: Multiple regression analyses were used to determine whether coping factors were associated with either energy provided by snacks or Healthy Eating Index-2010, adjusting for age, sex, race, socioeconomic status, education, literacy, and perceived stress. Coping was measured by the Brief COPE Inventory with instrument variables categorized into three factors: problem-focused coping, emotion-focused coping, and use of support. Perceived stress was measured with the 4-item Perceived Stress Scale. RESULTS: Adjusting for perceived stress and selected demographic characteristics, emotion-focused coping strategies were associated with greater energy intakes from snacks (P=0.020), and use of coping strategies involving support was positively associated with better diet quality (P=0.009). CONCLUSIONS: Energy contributed by snacks and diet quality were affected by the strategy that an individual used to cope with stress. The findings suggest that health professionals working with individuals seeking guidance to modify their eating practices should assess a person's coping strategies to manage stress.

Health Literacy and Education Predict Nutrient Quality of Diet of Socioeconomically Diverse, Urban Adults.

BACKGROUND: Research has shown that health literacy may be a stronger predictor of health than age, employment status, education level, race, and income. Evidence supports a strong link between low health literacy and poor dietary management of chronic diseases. OBJECTIVE: The aim was to evaluate the relationship of micronutrient quality of diet, health numeracy and health literacy in White and African American adults randomly selected from 13 Baltimore neighborhoods. DESIGN: Cross-sectional analysis of Wave 3 (2009-2013) of the longitudinal Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study initiated in 2004. MAIN OUTCOME MEASURES: Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM). Health numeracy was measured using the numeracy subscale of the Test of Functional Health Literacy in Adults (TOFHLA). Nutrient-based diet quality was measured using Mean Adequacy Ratio (MAR-S) scores calculated from 17 micronutrients from diet plus dietary supplement intake. STATISTICAL ANALYSES: The relationship of MAR-S scores to the health literacy measures were explored with multiple ordinary least square regression models, adjusting for a number of potential confounders. RESULTS: REALM but not numeracy was associated with MAR-S; significant covariates included age, current cigarette smoking status, and energy intake. The interactions of race and educational attainment, and REALM and educational attainment were significant, with the relationship between REALM and MAR-S becoming stronger as education level increased. CONCLUSION: There is a synergistic relationship between health literacy and educational attainment in predicting nutrient-based diet quality. Education was a stronger predictor for Whites compared to African Americans emphasizing the need for health professionals to focus on both education and literacy when creating and providing diet and health-related interventions and resources.

Gender-specific research on mental illness in the emergency department: current knowledge and future directions.

Mental illness is a growing, and largely unaddressed, problem for the population and for emergency department (ED) patients in particular. Extensive literature outlines sex and gender differences in mental illness' epidemiology and risk and protective factors. Few studies, however, examined sex and gender differences in screening, diagnosis, and management of mental illness in the ED setting. Our consensus group used the nominal group technique to outline major gaps in knowledge and research priorities for these areas, including the influence of violence and other risk factors on the course of mental illness for ED patients. Our consensus group urges the pursuit of this research in general and conscious use of a gender lens when conducting, analyzing, and authoring future ED-based investigations of mental illness.

The prevalence of trauma and childhood adversity in an urban, hospital-based violence intervention program.

Hospitals represent a promising locus for preventing recurrent interpersonal violence and its psychological sequella. We conducted a cross-sectional analysis to assess the prevalence of post-traumatic stress disorder (PTSD) and adverse childhood experiences (ACEs) among victims of interpersonal violence participating in a hospital-based violence intervention program. Participants completed PTSD and ACE screenings four to six weeks after violent injury, and data were exported from a case management database for analysis. Of the 35 program participants who completed the ACE and/or PTSD screenings, 75.0% met full diagnostic criteria for PTSD, with a larger proportion meeting diagnostic criteria for symptom-specific clusters. For the ACE screening, 56.3% reported three or more ACEs, 34.5% reported five or more ACEs, and 18.8% reported seven or more ACEs. The median ACE score was 3.5. These findings underscore the importance of trauma-informed approaches to violence prevention in urban hospitals and have implications for emergency medicine research and policy.

Depression as a risk factor for breast cancer: investigating methodological limitations in the literature.

PURPOSE: A relationship between depression and the development of breast cancer has not been convincingly shown in the research conducted over the past three decades. METHODS: In an effort to better understand the conflicting results, a review was conducted focusing on the methodological problems associated with this literature, including time frame between the assessment of depression and the diagnosis of breast cancer and the use of somatic items in measuring depression. Fifteen breast cancer prospective studies were reviewed. RESULTS: While twelve of the studies found positive associations between depression and breast cancer development, three studies found negative associations. With regard to the predictive associations between depression and breast cancer incidence, the findings revealed that (a) studies using a longer time frame found a stronger association than studies using a shorter time frame and (b) studies utilizing depression measures that did not contain somatic items found a smaller association than studies utilizing depression measures that did contain these items. CONCLUSIONS: Future studies should ensure that sufficient periods of time between the measurement of depression and the assessment of cancer and avoid measuring depression using somatic items.

Future challenges in analysis and treatment of human immune senescence.

Immune functions decline with age; immunorestorative approaches have been explored in laboratory animals and humans with definite, but limited success. In the clinical setting, the age-associated immune deficiency (immunesenescence) is compounded by the presence of comorbidities that are associated with a functional decline in immunity. Thus, any successful immune reconstitution strategy for humans must involve treatment of the underlying diseases. Furthermore, general health measures such as nutrition and exercises may have powerful effects on restoring immunity, to the extent that malnutrition and a sedentary lifestyle have contributed to existing immune deficiency. More selective approaches, such as with specific cytokines or organ transplantation are of experimental interest but are quite distant from achieving clinical applicability as interventions to restore immunity in the frail elderly.