Using serial cross-sectional surveys to create a retrospective nested cohort to determine HIV incidence from 20 US cities.

OBJECTIVE: To estimate HIV incidence using successive cross-sectional surveys by creating retrospective nested cohorts among MSM, people who inject drugs (PWID), and heterosexually active persons (HET). DESIGN: Cohorts were created among participants who had at least one repeat observation across four surveillance cycles from National HIV Behavioral Surveillance in 20 US cities. METHODS: Repeat participants were identified using a combination of date of birth, race/ethnicity, metropolitan statistical area, and gender. The analysis was limited to participants who tested negative for HIV at baseline and were assumed to be at risk between cycles. We calculated person-years at risk from the individual time between cycles and used the total number of seroconversions to estimate incidence and a Poisson distribution to approximate variance. Rate ratios were calculated using age, gender, race/ethnicity, and region. RESULTS: From 2008 to 2019, successive surveys recaptured nested cohorts of 1747 MSM, 3708 PWID, and 1396 HET. We observed an incidence rate of 2.5 per 100 person-years [95% confidence interval (CI) 2.1-2.8) among MSM; 0.6 per 100 person-years (95% CI 0.5-0.7) among PWID; and 0.3 per 100 person-years (95% CI 0.1-0.4) among HET. HIV incidence was higher among younger MSM, black MSM (compared with white MSM), and PWID residing in the South and territories (compared with the Midwest). CONCLUSION: These estimates are consistent with previously published incidence estimates from prospective cohort studies among these populations. Using repeat cross-sectional surveys to simulate a cohort, may serve as another strategy in estimating HIV incidence.

Implementation of a Medical Clearance Algorithm for Psychiatric Emergency Patients.

BACKGROUND: Despite evidence demonstrating limited benefit, many clinicians continue to perform routine laboratory testing of well-appearing children to medically clear them before psychiatric admission. METHODS: We conducted a quality improvement project to reduce routine laboratory testing among pediatric patients requiring admission to our psychiatric unit. We convened key stakeholders whose input informed the modification of an existing pathway and the development of a medical clearance algorithm. Our outcome was a reduction in routine laboratory testing for children requiring psychiatric admission. Our balancing measure was the number of patients requiring transfer from the inpatient psychiatry unit to a medical service. We used run charts to evaluate nonrandom variation and demonstrate sustained change. RESULTS: Before the introduction of the new medical clearance algorithm, 93% (n = 547/589) of children with psychiatric emergencies received laboratory testing. After implementing the medical clearance algorithm, 19.6% (n = 158/807) of children with psychiatric emergencies received laboratory testing. Despite a decreased rate of routine testing, there were no transfers to the medical service. CONCLUSIONS: Implementing a medical clearance algorithm can decrease routine laboratory testing without increasing transfers to the medical service among children requiring psychiatric admission.

Impact of Universal Suicide Risk Screening in a Pediatric Emergency Department: A Discrete Event Simulation Approach.

OBJECTIVE: The aim of this study was to use discrete event simulation (DES) to model the impact of two universal suicide risk screening scenarios (emergency department [ED] and hospital-wide) on mean length of stay (LOS), wait times, and overflow of our secure patient care unit for patients being evaluated for a behavioral health complaint (BHC) in the ED of a large, academic children's hospital. METHODS: We developed a conceptual model of BHC patient flow through the ED, incorporating anticipated system changes with both universal suicide risk screening scenarios. Retrospective site-specific patient tracking data from 2017 were used to generate model parameters and validate model output metrics with a random 50/50 split for derivation and validation data. RESULTS: The model predicted small increases (less than 1 hour) in LOS and wait times for our BHC patients in both universal screening scenarios. However, the days per year in which the ED experienced secure unit overflow increased (existing system: 52.9 days; 95% CI, 51.5-54.3 days; ED: 94.4 days; 95% CI, 92.6-96.2 days; and hospital-wide: 276.9 days; 95% CI, 274.8-279.0 days). CONCLUSIONS: The DES model predicted that implementation of either universal suicide risk screening scenario would not severely impact LOS or wait times for BHC patients in our ED. However, universal screening would greatly stress our existing ED capacity to care for BHC patients in secure, dedicated patient areas by creating more overflow.

A study of the dopamine transporter using the TRACT assay, a novel in vitro tool for solute carrier drug discovery.

Members of the solute carrier (SLC) transporter protein family are increasingly recognized as therapeutic drug targets. The majority of drug screening assays for SLCs are based on the uptake of radiolabeled or fluorescent substrates. Thus, these approaches often have limitations that compromise on throughput or the physiological environment of the SLC. In this study, we report a novel application of an impedance-based biosensor, xCELLigence, to investigate dopamine transporter (DAT) activity via substrate-induced activation of G protein-coupled receptors (GPCRs). The resulting assay, which is coined the 'transporter activity through receptor activation' (TRACT) assay, is based on the hypothesis that DAT-mediated removal of extracellular dopamine directly affects the ability of dopamine to activate cognate membrane-bound GPCRs. In two human cell lines with heterologous DAT expression, dopamine-induced GPCR signaling was attenuated. Pharmacological inhibition or the absence of DAT restored the apparent potency of dopamine for GPCR activation. The inhibitory potencies for DAT inhibitors GBR12909 (pIC50 = 6.2, 6.6) and cocaine (pIC50 = 6.3) were in line with values from reported orthogonal transport assays. Conclusively, this study demonstrates the novel use of label-free whole-cell biosensors to investigate DAT activity using GPCR activation as a readout. This holds promise for other SLCs that share their substrate with a GPCR.

Confidence level of pediatric trainees in management of shock states.

AIM: To assess overall confidence level of trainees in assessing and treating shock, we sought to improve awareness of recurrent biases in clinical decision-making to help address appropriate educational interventions. METHODS: Pediatric trainees on a national listserv were offered the opportunity to complete an electronic survey anonymously. Four commonly occurring clinical scenarios were presented, and respondents were asked to choose whether or not they would give fluid, rank factors utilized in decision-making, and comment on confidence level in their decision. RESULTS: Pediatric trainees have a very low confidence level for assessment and treatment of shock. Highest confidence level is for initial assessment and treatment of shock involving American College of Critical Care Medicine/Pediatric Advanced Life Support recommendations. Children with preexisting cardiac comorbidities are at high risk of under-resuscitation. CONCLUSION: Pediatric trainees nationwide have low confidence in managing various shock states, and would benefit from guidance and teaching around certain common clinical situations.

Violence, violence prevention, and safety: a research agenda for South Africa.

Violence is a serious problem in South Africa with many effects on health services; it presents complex research problems and requires interdisciplinary collaboration. Two key meta-questions emerge: (i) violence must be understood better to develop effective interventions; and (ii) intervention research (evaluating interventions, assessing efficacy and effectiveness, how best to scale up interventions in resource-poor settings) is necessary. A research agenda to address violence is proposed.